At a meeting of the American Physical Therapy Association not too long ago, four clinical experts gave an extensive workshop on cervical radiculopathy. The workshop was packed—standing room only. Great emphasis was placed on clinical diagnosis using upper limb tension tests (ULTTs).
Two things struck me at the end of this several-hour workshop. First, advanced imaging was given scant attention. This is understandable given the limited ability within the physical therapy profession to order and interpret such studies. Second, the clinical tests for diagnostic confirmation—particularly the ULTTs supported by Wainner (1) et al.’s 2003 work—are predicated on the presence of pain in the arm, forearm, hand, and/or fingers.
So, when the floor opened for final questions, I stood and asked the experts to briefly comment on the association between cervical radiculopathy and scapular pain. In turn, each expert stated there was no association, and that scapular pain in the presence of neck pain would be related to cervical facet pathology, not cervical radiculopathy.
Having trained and worked closely with spine surgeons over the years, I clearly understood there was an association, so I was puzzled by this response. No, I was bothered, and this gave way to genuine concern. Here was a large lecture hall at a convention center full of intensely interested colleagues from the non-surgical spine care community who witnessed an open dismissal of scapular pain as a possible manifestation of cervical radiculopathy.
But then the PhD-ingrained “you really know next to nothing” impulse bubbled up reflexively in my thinking, and I had to ask: “What does the literature say? What do we really know?”
We chiropractors are likely familiar with the classic work of Aprill, Dwyer, and Bogduk (2) —a study conducted right here in Colorado, actually—who mapped pain referral patterns after injecting cervical facets with hypertonic saline. This gave us confirmation that looking to the cervical spine in patients presenting with neck pain combined with pain in and around the scapula was a good idea. We may have even adopted the common understanding that “radicular pain” is synonymous with pain in the arm, forearm, hand, and/or fingers—or at least tingling, numbness, or other dysesthesias if not pain.
Again, I thought, “What does the literature say?” Street rumors get started—even clinical street rumors—and they can get passed along like the game “Telephone.”
Back in my hotel room, I did a little homework online and found that, yes, the North American Spine Society (NASS) guidelines suggested that scapular pain could be a manifestation of cervical radiculopathy, backed up by a paper published in 2011.
Thus, the idea for a scoping review was born. Soon, an international team (for whom I am sincerely grateful and without whom this project would not have crossed the finish line) with expertise in neck pain research, pain science, and rehabilitation was assembled to work on this project. Research is a team sport!
Knowing that “bench to bedside” knowledge translation traditionally takes 17 years, I sought help from the NCMIC Foundation, who graciously provided enough funds to disseminate our preliminary study design and findings to the spine research community. This resulted in poster presentations at the International Back and Neck Pain Research Forum in Holland and the ACC-RAC conference in San Diego in 2024.
The final review was published on May 29, 2025, in the North American Spine Society Journal (NASS J). It is available for you to read free of charge here.
Four lessons learned through this research:
First, research is fun. Identifying gaps in knowledge—then narrowing those gaps a bit—is satisfying both as a clinician and as a researcher. If you’ve read this far, please consider what role you might play as a clinician-scientist. It’s never too late to get involved. Case reports are great, and an academic degree such as a Master’s or PhD might be a good fit for you. Please consider it—our profession needs you! If you are early in your clinical career, this invitation is especially for you.
Second, the common bond established with co-investigators makes the work all that much more satisfying. It’s a struggle. It takes resilience and stick-to-it-iveness, but it is enriching. Relationships matter most.
Third, the presence of pain or symptoms in the arm, forearm, hand, and/or fingers are NOT necessary for the diagnosis of cervical radiculopathy. “Radicular pain” can be confined to the neck, or to the neck plus trapezius area, or to the neck plus scapular area, etc., WITHOUT any arm pain. So, when taking a history and conducting the initial examination, note the mechanism of onset and the possible implications for the cervical intervertebral disc.
Fourth, and as a corollary to the above, cervical radicular pain often initially presents as scapular pain. That is, in the medial scapula (upper, middle, or lower), across the top of the scapula along the scapular spine and trapezius, or even in the infraspinous fossa. Tanaka (3) and Mizutamari (4) published diagrams that even correlate the scapular subregion of pain to cervical nerve root levels. I have found these helpful, though not always exact, of course. After days, weeks, or even up to several months, radicular pain may advance to include shoulder (deltoid), arm, forearm, or hand/finger pain, and the radicular pain may leave the scapular area as it peripheralizes down the arm. This is quite common.
The take-home message from the fourth observation is this: as you obtain the patient’s history, note the evolution of pain from its onset to its present state in your clinic, and note the length of time the patient persisted with pain prior to presenting to your clinic. You may find that you are able to diagnose a true cervical radiculopathy before it ever peripheralizes to the arm/forearm/hand. I am convinced that early, correct diagnoses can lead to better outcomes. And that is the goal of clinical science.
Joel Carmichael, DC, PhD practices at The Center for Spine, Sport & Physical Medicine in Colorado. He teaches at Universidad Central del Caribe in Puerto Rico and maintains volunteer clinical faculty status at the University of Colorado School of Medicine. His research seeks to improve the practice habits of sport and spine professionals. Dr. Carmichael loves teaching, latté art, C.S. Lewis, and an occasional morsel of chocolate. He and his wife enjoy morning strolls with their golden retrievers, Stella and Noli.
References:
1. Wainner RS et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976) 2003 Vol. 28 Issue 1 Pages 52-62. https://doi.org/10.1097/00007632-200301010-00014
2. Aprill C, Dwyer A, and Bogduk N. Cervical zygapophyseal joint pain patterns. II: A clinical evaluation. Spine (Phila Pa 1976) 1990 Vol. 15 Issue 6 Pages 458-61. https://doi.org/10.1097/00007632-199006000-00005
3. Tanaka Y et al. Cervical roots as origin of pain in the neck or scapular regions. Spine (Phila Pa 1976) 2006 Vol. 31 Issue 17 Pages E568-73. https://doi.org/10.1097/01.brs.0000229261.02816.48
4. Mizutamari M et al. Corresponding scapular pain with the nerve root involved in cervical radiculopathy. J Orthop Surg (Hong Kong) 2010 Vol. 18 Issue 3 Pages 356-60. https://journals.sagepub.com/doi/pdf/10.1177/230949901001800320
