Cervical Spine and Shoulder Complex: Landmarks, Scapulohumeral Rhythm, and Typical Dysfunctions

1) Palpation map (clinically efficient sequence)

Goal: build a quick “orientation map” that links what you feel to what you expect to see during neck and shoulder movement. Use a consistent order so you can re-check landmarks after movement tests.

A. Cervical spine: midline to lateral

• C7 spinous process (vertebra prominens): palpate at the base of the neck. Confirm by asking the patient to extend the neck slightly: C7 typically moves less than C6 (C6 glides anteriorly and becomes less prominent).
• C2 spinous process: palpate just inferior to the occiput in the midline. Ask for gentle rotation; C2 is a useful reference for upper cervical movement behavior.
• Transverse processes (C3–C6): palpate anterolaterally (carefully, light pressure). Use for side-to-side symmetry checks and to orient to the scalene region. Avoid sustained deep pressure over the carotid sinus region.

B. Clavicle and sternoclavicular (SC) joint

• Clavicle shaft: trace from medial to lateral. Note step-offs, tenderness, or asymmetry.
• SC joint: locate at the medial clavicle–manubrium junction. Observe movement during shoulder elevation: the clavicle should elevate and posteriorly rotate with arm elevation.

C. Acromioclavicular (AC) joint and acromion

• AC joint: find the small gap between distal clavicle and acromion. Compare sides for prominence and local tenderness, especially with cross-body positions.
• Acromion: palpate anterior and lateral edges; it frames the subacromial region clinically (symptom reproduction here often relates to rotator cuff/bursa load sensitivity rather than a single “impingement structure”).

D. Scapula: borders, spine, and coracoid

• Scapular spine: follow from medial to lateral to the acromion. Useful for observing posterior tilt and upward rotation during elevation.
• Medial border: palpate from superior angle down to inferior angle. Watch for winging or excessive internal rotation (prominent medial border) during arm movement.
• Inferior angle: a practical marker for upward rotation; it should move laterally and upward with arm elevation.
• Coracoid process: palpate just inferior to the lateral third of the clavicle, medial to the humeral head. Commonly tender in anterior shoulder pain presentations; interpret in context (local tenderness is not a diagnosis).

E. Humeral head and bicipital groove region

• Greater tubercle region: palpate lateral to the acromion with the arm in slight extension and external rotation; this approximates rotator cuff tendon insertion region clinically.
• Humeral head position: from the anterior shoulder, palpate the humeral head while the patient gently externally rotates; note anterior translation or apprehensive guarding.
• Bicipital groove region: palpate anteriorly between greater and lesser tubercles with the arm in slight external rotation; interpret tenderness carefully because multiple tissues converge here.

2) Movement analysis: linking cervical ROM, shoulder elevation, scapulohumeral rhythm, and thoracic contribution

A. Cervical ROM (screen with symptom behavior)

Use a symptom-guided approach: you are not only measuring range, you are mapping what movements change the patient’s familiar symptoms and where they feel them.

• Flexion/extension: note symptom location (neck vs shoulder vs arm), quality, and whether symptoms centralize (move proximally) or peripheralize (move distally).
• Rotation and side-bending: compare sides; observe coupled motion and whether shoulder symptoms change with neck movement.
• Quadrant positions (combined extension/rotation/side-bend): use only if irritability is low; these positions can provoke foraminal loading and are not appropriate early in highly irritable presentations.

B. Shoulder elevation: what to watch from the back and side

Assess active elevation in the scapular plane (approximately 30–45° anterior to the frontal plane) and in pure abduction/flexion if tolerated. Watch the sequence: humerus, scapula, clavicle, thorax.

• Painful arc behavior: note where pain begins, peaks, and eases. A mid-range pain increase during elevation can reflect load sensitivity of subacromial tissues, but interpretation must include strength, irritability, and neck contribution.
• Quality of motion: look for hitching, early scapular shrug, or trunk side-bend substitution.
• End-range strategy: does the patient gain range by lumbar extension or thoracic extension rather than glenohumeral/scapular motion?

C. Scapulohumeral rhythm (practical clinical concept)

Scapulohumeral rhythm describes the coordinated contribution of glenohumeral motion and scapulothoracic motion during arm elevation. Clinically, you are looking for timing (when the scapula starts moving), amount (how much upward rotation/posterior tilt/external rotation), and control (smooth vs jerky).

• Typical pattern: early elevation includes more glenohumeral motion; as elevation continues, scapular upward rotation and posterior tilt increase to maintain subacromial clearance and optimize rotator cuff function.
• Common deviations: early excessive upper trapezius-driven shrug, insufficient upward rotation, excessive scapular internal rotation (prominent medial border), or reduced posterior tilt (anterior tipping).
• How to check quickly: place one hand lightly on the scapular spine and inferior angle while the patient elevates; compare sides for timing and smoothness.

D. Thoracic contribution (often the hidden limiter)

Thoracic extension and rotation influence scapular position and the ability to reach overhead without compensations. A stiff thorax can force the shoulder complex to “borrow” motion, increasing symptom provocation.

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• Observation: during elevation, does the thorax extend early (rib flare) or remain rigid?
• Quick test: seated thoracic extension over chair back or foam roll (if available). Re-test shoulder elevation immediately after: a meaningful change suggests thoracic mobility is a modifiable driver.

3) Common patterns (what they look like and how to differentiate)

A. Rotator cuff–related pain (load and capacity problem)

Often presents as lateral shoulder pain with reaching, lifting, or overhead tasks. The key clinical reasoning is whether symptoms reflect reduced tendon capacity relative to load, rather than a single structural “tear” narrative.

• Typical findings: pain with resisted external rotation or abduction (variable), pain with elevation under load, night discomfort when lying on the affected side, and reduced tolerance to repeated overhead tasks.
• Movement clues: painful arc, protective scapular shrug, reduced eccentric control on lowering.
• Differentiation tips: if neck movements reproduce the familiar shoulder pain, or if symptoms extend below the elbow with paresthesia, consider cervical contribution as primary or co-existing.

B. Subacromial pain patterns (symptom behavior, not a single structure)

“Subacromial pain” is a useful clinical label for pain provoked by elevation/loading in positions that compress or tension the rotator cuff/bursa region. It is best treated as a pattern of irritability and load sensitivity.

• Typical findings: pain in mid-range elevation, pain with sustained overhead postures, relief with unloading, and variable strength inhibition due to pain.
• Scapular association: insufficient upward rotation/posterior tilt may increase symptom provocation, but scapular changes can also be protective strategies rather than the cause.

C. Scapular dyskinesis (control/timing issue, often secondary)

Scapular dyskinesis refers to altered scapular motion (timing, direction, smoothness). It is common in painful shoulders and in asymptomatic athletes; interpret it as a contributor or consequence depending on symptom change with correction.

• What you see: medial border prominence (internal rotation), early shrug (elevation dominance), winging during pushing or lowering, or asymmetrical upward rotation.
• Clinical test idea: apply gentle manual assistance into upward rotation/posterior tilt during elevation. If pain decreases and range improves, scapular control may be a priority early.

D. Cervical referral to the shoulder (don’t miss it)

Cervical structures can refer pain to the shoulder region and can also sensitize the shoulder to load. The key is whether shoulder symptoms are strongly modulated by neck position/movement and whether neurological features are present.

• Clues: shoulder pain reproduced by cervical rotation/extension, symptoms that change with sustained neck posture, pain that is diffuse or extends beyond the shoulder, or associated paresthesia/weakness.
• Practical differentiation: compare shoulder elevation with the neck neutral vs slightly flexed/rotated away; meaningful symptom change suggests cervical contribution.

4) Safe testing selection based on irritability and symptom provocation

Choose tests to answer a question, not to “collect positives.” Start with low-threat, low-compression options and escalate only if the presentation is low irritability and the result will change management.

A. Irritability-based decision guide

B. Step-by-step: a safe shoulder test sequence (modifiable)

1. Baseline symptoms: location, intensity, irritability (how long symptoms last after provocation).
2. Active elevation (scapular plane): note painful arc, scapular strategy, trunk substitution.
3. Cervical screen: rotation/extension/side-bend to see if shoulder symptoms change.
4. Symptom modification: try scapular assistance (upward rotation/posterior tilt) and/or thoracic extension cue; re-test elevation.
5. Graded isometrics: external rotation, abduction, internal rotation at neutral; start at 20–30% effort and increase only if tolerated. Note pain vs weakness vs pain-inhibited weakness.
6. Selective special tests (only if needed): choose 1–2 that match the hypothesis and irritability. Stop if symptoms spike or linger.

C. Step-by-step: a safe cervical contribution check

1. Shoulder symptom baseline: pick a comparable sign (e.g., painful elevation to 90°).
2. Neck movement effect: repeat the comparable sign with neck neutral vs slight flexion vs rotation away/toward symptoms.
3. Sustained posture test (brief): 20–30 seconds of cervical retraction or gentle unloading (supported arm/neck) and re-test the comparable sign.
4. Interpretation: if shoulder pain meaningfully changes with neck position, include cervical management in the plan even if shoulder tests are positive.

5) Basic treatment reasoning: what to prioritize and why

A. When to prioritize scapular control

• Indications: visible dyskinesis plus symptom improvement with scapular assistance; early shrug dominance; pain reduced when the scapula is guided into upward rotation/posterior tilt.
• Early focus: low-load motor control in tolerated ranges (e.g., wall slide with posterior tilt cue, scapular setting during supported elevation).
• Progression idea: move from supported to unsupported, from slow to functional speed, and from low to moderate load while maintaining smooth scapular motion.

B. When to prioritize rotator cuff loading

• Indications: pain primarily with resisted tasks and elevation load, tolerable irritability, and no strong cervical modulation; weakness or poor endurance in external rotation/abduction patterns.
• Early focus: isometrics at neutral (external rotation/abduction) to build tolerance and reduce pain sensitivity; then isotonic loading in scapular plane.
• Dosing principle: choose a load that produces tolerable discomfort (if any) and does not cause prolonged flare. Track 24-hour response.

C. When to prioritize thoracic mobility

• Indications: limited thoracic extension/rotation, early rib flare compensation, and immediate improvement in shoulder elevation after thoracic extension cue or mobilization.
• Early focus: repeated thoracic extension/rotation drills integrated into reaching tasks (e.g., seated extension with arms supported, open-book rotations).
• Clinical goal: reduce the need for compensatory shoulder elevation strategies by restoring a better base for scapular motion.

D. When to prioritize neural considerations (without repeating nerve anatomy)

• Indications: symptoms extending distally, paresthesia, strong symptom modulation with neck position, disproportionate pain to shoulder loading, or protective guarding with minimal shoulder provocation.
• Early focus: reduce sensitivity drivers (posture/load management, gentle cervical mobility within tolerance, graded exposure). Avoid aggressive stretching into neural provocation early.
• Integration: treat shoulder capacity while respecting neural irritability—often by using supported positions and lower ranges initially.

Case-based flowcharts (two common presentations)

Flowchart 1: Lateral shoulder pain with overhead reaching (suspected rotator cuff/subacromial pain pattern)

START: Pain with overhead reach / lifting, lateral shoulder pain ± night discomfort
  |
  |-- Step 1: Irritability check
  |     - Rest/night pain? prolonged after-effects? guarding?
  |     -> High irritability: go to Step 2A
  |     -> Moderate/low: go to Step 2B
  |
  |-- Step 2A (High irritability): Choose low-provocation tests
  |     - AROM elevation in scapular plane (stop before flare)
  |     - Gentle ER/ABD isometrics at 20–30% effort
  |     - Scapular assistance re-test
  |     - Cervical screen (rotation/extension) to rule in/out modulation
  |     -> If scapular assistance reduces pain: prioritize scapular control + load management
  |     -> If isometrics reduce pain and tolerated: begin cuff isometrics program
  |     -> If neck strongly modulates: add cervical/thoracic strategy early
  |
  |-- Step 2B (Moderate/low irritability): Capacity profiling
  |     - Resisted ER/ABD (graded), endurance holds
  |     - Observe lowering phase control
  |     - Thoracic extension re-test of elevation
  |     -> If weakness/endurance deficit dominates: prioritize progressive cuff loading
  |     -> If thoracic re-test improves range/pain: add thoracic mobility as key driver
  |     -> If scapular assistance improves: add scapular control alongside cuff loading
  |
  |-- Step 3: Build plan (first 2–4 weeks)
  |     - Choose 1–2 primary targets (cuff capacity, scapular control, thoracic mobility)
  |     - Monitor 24-hour response and functional comparable sign (elevation/lift)
END

Flowchart 2: Shoulder pain with neck stiffness and intermittent arm symptoms (suspected cervical referral with shoulder sensitivity)

START: Shoulder region pain + neck stiffness ± intermittent distal symptoms
  |
  |-- Step 1: Identify comparable sign
  |     - Example: shoulder elevation reproduces pain OR sustained desk posture triggers pain
  |
  |-- Step 2: Cervical modulation check
  |     - Repeat comparable sign with neck neutral vs flexed vs rotated
  |     -> If symptoms change meaningfully: cervical contribution likely -> Step 3
  |     -> If no change: proceed with shoulder-led assessment (Flowchart 1)
  |
  |-- Step 3: Irritability and safety
  |     - High irritability or distal symptoms easily provoked?
  |     -> Yes: avoid aggressive shoulder special tests and end-range neck loading
  |     -> No: proceed with graded shoulder strength tests in supported positions
  |
  |-- Step 4: Prioritize interventions
  |     - If neck position drives symptoms: prioritize cervical/thoracic strategies + education on posture/load
  |     - Add scapular/cuff exercises only in ranges that do not peripheralize symptoms
  |     - Use supported arm positions to reduce neural/neck load during early strengthening
  |
  |-- Step 5: Re-test comparable sign each session
  |     - Improvement with cervical/thoracic change? continue progression
  |     - If shoulder capacity becomes limiting: shift emphasis to cuff loading/scapular control
END