To the Editor:
The excellent report of Yamaguchi (1) in the current issue of the Journal reviews the
epidemiology of symptomatic and asymptomatic rotator cuff disease in an
attempt to elicit the factors
important for the development of symptoms. We have described a series of
patients with rotator cuff disease who presented with "neck" pain yet denied shoulder symptoms(2), and we think this may account for a substantial
number of "asymptomatic" patients. Turner et al.(3) have likewise shown
that shoulder impingement is prevalent in whiplash injuries at a similar frequency (3). We now think
that MacNab's(4) demonstration of the absence of nerve fibers in the involved
rotator cuff best explains the lack of shoulder symptoms, and the "neck"
pain is best explained as pain in the Supraspinatus muscle. We believe
that this specific chronic neck pain is localized in the upper back and
not in the neck, and it is caused by a painful Supraspinatus muscle resulting
from "asymptomatic" rotator cuff disease.
Pain is common at this
location, and is misdiagnosed as Trapezius spasm, trigger points,
herniated disc, and whiplash-associated disorder. The shoulder condition
usually remains undiagnosed as it is “asymptomatic.” We speculate that
the prevalence of asymptomatic rotator cuff disease may approximate the
number of patients with intractable chronic neck pain at this location in
the upper back. Clinicians and Researchers should enquire about the
presence of neck pain when examining shoulder patients, and if present,
the location of neck pain should be further delineated. (For example:
upper, middle and lower neck and upper back (the anterior neck is ENT
territory.) Patients and care givers alike incorrectly refer to the upper
back as the neck, and thus ignore the “asymptomatic” shoulder.
The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.
References:
1) Yamaguchi K, Ditsios K, Middleton W, Hildebolt C, Galatz L, Teefey
S.
The Demographic and Morphological Features of Rotator Cuff Disease. A
Comparison of Asymptomatic and Symptomatic Shoulders. J Bone and
Joint Surgery. 88A. 1699-1704.
2) Gorski J, Schwartz L. Shoulder Impingement Presenting as Neck
Pain,
J Bone and Joint Surg, 2003, 85A, 635-638.
3) Chauhan SK, Pechham T, Turner R. Impingement Syndrome Associated
with Whiplash Injury. J Bone Joint Surg. 2003 85B, 408-10.
4) Macnab I, McCulloch J. Neck Ache and Shoulder Pain. Baltimore:
Williams and
Wilkens: 1983. 318-319.
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