MILITARY MEDICINE, 187, 9/10:e1240, 2022

Shoulder Pain of Spinal Source in the Military: A Case Series

CPT Joseph A. Hathcock, PT, DPT SP, USA*; CPT Chris W. Boyer, PT, DPT SP, USA†;
MAJ Jamie B. Morris, PT, DPT, DSc SP, USA‡

ABSTRACT Musculoskeletal injury (MSI) presents the greatest threat to military mission readiness. Atraumatic
shoulder pain is a common military MSI that often results in persistent functional limitations. Shoulder orthopedic
evaluation presents many diagnostic challenges, due in part to the possibility of a spinal source of symptoms. This case
series outlines the use of mechanical diagnosis and therapy to screen the cervical and thoracic spine in active duty (AD)
service members (SMs) with a chief complaint of unchanging or worsening shoulder pain. All three SMs previously

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received shoulder-specific diagnoses from experienced clinicians, yet repeated movements revealed a possible spinal
nociceptive driver that guided targeted intervention. Treatment directed only at the cervical spine resulted in a clinically
important improvement within an average of 10 days from the initial evaluation, return to duty (RTD) within an average
of 32 days, and continued resolution at 3 months. SMs can independently complete the screening process with guidance
from healthcare providers, ultimately shaping the treatment strategy and possibly facilitating self-management of future
recurrence. This case series demonstrates that identification of shoulder pain of spinal source in the military population
may be an important step in facilitating timely RTD. These cases also highlight the use of a standardized, systematic
method to screen the cervical and thoracic spine that concurrently reveals the indicated treatment. Further research to
determine the prevalence of shoulder pain of spinal source in the AD population and its impact on RTD rates has the
potential to reduce the substantial burden of MSI in the military.

INTRODUCTION 12 months,5 and, in some military populations, 17% of

Musculoskeletal injury (MSI) places an overwhelming bur-
den on U. S. Military combat readiness, accounting for 53%
to 75% of all medically non-deployable service members
(SMs).1 In 2019, upper extremity MSIs were the third most
common complaint at military medical encounters.2 Addi-
tional data demonstrate that military shoulder injuries com-
prise 63% of upper extremity MSIs, with 82% of cases
resulting from shoulder overuse.3
Despite the high annual incidence of atraumatic shoulder
pain, current management strategies have variable outcomes.
Exercise therapy is the first-line treatment,4 yet persistent
functional impairment is common. Forty-one percent of cases
in the general population have persistent symptoms after
* Department of Rehabilitation Medicine, Brooke Army Medical Center,
Fort Sam Houston, TX 78234, USA
† 97th Military Police Battalion, Fort Riley, KS 66442, USA
‡ Army-Baylor Doctoral Program in Physical Therapy, Fort Sam Houston,
TX 78234, USA
Content was presented in part as an abstract on the Military Health
System Research Symposium website in July 2020, as a virtual poster for the
Military City USA Trauma Collaborative Conference on August 26, 2020, as
a virtual poster for the Army-Baylor Graduate School Research Symposium
on September 9, 2020, and as a virtual platform presentation at the APTA
Combined Sections Meeting 2021.
The view(s) expressed herein are those of the author(s) and do not reflect
the official policy or position of Brooke Army Medical Center, the U.S.
Army Institute of Surgical Research, the U.S. Army Medical Department,
the U.S. Army Office of the Surgeon General, the Department of the Army,
the Department of the Air Force, the Department of Defense, or the U.S.
government.
doi:https://doi.org/10.1093/milmed/usab059
Published by Oxford University Press on behalf of the Association of
Military Surgeons of the United States 2021. This work is written by (a) US
Government employee(s) and is in the public domain in the US.
recruits reporting shoulder pain are discharged early due to
continued limitations.6 Unsuccessful exercise therapy often
leads to surgical intervention, and 50% of SMs undergo-
ing surgery for shoulder pain have a diagnosis of atrau-
matic impingement.7 However, the surgical intervention for
impingement, subacromial decompression, consistently fails
to demonstrate benefit over placebo surgery.8,9
Inconsistent treatment outcomes may derive in part from
an inaccurate diagnosis. Clinicians continue to rely on ortho-
pedic special tests (OSTs) to reveal a pathoanatomic source
of pain, despite evidence that most OSTs lack diagnostic
value.10–12 Many providers base management decisions on
diagnostic imaging results, yet MRI reveals similar abnor-
malities in both symptomatic and asymptomatic shoulders.13
Instead, a diagnosis may be more accurately determined
through the exclusion of other potential sources of symptoms
such as the cervical or thoracic spine.14
One system of evaluation and treatment that incorporates
the screening of the spine for extremity complaints is mechan-
ical diagnosis and therapy (MDT). In fact, when utilizing
the standardized repeated movement assessment practiced in
MDT, nearly half of all reported atraumatic shoulder pain
is revealed to be of spinal source and resolves without local
shoulder treatment.15 Unfortunately, current randomized con-
trolled trials use variable methods to screen shoulder pain for
spinal contributions, contributing to diagnostic uncertainty.16
This case series uniquely outlines the use of MDT to system-
atically diagnose and treat active duty (AD) SMs presenting
with shoulder pain to facilitate rapid return to duty (RTD).
METHODS
The CARE (CAse REport) reporting guidelines provided an
outline for this case series. This structure is intended to

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 Shoulder Pain of Spinal Source in the Military
improve upon transparency and completeness of published
case reports in medical literature.17
Patient Characteristics
Cases were selected from consecutive patient encounters from
January 2020 to February 2020 at AD military physical ther-
apy (PT) clinics at Fort Sam Houston, TX, and Fort Riley, KS.
Inclusion criteria included (1) pain and functional limitations
previously diagnosed by a medical professional as shoulder
pathology, (2) PT assessment revealing a spinal source of
pain, and (3) less than 3-month duration of current episode.
SMs excluded if they were not appropriate for PT interven-
tion, had a traumatic mechanism, or had musculoskeletal
complaints other than shoulder pain. Evaluation, intervention,
and outcomes were documented in the Electronic Medical
Record.
Mechanical Diagnosis and Therapy
MDT involves the use of specific movements and positions
to alter symptoms and range of motion (ROM), thereby shap-
ing an appropriate treatment strategy.18 Screening the cervical
and thoracic spine is an integral part of MDT assessment
of upper extremity pain. Each SM presenting with shoulder
pain underwent screening of the spine with repeated move-
ments and/or sustained positioning. Upon identifying a direc-
tional preference, the therapists prescribed the corresponding
exercise. To best reflect the pragmatic context of military
medicine, neither therapist held a certification in MDT.
Outcome Measures
Each SM completed the Quick Disabilities of Arm, Shoul-
der, and Hand (QuickDASH) outcome form at their initial
visit, periodic re-evaluations, and discharge to assess func-
tional status. The QuickDASH demonstrates good test–retest
reliability and responsiveness, with a reported minimal clini-
cally important difference (MCID) of eight points for patients
with shoulder pain.19
Service members rated subjective improvement on a
15-point (−7 to +7) Global Rating of Change scale at follow-
ups. A change score of +5 or greater is considered a clinically
important improvement, as patients with lower scores are
observed to need continued treatment.20
CASE 1
Patient Information
A 25-year-old AD male soldier training to be a medic pre-
sented to PT. Primary care referred him with a diagnosis
of rotator cuff strain. The chief complaint was left shoul-
der pain preventing vigorous exercise—his most meaningful
functional limitation.
The soldier reported acute onset of localized left shoulder
pain 6 days prior after slipping out of the pushup position.
MILITARY MEDICINE, Vol. 187, September/October 2022
The pain was unchanging despite rest and traditional shoul-
der stability rehabilitation exercises. Sites of intermittent pain
included the diffuse anterior shoulder and along the poste-
rior deltoid. Numbness and tingling occasionally occurred
along the ulnar distribution from the shoulder to fingertips
when lying on the left side. The highest rating of pain within
48 h was 5/10 on the Defense and Veterans Pain Rating Scale
(DVPRS).
The soldier reported no red or yellow flags. He previ-
ously injured the same shoulder training martial arts more
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than 7 years prior, attended PT, and achieved full resolution of
symptoms. A painful popping sensation he experienced after
his prior injury returned with the recent injury. The soldier
also reported a new feeling of instability and subluxation.
Clinical Findings
Neurological screening of the upper extremities revealed no
sensory or motor deficits. The left upper limb tension test
reproduced posterior shoulder pain. The soldier maintained
full, symmetrical active and passive shoulder ROM bilater-
ally, a factor that may predict spinal referral.21 Symptom
baselines were pain during movement in active shoulder flex-
ion, active shoulder abduction, hand-behind-head (HBH),
and pain with external rotation (ER) manual muscle testing
(MMT). The soldier had no noticeable movement loss or
symptom reproduction with cervical spine ROM testing with
overpressure.
The clinician performed repeated movement testing with
seated retraction–extension (Fig. 1). This movement targets
the mid and lower cervical spine, which corresponds with lev-
els of innervation of both the shoulder and the ulnar sensory
distribution. Following twenty repetitions to end ROM, the
soldier no longer had pain with shoulder flexion or abduc-
tion, reported less pain with ER MMT, and noted that the
previously consistent clicking sensation abated.
Therapeutic Intervention and Diagnostic
Assessment
The initial evaluation led to a provisional MDT classification
of cervical derangement, a classification indicating that a con-
dition rapidly improves by moving in a directional preference.
The soldier was instructed to continue the evaluation inde-
pendently by performing the exercise for 10 repetitions every
2 h to 3 h, while temporarily avoiding cervical flexion and
protrusion.
Three days later, shoulder flexion remained pain free, but
the effect of loaded retraction–extension plateaued, indicating
that a force alternative might be required. Prone cervical end-
range extension (Fig. 2) sustained for 5 min abolished pain
with remaining baseline movements and restored symmetrical
ER strength. Rapid within-session improvements were effec-
tive in communicating the importance of the home exercises
and confirmed the classification.
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 Shoulder Pain of Spinal Source in the Military
FIGURE 1. Repeated cervical retraction–extension in sitting. (1) Position patient in sitting with a lumbar support and instruct them to sit tall; (2) patient
performs cervical retraction to end range; (3) patient fully extends cervical spine; (4) self-overpressure may be applied through small rotations at end range
to progress force.
FIGURE 2. Sustained cervical extension in prone. (1) Position patient in
prone resting on elbows; (2) patient props the cervical spine in extension with
their fingertips; (3) position elbows further forward until end-range strain is
felt and hold position as indicated.
At the final in-clinic visit, shoulder pain was no longer
reproducible. The soldier performed 10 repetitions of 11 kg
overhead press with no return of symptoms. The clinician pre-
scribed a progressive loading strategy in accordance with the
MDT return-to-function process.
Outcomes
The soldier required five visits across the span of 15 days
to begin return to function, ultimately resulting in 29 days
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from the initial evaluation to RTD with no shoulder pain. The
clinician contacted the soldier 10 days after the final visit to
ensure no recurrence of symptoms before expiration of the
profile and discharge from therapy. Global Rating of Change
and QuickDASH outcomes demonstrated clinically impor-
tant change within 15 days (Table I), and the soldier reported
continued resolution at 3-month follow-up.
CASE 2
Patient Information
A 21-year-old male AD sailor in the Hospital Corpsman
Advanced Technical Field Program presented to a direct-
access PT clinic. The chief complaint was right shoulder pain
limiting pullups and pushups. Missing or failing an upcom-
ing fitness test in 2 weeks would eliminate him from the
Search and Rescue Medical Technician training pipeline, thus
making pullups and pushups the most meaningful functional
limitations.
The sailor reported insidious onset of aching pain 3 months
prior during basic training. The pain was steadily worsening,
rated as a constant 3/10 on the DVPRS in the diffuse ante-
rior shoulder, intermittently radiating proximally to the neck
and distally to the elbow. The highest pain rating in the past
48 h was 8/10. He reported crepitus with elevation and denied
numbness or tingling.
Red and yellow flag screening was negative. Another clin-
ician evaluated the sailor at the PT clinic 6 weeks prior for
the same issue. At that time, he was diagnosed with a rotator
cuff strain, given 2 weeks of limited duty, and told to follow-
up as needed. No assessment of the cervical or thoracic spine
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 Shoulder Pain of Spinal Source in the Military
TABLE I. Outcome measures for each service member during physical therapy care.
Quick Disabilities of Arm, Shoulder, and Hand
Initial Days to MCID Discharge (score / days* )
Case 1 18.18% 15 6.82% / 25
Case 2 25% 8 11.36% / 8†
Case 3 54.5% 7 0% / 62
* numberof days since initial evaluation
† service
member did not follow-up after passing fitness test
Abbreviations: MCID, minimal clinically important difference
was documented. He reported that the rest was helpful, but the
pain returned immediately after RTD.
Clinical Findings
Upper extremity neurological screening revealed normal
strength and sensation, with a diminished brachioradialis
reflex on the right. Shoulder active and passive ROM was
symmetrical bilaterally. Pain increased during movement in
active flexion and abduction. Hand-behind-back (HBB) and
HBH increased pain, and ER MMT was strong with pain. Cer-
vical spine active ROM revealed no notable movement loss,
but anterior shoulder pain increased with overpressure in right
lateral flexion.
Cervical spine repeated movement assessment did not
improve baselines but variably produced radiating symp-
toms to the elbow, identifying the cervical spine as a pos-
sible source of symptoms. Sustained cervical retraction and
retraction–extension decreased pain with active flexion only
while holding the position.
Diagnostic Assessment and Therapeutic
Intervention
After the initial evaluation, the primary differential classifi-
cations included chemical pain, mechanically unresponsive
radicular syndrome, and cervical derangement. For further
assessment, the clinician prescribed 10 repetitions of cer-
vical retraction–extension every 2 h to 3 h with temporary
avoidance of cervical flexion and protrusion.
Within 4 days, constant pain was no longer present. The
sailor attributed this to rest, and it may represent resolution
of a chemical component due to acute irritation. Active flex-
ion and abduction demonstrated partial improvement, and
cervical right lateral flexion with overpressure no longer pro-
duced shoulder pain. Hand-behind-back and ER MMT did
not improve. Repeated cervical retraction–extension showed
no effect, so the clinician transitioned to mid-range move-
ments as a force alternative. Repeated retraction with self-
overpressure to produce mid-range extension of the lower
cervical spine abolished pain with active flexion and ER MMT
while decreasing pain with HBB.
During the next 4 days, the treatment strategy of retrac-
tion plateaued, requiring progression to end ROM with
MILITARY MEDICINE, Vol. 187, September/October 2022
Global Rating of Change
Days to MCID Discharge (score / days* )
15 +6 / 25
6 +6 / 8†
7 +7 / 62
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retraction–extension to fully resolve objective baselines. Con-
tinued rapid improvements confirmed a spinal nociceptive
driver.
Follow-up and Outcomes
After 8 days and four total visits, the sailor reported 90% over-
all sustained improvement (Table I). The clinician prescribed
a loading progression to return to function before the fitness
test, which the sailor completed with no pain or limitations.
Three months later, the sailor reported no recurrence and no
need for further treatment.
CASE 3
Patient Information
A 31-year-old AD male military police soldier presented to a
Battalion Holistic Health and Fitness (H2F) clinic. His chief
complaint was left shoulder pain preventing functional use of
the upper extremity. Inability to train bench press represented
the most meaningful functional limitation.
Pain onset occurred suddenly after supporting a heavy
beam on his left shoulder for a prolonged period 6 days
earlier. Constant 4/10 pain on the DVPRS persisted at the dif-
fuse anterolateral shoulder, the left lower cervical spine, and
the posterior arm, with intermittent radiating pain along the
forearm and into the third and fourth digits of the hand.
The soldier was evaluated by medics on scene, who
believed the shoulder to be dislocated and attempted reduc-
tion, worsening the condition. An emergency room physician
performed radiographs that were negative for dislocation and
fracture. The soldier was diagnosed with left shoulder pain
and prescribed anti-inflammatories with sling immobilization.
The soldier reported no red or yellow flags and no improve-
ments with rest, medication, or passive ROM since the injury
onset.
Clinical Findings
The H2F athletic trainer performed an initial evaluation and
utilized repeated movements to screen the cervical spine. He
noted rapid, sustained improvements in baselines with cer-
vical retraction and retraction–extension. He was prescribed
retraction–extension for 10 repetitions every 2 h to 3 h, while
temporarily avoiding cervical flexion and protrusion.
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 Shoulder Pain of Spinal Source in the Military
FIGURE 3. Repeated cervical lateral flexion in sitting. (1) Position patient in sitting with lumbar support and instruct them to sit tall; (2) patient performs
partial cervical retraction; (3) patient laterally flexes the cervical spine into the target direction as indicated; (4) self-overpressure may be applied at end range
with the ipsilateral hand to progress force.
Twenty-four hours later, the soldier followed up with PT
for further assessment. The upper limb tension test worsened
pain and demonstrated loss of motion on the affected side.
Left Spurling’s special testing was positive. Cervical spine
ROM testing revealed minimal loss of flexion and retraction,
with moderate loss of extension. Right and left rotation were
full, but left rotation worsened arm pain and produced fore-
arm pain. Left shoulder active flexion and abduction ROM
were limited to 90◦ by anterolateral shoulder pain. Motor and
sensory testing presented variable findings at each visit, with
no discernable pattern or progressive worsening.
During cervical spine repeated movement assessment, the
home exercise of retraction–extension peripheralized pain to
the hand. Using MDT, end-range sagittal movements may
reveal a lateral component requiring an off-sagittal direc-
tion. The clinician altered the direction to left lateral flexion
(Fig. 3), resulting in centralization of pain to the left acromio-
clavicular joint. Shoulder abduction, though still painful,
improved to normal limits.
Diagnostic Assessment and Therapeutic
Intervention
The first evaluation revealed a predominately spinal source of
shoulder pain. At the second visit, improvements were main-
tained, yet high irritability persisted. The clinician referred the
soldier to primary care to discuss steroidal pain management
options due to evidence for efficacy in conjunction with MDT
treatment.22–24
Following oral steroids, constant symptoms were mini-
mal, representing the resolution of the chemical component.
This allowed further mechanical assessment to reveal a direc-
tional preference for cervical left rotation. Within two more
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visits, the soldier could independently use the exercise to cen-
tralize and abolish all pain and resolve objective baselines.
The clinician prescribed 10 repetitions of cervical retraction–
extension twice per day for prevention and initiated return to
function.
Follow-up and Outcomes
Outcome measures demonstrated a clinically important
change within 7 days (Table I) and prior to oral steroid inter-
vention. After six encounters, the soldier returned to his
normal powerlifting routine with continued resolution at the
3-month follow-up.
DISCUSSION
This case series is the first reported use of repeated move-
ments to screen for spinal contributions to shoulder pain in AD
SMs. The predominant strength of our report is the demon-
stration of a systematic classification and treatment system
to attain similar results in three individuals from different
AD populations within the pragmatic context of the military
environment. Each SM received a shoulder-specific diagno-
sis after evaluation by highly trained providers before their
initial MDT evaluation, representing a missed opportunity
to optimize care. If providers and unit medics screen the
spine more thoroughly, outcomes and costs may improve
through earlier targeted treatments and a reduction in unneces-
sary imaging. Additionally, the MDT approach was founded
with the intention of promoting patient self-efficacy through
the utilization of self-generated forces for assessment and
treatment. Effective self-management strategies are associ-
ated with a more internal locus of control and heightened
outcomes when compared to patients who rely on regular ther-
apy appointments.25,26 Optimizing internal locus of control
MILITARY MEDICINE, Vol. 187, September/October 2022
 Shoulder Pain of Spinal Source in the Military
through patient empowerment may also enhance adherence
to prescribed interventions.27
Interpretation of this case series is limited by the lack of
comparison and our inability to infer causality or prevalence.
Prospective studies to determine prevalence and outcomes
within the military, in conjunction with studies investigating
the reliability of screening procedures across medical disci-
plines, may reveal the possible benefits of implementing this
approach. Another limitation is the low training level of the
treating clinicians, which may limit assessment reliability.
However, the ability to still apply the MDT approach with
successful outcomes may represent the feasibility of teaching
the screening methods to other non-certified providers. This
would present an advantage over current evaluation methods
that do not demonstrate consistent reliability, even among
specialized clinicians.28,29
The challenge of differentiating shoulder and spine pathol-
ogy is well documented. Cannon and colleagues recommend
electrodiagnostic testing to screen challenging patients diag-
nosed with shoulder impingement due to a high prevalence
of abnormal electromyography (EMG) findings.30 They con-
cluded that the presence of local pathology does not exclude
the possibility of spinal contributions,30 an important find-
ing when such pathology is often revealed through MRI or
OSTs with questionable validity.10–13,31,32 Roberson et al.
diagnosed isolated cervical radiculitis in patients with shoul-
der pain based on a radicular pain pattern, positive Spurling
or Lhermitte signs, and a negative physical examination of the
shoulder, yielding a shoulder pain of spinal source prevalence
of 4%.33 In contrast, McClatchie and colleagues demonstrated
that the spine may contribute to shoulder pain in the absence of
cervical objective findings and recommended advanced man-
ual therapy techniques to screen for a spinal component.34
Some diagnostic guidelines even suggest MRI, EMG, and
corticosteroid injections at the neck and shoulder to confirm
diagnosis when provocative testing is positive.35 Meanwhile,
MDT assessment reveals a higher prevalence of shoulder
pain of spinal source between 27% and 48%,15,36 possibly
due to revealing spinal components in those with no cervical
objective findings and positive OSTs rapidly resolving with
repeated movements.32
Once shoulder pain is identified to be of spinal source
through mechanical assessment, reductive movements reveal
a treatment strategy. Experienced MDT clinicians treating
cervicogenic shoulder pain with a directional preference
report that 37% discharge within 2 weeks and 83% by 4
weeks.36 The soldier from case 3 exceeded this time frame due
to severity, complexity, and operational constraints, yet rapid
improvements across all cases reflect previously reported
outcomes. Traditional diagnoses of our cases may be cer-
vical radiculitis, radiculopathy, or referred pain.37,38 Unfor-
tunately, there is no consensus definition for arm pain of
spinal origin,38 but usual care may require 4-6 months for
clinically important improvements, with complete recovery
ranging from 2 to 3 years.39 After resolution, symptoms may
MILITARY MEDICINE, Vol. 187, September/October 2022
recur within the next 5 years in one-third of cases,39 but using
MDT may empower the patient to use preventive measures
and manage symptoms independently should they recur.40
Identifying shoulder pain of spinal source in the AD popu-
lation may be an important step in developing an appropriate
treatment strategy to facilitate timely RTD. Further research to
determine the prevalence and impact on RTD has the potential
to reduce the extensive burden of MSI in the military.
ACKNOWLEDGMENTS
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The authors thank Rachel Hathcock, RN, CRA, and CPT Ben Campbell, PT,
DPT, for providing editorial assistance. Photographs were taken by Dr Teddy
Ortiz, PT, DPT.
FUNDING
None declared.
CONFLICT OF INTEREST STATEMENT
None declared.
ETHICAL APPROVAL
This manuscript was approved by the Brooke Army Medical Center Human
Research Protection Office.
PERMISSIONS
No copyrighted materials requiring permissions are present in this
manuscript.
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MILITARY MEDICINE, Vol. 187, September/October 2022