Red Flag Screening and Cervical Contributions

List the major categories of red flags that may present during a MSK exam

Infection

Neoplasm

Fx

Vascular disorders

Visceral disease
Neurological compromise

Mechanical Pain

Reproduced with movement and relieved with rest

Varies based on position

Systemic Pain

Constant, progressive/aggressive pain unrelated to movement

Red flag features of cancer-related shoulder pain

Unexplained weight loss

constant night pain

fatigue

history of cx (not in 5 year remission yet)

Pain not changed with movement

Fx presentation

Trauma or fall

Sudden severe pain, inability to move limb

Localized tenderness

Risk increased with osteoporosis or age

Infection and systemic disease symptoms

Fever

Malaise

Swelling/warmth (especially in lower arm)

Rapid symptom progression

Accompanied with systemic illness

Neuro red flags

Progressive wkness, B symptoms (CNS involvement), bowel/bladder dysfunction (cauda equina), gait disturbances

Require urgent referral

Why might UE symptoms arise with vascular dysfunction?

Stroke (vascular compromise) - BS, cerebellar, vertebral arteries

CV conditions (MI)

TOS

What are the symptoms of vascular presentations?

Arm heaviness, color change, CV symptoms

What is a high concern when seeing red flags?

Cancer/infection referring to shoulder (ask pt to call for PCP to get in now)

What historical findings most strongly suggest systemic disease rather than mechanical pain?

Fever, chills, night sweats

Unexplained weight loss

Fatigue

Nausea/vomiting

SOB

Dizziness

Constant pain/night pain

Pain not related to movement/position

Why must red flag screenings occur before region-specific testing?

To determine whether serious pathology is present and if referral is needed

How does unexplained weight loss combined with night pain alter exam stragety?

We should prioritize medical screening and referral (neoplasm possibility)

How does the exam change once the decision of referring out is made?

Focus on ID and documenting concerning findings rather than MSK testing to comm with healthcare provider

Why must the cervical spine be screened in patients presenting with shoulder or arm pain?

To rule out cervical pathology (they might og from here)

TOS compression, spinal pathology, neurologic compromise

If there is a consistency in neurologic compromise, what must be done?

Neuro screen (IDs nerve root involvement)

What findings are most consistent with cervical radicular involvement?

Radiating arm pain

Dermatomal sensory changes

Myotomal wkness

Altered reflexes

Symptoms change with c/s motion or compression

What is cervical radiculopathy and its symptoms?

Pinched nerve in the neck

Radiating arm pain, numbness/tingling, dermatomal sensory changes, wkness

How to test cervical radiculopathy?

Spurling, cervical rotation, distraction, ULTT (median)

How does dermatomal sensory change influence your differential reasoning?

Dermatomal sensory loss suggests nerve root involvement and tells us to hone in on c/s

Cervical pain

Radiates down arm

Follows dermatomal pattern

Changes with neck movement

Shoulder pain

Localized to shoulder and pain with shoulder movement

TOS

Vascular and/or neurologic in nature (scalene, costoclavicular, pec minor triangle)

Non-dermatomal pattern of N/T/B (neuro)

Cold/heavy feeling (vascular)

Responds to positional occlusion

What findings are concerning with TOS

Progressive neuro loss or sensation (atrophy, reflexes)

Progressive vascular compromise (lack of circulation)

T/s findings

Limited ROM (flexibility or joint play)

Postural (upper cross)

Scapular dyskinesis (motor control deficits)

Key tests during upper quarter

c/s AROM with OP (rule out cervical involvement)

t/s AROM with OP (rule in thoracic impairments)

Neuro screen (rule out UMN lesion)

RIMS (confirm contractile pathology vs neurologic wkness)

TOS and ULTT (assess positional/tension tolerance)

Vertebrobasilar insufficiency (VBI)

Dizziness with rotation, blurred vision, nausea, CV RF

5 Dsand 3 Ns associated with VBI