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.