Cervical Spine Referral Patterns: Clinical Implications of Non-Local Pain Presentation

Cervical Spine Referral Patterns: Clinical Implications of Non-Local Pain Presentation

By:  Anna Staehli Wiser, DPT, FAAOMPT

Introduction
Pain localized between the spine and scapula—especially along the medial scapular border—is a common clinical complaint that can sometimes prove resistant to conventional thoracic interventions such as joint mobilization, massage, and therapeutic exercise. There is evidence to suggest that such persistent upper back pain may not be local in origin, but rather referred from cervical spine pathology, particularly involving intervertebral disc dysfunction. This phenomenon, initially described by Cloward and later expanded upon by Bogduk, highlights the importance of recognizing cervical referral patterns in clinical practice. This article examines the underlying mechanisms and clinical implications of cervical spine referral to the scapular and upper thoracic region, underscoring the need for accurate diagnosis and targeted cervical intervention when localized treatments fail.

Cervical Discogenic Pain and Referral Patterns
The concept of referred pain from cervical disc pathology was first described by Dr. J. Cloward in 1959. Through the stimulation of cervical intervertebral discs using intradiscal needle insertion, Cloward demonstrated consistent patterns of pain referral, most notably to the medial border of the scapula1. This phenomenon, now known as the Cloward Sign, remains a foundational observation in understanding cervical-thoracic referred pain.

Building upon Cloward’s findings, Bogduk and colleagues provided a more detailed anatomical and neurophysiological basis for cervical referral patterns. Their work illustrated that each level of the cervical spine—particularly from C4 to C7—produces a distinct and reproducible distribution of referred pain2. These patterns often extend into regions traditionally attributed to thoracic origin, such as the trapezius, scapular border, and posterior shoulder girdle.

Clinical Relevance and Diagnostic Considerations
The clinical implication is significant: patients presenting with persistent scapular or posterior shoulder pain may be misdiagnosed if the cervical spine is not thoroughly assessed. Cervical dysfunction, especially discogenic sources, may not always manifest with classic neck pain, further complicating diagnostic clarity.

Effective evaluation includes a thorough cervical spine assessment, including range of motion testing, neural tension signs, and provocation testing.  Segmental mobility assessment and palpation can help localize the source of pain.

Conservative Management Strategies
Once cervical involvement is suspected or confirmed, therapeutic focus should shift accordingly. Mechanical diagnosis and therapy (MDT)-based exercises, such as cervical retraction and extension movements, have demonstrated efficacy in alleviating symptoms associated with cervical discogenic pain3. These movements promote centralization of symptoms and restore normal disc mechanics.

Self-care approaches, including postural correction, ergonomic adjustments, and cervical stabilization exercises, can further support long-term resolution of symptoms.

Example of cervical retraction exercise: 

Example of cervical extension exercise:

Conclusion
Referred pain from cervical spine pathology is an important differential diagnosis in cases of persistent upper thoracic and scapular pain. The pioneering work of Cloward and the mapping studies of Bogduk underscore the importance of understanding cervical referral patterns. A high index of suspicion and targeted cervical interventions can often resolve symptoms that seem unresponsive to thoracic-focused treatment.

 References

1. Cloward JF. Cervical discography: A contribution to the etiology and mechanism of neck and arm pain. The Annals of Surgery. 1959;150(6):1052-1064.

2. Bogduk N, Marsland A. The cervical zygapophysial joints as a source of neck pain. Spine (Phila Pa 1976). 1988;13:610-617.

3. Mckenzie RA, May S. The Cervical and Thoracic Spine: Mechanical Diagnosis and Therapy. Spinal Publications; 2000.