Cervical Radiculopathy: Arm Pain That Starts in the Neck

Arm pain that runs from the neck into the shoulder, down the arm, and sometimes into a specific finger or two has a specific clinical name: cervical radiculopathy. It's the upper-extremity equivalent of sciatica — a nerve root irritated where it exits the spine, producing pain, numbness, weakness, or all three in the dermatome and myotome that nerve serves¹.

It's also one of the most common reasons we see new patients in their forties and fifties at Boreal Spine & Sport. The presentation is distinct enough that the diagnosis is usually clear on history and exam, and the prognosis with conservative care is generally good — which is the part patients most want to know.

How it presents

Cervical radiculopathy almost always shows up with a recognizable pattern:

• Pain that travels from the neck through the shoulder and down the arm.
• The arm pain is often more severe than the neck pain itself.
• Specific finger involvement — index and middle finger (C7), thumb (C6), or pinky and ring finger (C8) — is a strong clue to the level.
• Symptoms are often worse with certain neck positions, especially extension and rotation toward the painful side.
• Lifting the affected arm overhead and resting the hand on top of the head sometimes relieves the pain — the shoulder abduction relief sign, a fairly specific finding for radiculopathy.

Weakness, when present, follows the myotome of the affected nerve root: biceps and wrist extensors for C6, triceps and finger extensors for C7, finger flexors for C8.

What causes it

In adults under about 50, cervical radiculopathy is most often driven by a soft disc herniation compressing the exiting nerve root. In adults over 50, it's more often driven by foraminal stenosis from age-related degenerative changes — bony narrowing of the space the nerve travels through. Both produce a similar clinical picture, and both have surprisingly similar prognoses with appropriate conservative care².

What the imaging adds — and doesn't

The same imaging caveats apply here as in the lumbar spine. We covered this in our piece on the cervical spine and in the cervicogenic headache piece: degenerative findings on cervical MRI are extremely common in asymptomatic adults — disc bulges in 50% of asymptomatic 40-year-olds, foraminal stenosis in a meaningful fraction by age 50³.

For a patient with a clinically clear radiculopathy, MRI confirms the level when symptoms haven't responded to conservative care or when surgical or injection-based options are being considered. For a patient with a vague upper-extremity ache that doesn't fit a dermatomal pattern, MRI is far more likely to mislead than to clarify.

What conservative care actually does

The natural history of cervical radiculopathy is favorable. In a well-known cohort study, around 75% of patients with new cervical radiculopathy improved substantially without surgery over the first 4–6 months⁴. That doesn't mean conservative care is unnecessary — it means the comparison for any treatment is "what would have happened anyway," which is a fairly good baseline.

The treatments with the best evidence for accelerating that recovery: cervical spine manual therapy (mobilization and selectively manipulation), neural mobilization, scapular stabilization exercise, and a structured graded loading program for the cervical and shoulder girdle musculature⁵. Cervical traction has more equivocal evidence — likely useful in a subset of patients, not universally.

Cortisone injections (epidural or selective nerve root) and surgery have a role for patients whose symptoms don't respond to appropriate conservative care or who develop progressive neurologic deficit. They aren't first-line for the typical presentation.

What we look for at the first visit

The first visit for a suspected cervical radiculopathy is mostly about a careful exam: a clear neurologic screen, provocation testing (Spurling's, upper limb tension testing), assessment of the cervical and upper thoracic motion segments, and a look at the scapular stabilizers, which are routinely deconditioned in chronic neck-and-arm-pain patients. Imaging is ordered if red flags are present, if there's progressive neurologic deficit, or if conservative care fails an adequate trial.

From there, the rehab plan tends to look familiar to anyone who's been through Boreal's process: a manual therapy component to create movement, a loading component to keep it, and an education component to set expectations. There are no bad neck exercises, only too much too soon — and for a freshly irritated nerve root, the dose curve is unforgiving in the first two weeks.

The takeaway

Arm pain that follows a clear pattern and starts in the neck is usually a tractable problem. Most cases improve over weeks to months with conservative care. The exam, not the MRI, drives the early decisions. And the patients who do best are the ones who get a structured plan early instead of cycling through passive treatments and waiting to see what happens.

References

1. Childs JD, Cleland JA, Elliott JM, et al. Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9):A1–A34.
2. Wong JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature. Spine J. 2014;14(8):1781–1789.
3. Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015;40(6):392–398.
4. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy: a population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117(2):325–335.
5. Thoomes EJ, Scholten-Peeters W, Koes B, Falla D, Verhagen AP. The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review. Clin J Pain. 2013;29(12):1073–1086.

Author: Dr. Michael Minenna D.C., B.Sc., SFMA, FMS — Boreal Spine & Sport, Winnipeg, Manitoba.