Cervical Radiculopathy (Cervical Radicular Pain)

Who: Usually 45–55, usually no incident at all. Age-adjusted incidence peaks at 202.9 per 100,000 in the 50–54 group.
What: Unilateral arm pain, worse than the neck pain, running below the shoulder in a dermatomal band, ± paraesthesia, numbness or myotomal weakness.
How it behaves: Aggs: cervical extension, ipsilateral rotation, sustained end-range postures, a long sit at a screen. Eases: unloading, supine, arm overhead or hand in the pocket.

The illness script in one line:

A cervical nerve root under mechanical and inflammatory load — so the arm outruns the neck, the paraesthesia maps a dermatome, and the myotome tells you which root long before a scan does.

The one thing to take from this page:

This is the mirror image of its lumbar sibling. At the lumbar end the clinical tests are weak and the management evidence is enormous. Here the clinical tests are genuinely good and the management evidence is close to empty. Do not import lumbar confidence into a neck.

[1][2][3][4][5][6]

No Australian guideline exists for this presentation. Checked live on 1 Sep 2026 against the complete ACSQHC clinical care standards index: twenty-one standards, and the only musculoskeletal ones are Low Back Pain (2022) and Osteoarthritis of the Knee (2024). No neck standard. No RACGP guideline. The nearest Australian document is the 2014 SIRA whiplash guideline — different pattern, eleven years old.

Anchored to Kjaer et al. (2017) — the Danish Health Authority national clinical guidelines, the only national guideline that names cervical radiculopathy in its title and grades it separately from non-specific neck pain [7] — and to Neck Pain: Revision 2017 [8] as the profession anchor, named and nothing more. When your educator asks "says who?", the honest answer is Denmark, on the authors' own stated low-quality evidence or consensus.

Patterns > Labels. "C7 radiculopathy" names a root. Arm-dominant, below the shoulder, dermatomal, with nothing dangerous happening to the cord names the problem you can manage this week. Check the level with your educator; don't chase it with your hands.

Five stages, in order. And here the subjective isn't just first — it is the part with accuracy attached. In 134 consecutive patients with suspected radiculopathy, assessed against a specialist diagnosis plus corresponding MRI, three history items reached high specificity and two reached high sensitivity. Then the honest sentence: none of them reached a moderate or high likelihood ratio, and the authors warn there is no gold standard for this pattern at all [9].

MAIN PROBLEM

"It's the arm. It started in the neck a couple of weeks back, but now it's the arm — down into the thumb and first two fingers, pins and needles all day. I didn't do anything to it."

Arm > neck is the sentence you are listening for, and it is one of the high-specificity items. Ask them to rank it: which would you get rid of first?

BODY CHART

• P1 is usually distal in this pattern — forearm, thumb, fingers — with a proximal P2 in the neck or scapular region. That is the flip from the mechanical neck pain page, where P1 sits in the neck itself.
• Draw the band and draw where it starts. Symptoms below the shoulder in a dermatomal strip is the line between this pattern and a PIV joint or discogenic referral.
• Mark paraesthesia and numbness separately from pain — paraesthesia is the item with high sensitivity, so its absence lowers the probability. Mark the myotome any weakness sits in.
• Check and mark the other arm. Bilateral is a myelopathy question, not a body-chart detail.
• Expect C7 first, then C6 — but map what they draw, not what you expect.

BEHAVIOUR

• Coding: usually In — intermittent, position-driven — moving to P when irritable. Morning stiffness <30 min = M; >30 min = In, and that should make you re-ask about inflammatory features.
• Aggs: cervical extension, ipsilateral rotation and side flexion, sustained end-range postures, prolonged flexion at a laptop, and any sustained arm-out task. Ask about ironing by name — "provocation when ironing" was one of the high-specificity items, and it is the same manoeuvre as a sustained arm-out reach.
  Eases: unloading, lying supine, arm overhead, walking with the hand in the pocket. Those last two are the same physiological trick, and one of them is the shoulder abduction relief sign you were already taught.
• 24-hr pattern: sustained end-range postures, a laptop day and any arm-out task build it; lying supine and the arm overhead ease it. Morning stiffness under 30 minutes = M.
• Severity: VAS 0–10 at best / at worst / right now.
• Irritability decides your dosage — all three parts. Resting symptoms present? How vigorous is the provoking activity? How long to settle? High irritability means ULNT to P1 only, no overpressure (o.p.), sliders rather than tensioners.
• Classify by predominant pain mechanism before you classify by structure. That is the framing this page borrows from the spine-related arm pain algorithm — mechanism first, level of clinical concern second, safety-netting throughout [10]. It is consensus, not accuracy data, and it is cited for structure only.

HISTORY

• Onset: usually insidious. Only 14.8% of a whole population had preceding physical exertion or trauma, and 41% had a past lumbar radiculopathy [1]. "Nothing happened" is the typical story here, not a red flag.
• Duration matters more than you think. Median time from symptom onset to diagnosis in that population was 15 days. Longer symptom duration, higher baseline NDI, multi-segment involvement and severe foraminal stenosis were the independent predictors of the persistent poor outcome group ([4], bias-corrected C-statistic 0.76, 95% CI 0.70–0.82). Single-centre and retrospective — use the shape, not the percentages.
• Previous episodes, previous imaging, previous injections or surgery, and what helped.
• What they've been told. Someone holding a report that says "C6/7 foraminal stenosis" is managing a different problem in their head from the one in their arm.

SPECIAL / SCREENING QUESTIONS

Every patient. Every time. Before you touch them.

• Myelopathy, asked directly: both hands? Dropping things, fumbling buttons, handwriting changed? Unsteady on your feet? Any bladder change? See section 4, and cross-link the cervical myelopathy page — don't learn it twice.
• CAD/VBI: the 5 D's and 3 N's. Different screen, different urgency — cervical arterial dysfunction.
• Progressive weakness. "Is the arm getting weaker?" Weakness alone is not an emergency. Deteriorating weakness is.
• The general cervical red flags carry over unchanged from the mechanical neck pain page. Screen them; don't restate them.

CLOSE THE SUBJECTIVE PROPERLY

Before you stand up, ask the three specific ones out loud: is the arm pain worse than the neck pain? Does ironing or a sustained arm-out task set it off? Does walking with your hand in your pocket ease it? Plus paraesthesia, yes or no. That is your hypothesis. Now go and test it — and remember that not one of those items reaches a +LR of 5, so you are raising a probability, not making a diagnosis.

Top three, one discriminating feature each. Rule out the dangerous one first, then split the two that actually look alike.

And three more you should be able to name:

• Cervical arterial dysfunction (CAD/VBI) — 5 D's and 3 N's, not dermatomal arm pain. Different screen, different urgency: CAD page.
• Peripheral entrapment (carpal, cubital, radial) — the distribution follows a peripheral nerve, not a dermatome, and neck movement doesn't change it. ULNT1 cannot separate them: for carpal tunnel its sensitivity ranged 0.4–0.93 and specificity 0.13–0.93, +LR 0.86–3.67 — useless as a stand-alone test for that job [12]. Map the dermatome and myotome against peripheral nerve territory instead ([13] — cited for the map, never for a number).
• Non-neuropathic spine-related arm pain — no dermatomal band, no paraesthesia, negative neurodynamics, intact neurological examination. Classify by mechanism and safety-net rather than commit [10].

Take your ranking to your educator with the discriminator attached. "Arm > neck, below the shoulder, C7 dermatome, 3 of 4 ULNTs positive, triceps jerk down, no UMN signs — so I've ranked it radicular" is a reasoning conversation. "I think it's a radic" isn't.