In the diagnosis and treatment of neck and shoulder pain, the most common is the soft tissue damage pain, but the neck and shoulder infectious diseases and related to the infection of residual neuralgia, neck and shoulder primary and metastatic tumors, mainly reflected in the neck and shoulder pain of systemic diseases, central pain, cardiothoracic and other visceral diseases caused by the neck, shoulder and upper extremity referred to pain is also not uncommon, and psychological pain is easy to be overlooked at the initial diagnosis. In order to reduce the misdiagnosis, this article outlines the diagnostic points of common neck and shoulder pain diseases other than acute bone and joint injuries. First, soft tissue damage neck and shoulder pain 1, extravertebral soft tissue damage neck and shoulder pain, neck and shoulder after acute injury, viral infections or febrile diseases caused by soft tissue damage, soft tissue chronic strain, so that the soft tissues to produce active or potentially aseptic inflammation of the pathological basis of the former caused by chronic pain in the neck and shoulder, the latter can be activated due to fixed posture for a longer period of time, slight twisting, wind, cold, dampness, cold, and other triggers. The latter can be activated by triggers such as prolonged fixed posture, mild twisting, wind, cold, dampness, cold and flu, etc. Sterile inflammation makes the pain worse or sudden. Neck and shoulder anatomy and physiology and function are closely linked, generally speaking, the neck soft tissue damage must have the same side of the shoulder soft tissue damage, only the former pain and pressure points often become dominant, the latter is potential; on the contrary, shoulder soft tissue damage must be at the same time with the neck and supraclavicular fossa of soft tissue damage. In addition, chronic soft tissue damage in the lumbosacral region and the back caused by muscle spasm or contracture can cause secondary damage to the soft tissue of the neck and shoulder. Depending on the site of active aseptic inflammation and the extent of involvement, the clinic may show different pain patterns. Diagnostic points: (1) pain characteristics: chronic people feel soreness and swelling with tightness in the neck and shoulder, although difficult but still tolerable. In acute cases, the pain is severe and intolerable. The pain can be reflected in one or both sides of the neck, neck and shoulder, neck and shoulder, back of the neck, back of the shoulder, suprascapular angle, suprascapular, infrascapular, infraspinatus, infraspinatus, infraspinatus, anterior shoulder, tendon sheath of the long head of the biceps brachii muscle, lateral elbow, medial elbow, fingers, ulnar side of the palm, and in some patients, there is a similar nerve radicular pain. (2) Medical history: detailed inquiries should be made about occupation, history of acute injury to the neck and shoulder, history of chronic strain such as prolonged head bowing, and history of chronic low back pain. (3) Patients may be accompanied by symptoms of cervical sympathetic disorder and insufficient blood supply to the vertebral artery, such as dizziness and vertigo, blurred vision, sudden collapse, tachycardia or bradycardia, abnormal sweating of the head, face, and upper limbs, abnormal sensation, elevated blood pressure, cold limbs, tinnitus and earache. (4) Obvious pressure and pain points in the neck and shoulder, and tense and sensitive fascial strips can be touched. (5) The range of motion of the neck, shoulder and neck-shoulder region may be restricted. Symptoms are alleviated after pressure-pain points are pushed and manipulated, and the range of restricted motion is improved. Most of the pressure pain points are treated well by intensive silver pinning. (6) Hoffmann’s sign is negative. Skin sensation was normal. (7) Blood tests are normal. (8) X-ray film can be seen in the cervical spine sequence changes, such as cervical spine physiological anterior protrusion increased, anterior protrusion degree decreased or disappeared, anticorrosive, lateral protrusion, “S”-shaped changes, scapular displacement, etc., which the vast majority of the cervical and shoulder pain is caused by soft tissue pain secondary to muscle spasm or contracture, is the result of the series of compensatory regulation of muscle mechanics. In addition, a series of degenerative changes in the cervical spine, unless the proliferation of bone lips obviously protruded into the spinal canal, and has compressed the spinal cord and induced the spinal canal epidural fat and other tissues in the occurrence of aseptic inflammation, it should not be considered as the cause of neck and shoulder pain. 2, within the spinal canal or inside and outside the spinal canal mixed soft tissue damage cervical shoulder pain cervical disc protrusion or bulging backward, the vertebral body of the posterior upper and lower margins of the bony lip hyperplasia, calcification of the posterior longitudinal ligament, from the front to the spinal cord to produce compression; vertebral plate hyperplasia, hyperplasia of the small joint synchondroma cohesion, the ligamentum flavum hyperplasia hypertrophy or ossification of the factors from the back to the spinal cord compression, resulting in stenosis of the vertebral canal, usually infringing on the vertebral fasciculus, resulting in the vertebral fascicular sign, i.e. “spinal cord cervical spondylosis”, which is usually painless. Only when damage occurs to the epidural soft tissues, resulting in aseptic inflammation or combined with extradural soft tissue damage, spinal cord compression and neck and shoulder pain coexist, i.e., mixed intradural or extradural soft tissue damage with degenerative protrusions. After spinal cord decompression and interbody fusion fixation through anterior cervical approach for painless “spinal cord-type cervical spondylosis”, if the spinal cord does not undergo irreversible degeneration, the symptoms of vertebral fascia involvement will be relieved immediately or gradually until they disappear. However, for patients with spinal cord compression with neck and shoulder pain, after anterior decompression surgery, the symptoms of spinal cord compression will be relieved and disappear, but the pain may not be improved, and it is often necessary to treat the pressure points, and if necessary, it is necessary to go through the posterior cervical route to get rid of the compression factors of the spinal cord at the back of the spinal cord, to loosen the soft tissues in the spinal canal, and to clear the extradural fat, or else it will be difficult to cure the intractable neck and shoulder pain. Diagnostic points (1) Pain characteristics: intractable soreness, numbness and swelling pain in the neck and shoulder, the back of the neck and shoulder and the upper limbs, often without typical radicular pain, and it is difficult to sleep in severe cases. (2) There are spinal cord compression symptoms, such as inflexible hand movements, weakness of grip, unsteady gait, numbness of upper and lower limbs, increased muscle tone, hyperreflexia, positive Hoffmann’s sign and/or Babinski’s sign, patellar clonus, ankle clonus and so on. (3) Conspicuous or no obvious pressure points in the neck and shoulders. (4) Normal blood test. (5) MRI of the cervical spine suggests anterior or anterior-posterior compression of the spinal cord, and signal changes of the spinal cord at the place of compression. (6) After spinal cord decompression and implant fusion fixation via anterior cervical approach, the spinal cord compression symptoms are relieved or disappeared, while the neck and shoulder pain still exists, it is necessary to consider the existence of aseptic inflammation in the vertebral canal or inside and outside of the vertebral canal, which is also a soft tissue damage. Infectious diseases of neck and shoulder and neuralgia related to infection 1, acute septic infection, acute septic infection of neck and shoulder bones and joints, soft tissues, there are many potential or skin infection foci. Diagnostic points (1) pain characteristics: acute onset, sudden and persistent pain centered on the infected foci, local refusal to touch and press, such as joints infected with refusal to move, and slight passive activity of the joints that is severe pain. (2) Localized redness, swelling, elevated skin temperature. (3) Fever, severe cases may have sepsis manifestations. (4) Significant increase in total white blood cell count and neutral white blood cell count, and accelerated blood sedimentation. (5) Pathogenic bacteria can be found in the smear of lesion puncture fluid, and the culture can be positive. (6) Blood culture may be positive. (7) X-ray or CT film: bone infection is usually seen around 10 days of osteoporosis, bone trabecular disorders, speckled osteolytic foci, and new bone formation can be seen with continued development. 2, neck and shoulder tuberculosis Diagnostic points (1) pain characteristics: insidious onset, mild pain, swelling of the affected bones and joints, early intermittent and then persistent dull pain, when the lesion stimulates the nerve root or nerve trunk pain aggravates, radiating up and down to the lesion. (2) There are mostly primary tuberculosis foci in the lungs. (3) It is mostly accompanied by toxic symptoms such as low fever and afternoon hot flashes. (4) Blood sedimentation is accelerated in the active stage. (5) In the later stage, there may be cold abscess or sinus tract formation with anhydrous caseous pus. (6) Pus smears and cultures may find acid-resistant bacilli. (7) Imaging examination: X-ray film, CT film, MRI early for osteoporosis. In the later stage, there is joint destruction and dead bone formation. 3, acute herpes zoster Diagnostic points (1) pain characteristics: acute onset, burning pain in the neck and shoulders, stinging pain with skin tearing sensation. 3 ~ 4 days gradually aggravated. The vast majority of pain lasts 2~3 weeks and gradually decreases to disappear. A small number of postherpetic neuralgia remains. (2) Neck and shoulder herpes: herpes can appear at the same time with neck and shoulder pain, or appear 1~2 days after the pain, or herpes first, followed by severe neck and shoulder pain. (3)There is often generalized discomfort, fever, headache, which may be accompanied by itching and gastrointestinal dysfunction. (4) Increased protein and cell count in cerebrospinal fluid (CSF). 4.Post-herpetic neuralgia Acute postherpetic neuralgia involved nerve demyelination, progressive crusting and fibrosis, in which large A fibers are more involved than small C fibers, causing chronic intractable neck, shoulder and upper extremity pain or trigeminal neuralgia. Diagnostic points (1) pain characteristics: persistent neck, shoulder, upper limb or trigeminal burning pain, Chen occurred to aggravate the tearing pain, months to years not to heal. (2) History of acute herpes zoster. (3) Above 60 years old is common. (4) Decreased or absent sense of touch, abnormal sensation, and hypersensitivity to pain in the affected dermatomes. (5) Skin crusting, loss of pigmentation, whitish-brown mottled or maculopapular rash. 5.Brachial plexus neuritis The etiology is unknown and may be related to infection and autoimmune reaction. Diagnostic points (1) pain characteristics: cut-like or burning pain, often radiating to the upper limbs, pain is persistent or paroxysmal exacerbation. (2) Acute or subacute onset after cold or influenza. (3) Weakness or paralysis of the scapular girdle muscles and upper limb muscles. Tendon reflexes are weakened or absent. (4) Sensory disturbances and vegetative symptoms are rare. (5) Most of the symptoms gradually disappear after 2~4 weeks and can be completely recovered, but a few of them may be delayed for several months or years and may leave myasthenia. Benign bone tumor and tumor-like disease Benign bone tumor such as osteoma, osteoid osteoma, osteochondroma, osteochondroma, chondroblastoma, etc.; Tumor-like disease such as isolated bone cyst, aneurysmal bone cyst, osteofibrous dysplasia, eosinophilic granuloma, bone hemangioma. Diagnostic points (1) Pain characteristics: long-term existence can be painless, some due to other diseases or traumatic injuries found by chance after taking films. Enlarged mass can cause local pain and discomfort by stimulating the surrounding tissues. (2)Slow onset, localized mass may be palpable. (3) Benign tumors of the cervical spine may cause corresponding symptoms if they compress the spinal cord. (4) Benign tumors with destruction of bone structure and tumor-like lesions are prone to fracture due to trauma. (5) Blood test is normal. (6) Imaging examination: X-ray, CT, etc. for benign tumor or tumor-like lesion manifestation. (7) Tissue biopsy if necessary to confirm the diagnosis. 2.Primary malignant bone tumor Osteosarcoma, parosteal osteosarcoma, Ewing’s sarcoma, chondrosarcoma, chordoma, myeloma, etc. can occur in the neck and shoulder bones. Diagnostic points (1) Pain characteristics: with the development of the disease, the pain is gradually aggravated, from intermittent vague pain to persistent severe pain. (2) Swelling can often be palpated in the neck and shoulder region, which develops rapidly and has obvious pressure pain. (3) There may be systemic symptoms in the early stage, such as low-grade fever and progressive emaciation. (4) There are mostly anemia, leukocytosis, and rapid blood sedimentation. Blood alkaline phosphatase is increased in osteosarcoma, the positive rate of urinary catecholamines in Ewing’s sarcoma is as high as 90%, and urinary Bence Jones protein is increased in myeloma patients. (5) Imaging examination: X-ray, CT, MRI have special manifestations such as bone destruction of corresponding malignant bone tumors. (6) Isotope scanning has specific nuclide concentration changes. (7) Pathologic examination has the value of confirming the diagnosis. 3.Primary bone tumors with malignant tendency Osteoblastoma and giant cell tumor of bone are mostly benign, but some of them can be transformed into malignant. (1) Characteristics of pain: the pain is generally light, mostly localized hidden pain, and a few may have radicular or dry neuralgia. If transformed into malignant pain increases. (2) Generally no systemic symptoms, the growth of the mass is slow. If transformed into malignant, the growth of the mass is fast, and there may be systemic symptoms. (3) Blood biochemistry and sedimentation are normal in benign cases, but blood sedimentation may be accelerated and anemia may occur in malignant cases. (4) The changes of X-ray and CT are fast in malignant transformation and have the characteristics of malignant tumor. (5) Pathological examination has diagnostic value. 4. Bone metastatic tumor Diagnostic Points (1) Pain characteristics: early hidden pain, gradually aggravated and fast development, especially at night, and cannot be relieved by general painkillers. (2) Most of them have the history of breast cancer, lung cancer, thyroid cancer and other malignant tumors, or no history of malignant tumors. (3) Most of them have systemic reaction. (4) Accelerated blood sedimentation. (5) X-ray film, CT film or MRI suggests osteolytic bone destruction, and periosteal reaction is mostly insignificant. (6) Nuclide scan with abnormal changes. (7) Tissue biopsy, if necessary, has the value of confirming the diagnosis. 5.Cervical spinal intravertebral tumors can be divided into extramedullary intradural, epidural and intramedullary tumors according to the positional relationship between the tumor and the spine and dura mater. The common tumors are chordoma, nerve sheath tumor, neurofibroma, glioblastoma. Diagnostic points (1) Pain characteristics: radicular pain of the involved nerves, mostly paroxysmal, aggravated by coughing and defecation. The pain is aggravated at night and in lying position. (2) Symptoms of cervical spinal cord compression or invasion. Such as spinal cord hemisection syndrome or spinal cord transverse damage sign. (3) Increased CSF protein content and positive Queckenstedt’s test. (4) MRI examination has special value. 6.Superior sulcus syndrome caused by apical lung tumor Diagnostic points (1)Pain characteristics: lesions often invade the C8 and T1 nerve roots, the neck and ulnar side of the upper limb show persistent pain, progressive aggravation, mostly severe pain, burning pain, tearing pain. (2) Intrinsic muscle atrophy of the hand. Reduced or absent sensation on the ulnar side. (3) Cervical sympathetic nerve involvement may lead to Horner’s syndrome. (4) EMG with denervation potentials. (5) X-ray, CT, or M RI reveals a tumor at the tip of the lung. (6) Tumor biopsy is mostly carcinoma of the lung tip or metastatic carcinoma. 7.Neck and shoulder peripheral nerve tumors Primary tumors of cervical plexus and brachial plexus include multiple neurofibromas, nerve sheath tumors, isolated neurofibromas, malignant nerve sheath tumors and so on. Secondary tumors and invasion by malignant tumors of peripheral tissues are also common. Diagnostic points (1) Pain characteristics: often persistent pain, progressive aggravation of traumatic pain and burning pain. (2) Progressive sensory abnormalities, severe sensory and motor loss. (3)Palpable mass in the neck and shoulder with obvious tenderness. (4) The mass is visible on X-ray and CT examination. (5) Pathology has diagnostic value. Fourth, the neck and shoulder pain caused by systemic diseases 1, rheumatic fever, a few first in the cervical spine and shoulder joints often bring some difficulties in early diagnosis. Diagnostic points (1) pain characteristics: acute onset of the majority of the affected joints red, swollen, hot and painful; a small number of insidious onset, joint pain. (2) The age of the first onset of disease is mostly 5~15 years old. (3) Fever, excessive sweating, general malaise, and rapid pulse are common at the onset of the disease. After the body temperature is normalized, the pulse still accelerates, showing the phenomenon of temperature-pulse separation. (4) Most have a history of upper respiratory tract infection before onset. (5) Acute arthritis symptoms mostly subside within 3 weeks, and the function can be restored to normal, but it can recur. (6) There is often carditis and skin damage, such as annular red shifts or subcutaneous nodules. (7) A few have manifestations of central and peripheral nervous system damage. (8) Accelerated blood sedimentation, leukocytosis, positive ASO and C-reactive protein (CRP) in the acute phase. (9) Pharyngeal swab culture may be positive for hemolytic streptococcus in the acute phase. (10) Electrocardiogram and cardiac X-ray may be altered. Rheumatoid arthritis is difficult to diagnose in the early stage in a small number of patients who start to suffer from one side of the neck, shoulder and elbow joints. Diagnostic points (1) Pain characteristics: shoulder and elbow joint swelling, neck and shoulder pain, aggravated by activities, a few have neuritis symptoms. (2) Most of the onset of disease is insidious, a few acute onset. It is often accompanied by fatigue, low-grade fever, hand numbness, and morning stiffness or rigidity of the affected joints. Joint deformity and dysfunction may remain. (3) The heart may be involved without clinical symptoms. (4) Juvenile rheumatoid arthritis (Still’s disease) should be considered in those who develop the disease before the age of 16 years with high fever, enlarged lymph nodes, hepatosplenomegaly, or complicated pericarditis. (5) During the active phase, the blood sedimentation is accelerated, C-reactive protein is increased, and more than 80% of rheumatoid factor (RF) is positive. (6) Synovial fluid is cloudy or there is incomplete mucin precipitation. (7) There are typical X-ray features in the later stage: osteoporosis, narrowing of the joint space, and multiple small capsule-like destruction under the joint surface. 3.Ankylosing spondylitis A few patients start from cervical arthritis in the early stage and develop neck, shoulder, back and upper limb pain. Diagnostic points (1) pain characteristics: insidious onset, the beginning of interstitial pain, months or years after the emergence of persistent pain, rest, especially at night aggravated, relieved after activities. (2)The onset of the disease is mostly around 20 years old, and the incidence rate of men and women is 6~7:1. (3)The cervical vertebrae protrude posteriorly or laterally, and the head may be in a fixed forward-flexed position, with progressive spinal ankylosis, and there are different degrees of hunchback. Thoracic expansion is progressively limited. (4) Blood sedimentation is accelerated during the active period, and 95% are positive for HLACB27. (5) X-ray manifestation: early osteoporosis, with the development of the disease can appear “square vertebrae”, the formation of intervertebral bone bridges, bamboo-like ankylosis. V. Central pain 1, thalamic pain and pseudothalamic pain Thalamic pain can occur when the thalamic ventral posterior lateral nucleus is damaged; cerebral peduncle, pontine, medulla oblongata and thalamus near the damage can occur pseudothalamic pain. Diagnostic points (1) pain characteristics: often for one side of the body spontaneous burning pain, tingling, there are a few for the head, face and upper limb pain, the onset of intolerable. Brain stem damage may appear ipsilateral neck and contralateral limb pain. (2) Some have a history of brain trauma or surgery. It is not uncommon to occur a few weeks to 2 years after a cerebrovascular accident. (3) It is accompanied by nociceptive alienation, hyperalgesia or hypersensitivity, and hypesthesia to touch. Positive neurologic signs in the affected area are present. (4) MRI may show damage to the thalamus or brainstem. 2. Cervicospinal Cavitation Syndrome Diagnostic Points (1) Pain characteristics: often unilateral scapular girdle and hand present periodic diffuse dull pain, sometimes severe burning pain. (2) Early atrophy of intrinsic muscle weakness in the hand, with upward progression. Upper extremity tendon reflexes disappear. (3) Impaired pain and temperature sensation and presence of other sensations characterize the disease. (4) MRI of the neck may suggest the existence of a cavity in the spinal cord. Sixth, cardiothoracic organ disease caused by neck and shoulder pain angina pectoris or myocardial infarction patients sometimes feel neck and shoulder pain, and to the upper limbs or hand radiation, especially the left upper limb medial, clinical attention should be paid to identify. 1, angina pectoris mostly in emergency situations, dull pain in the precordial area, and there is pressure heavy tightness; shortness of breath, sweating, nausea and ergonomics; rest and nitroglycerin can be taken to relieve the symptoms. Electrocardiogram often suggests ST segment lowering, if necessary, coronary angiography to help diagnosis. 2.Cardiac infarction is a common cause of cardiac death and disability. Its ferocious, according to the angina method of treatment is ineffective, often need to use morphine to relieve pain; electrocardiogram has typical changes, such as the emergence of pathologic Q wave, STCT dynamic changes, etc.; myocardial enzyme spectrum is abnormal; radionuclide scanning is abnormal. VII, psychological pain This is a problem that deserves attention, it can be alone or coexist with other non-psychological pain diseases. In ICDC10, it is called “pain syndromes without a specific organic etiology”. The American Psychiatric Association renamed it “idiopathic pain disorder” in DSMC IIICR. The diagnostic criteria are as follows: A. The primary disorder is preoccupation with pain for at least 6 months. B. Either (1) or (2): (1) There is no organic pathology or pathophysiologic mechanism (e.g., physical illness or injury) that can explain the pain after an appropriate examination. (2) If the organic disease in question is present, the pain complains of or causes impairment of social or occupational functioning to a much greater extent than could be caused by the organic disease. In the examination and diagnosis of patients with pain, among patients who cannot find organic lesions by repeated necessary examinations, whose personality remains intact, who are socially well-adjusted, who are self-aware of their disease, and who take the initiative to seek treatment. The disease should be considered in the following cases. (1) Pain that is vague, with an indeterminate and variable location. Most complain of cephalalgia, head and neck pain, anterior trunk pain, chest and upper extremity pain, and a few complain of external genital pain. (2) Some patients complain of generalized pain, usually more than two pain sites, mostly dull pain, often non-pulsatile, and when aggravated can be pulsatile. (3) Fixed persistent pain in a particular area, with a peculiar and very unpleasant feeling of constriction, and the patient has a peculiar thought process. (4) Difficulty in sleeping with the pain, but not waking up from sleep with the pain. (5) There is delusional pain or hallucinatory pain. (6) There is suspicious pain, accompanied by anxiety, nervousness and inexplicable fear. Although repeated and comprehensive examinations have been conducted in several hospitals, and medical personnel have told them that there is no organic disease, the patient firmly believes that he has a suspicious disease that has not been detected. (7) Often due to external suggestion or self-suggestion of the onset of a sudden loss of function of one side of the limb (no organic disease), the other part of the pain, mostly the left side of the pain, can be cured by suggestive methods, mostly hysteria. (8) Chronic pain is often accompanied by depression manifestations such as frustration and depression. (9) Onset in childhood, aggravated after puberty. Women with normal menstruation, excluding menopausal syndrome. (10) Those with similar family history.