You’ve got shoulder pain that’s keeping you up at night, and it isn’t going away. Your primary care clinician refers you to an orthopedic surgeon. You assume you’re headed for shoulder surgery.

Then the surgeon asks about your … neck?

It’s the right question, said orthopedic surgeon Dr. Mike Kissenberth — and you shouldn’t sign up for shoulder surgery unless your surgeon has asked it.

Kissenberth is a clinical professor of orthopedic surgery and specializes in complex reconstructions of the shoulder, elbow and knee at Novant Health Orthopedics & Sports Medicine in Greenville, South Carolina, where he also serves as the senior vice president of orthopedics for South Carolina.

On a daily basis, he sees patients struggling with shoulder pain — and roughly 1 in 3 walk away with a neck diagnosis.

Here’s what he wants you to know if you’re navigating shoulder pain.

1. Overlapping neck and shoulder issues are ‘exceptionally common.’

Your neck and shoulder aren’t just joined by bones, muscles, and tissue — they share nerve pathways so tightly linked that your brain may not always identify the true source of an injury.

If your shoulder hurts, you could have:

• A shoulder problem only
• A shoulder problem and a neck problem
• A shoulder problem causing symptoms in your neck
• A neck problem causing symptoms in your shoulder

Sound confusing? It can be, even for surgeons, Kissenberth said.

To be thorough, Kissenberth said, surgeons should evaluate “the joint above and the joint below” the joint causing pain. For example, “if you’re seeing a knee problem, evaluate the hip — and if you’re seeing a shoulder problem, make sure the cervical spine (neck) is evaluated.”

As a patient, it may seem unusual if your surgeon starts asking about your neck when you’re there for shoulder pain — but overlapping neck and shoulder issues are “exceptionally common,” so it’s important to investigate both areas, Kissenberth said.

What to do: If you’re seeking a medical opinion on your shoulder pain, ask your surgeon: “Are you also evaluating my cervical spine? Could any of my symptoms be coming from my neck rather than my shoulder?”

2. The first and most important part of examining a patient starts with a thorough history and asking appropriate questions — not just looking at imaging.

You may enter the surgeon’s office with imaging showing a torn rotator cuff, assuming surgery is next.

But surgeons “don’t just treat X-rays and MRIs, but must focus on the patient and use the studies as part of the clinical algorithm,” Kissenberth said. (For more on what a clinical algorithm is and how it helps surgeons, keep reading.)

For example, more than one-fourth of people in their 60s and over half of people in their 80s have a rotator cuff tear — but many don’t have a single symptom from that tear. In those cases, surgically repairing the rotator cuff could create risk and no benefit.

Instead of entering the room with an already-formed plan, a patient-centered surgeon will do the following:

• Ask questions, like when your symptoms started and what makes them worse. They should also ask about your age, other medical issues, and your job and hobbies.

This is called “taking a history,” and it helps them narrow in on potential causes for your problem. For example, being over 40, working a job with repetitive arm motion and lifting, and playing an arm-centered sport like tennis or baseball all increase your risk of shoulder injuries.

• Have you point to what hurts. Each type of orthopedic problem has a specific set of symptoms affecting a specific area. For example, a rotator cuff injury often causes a dull ache that worsens at night and could make it difficult to reach behind your back — but it shouldn’t cause pain below the elbow or down your entire arm, weakness, or numbness and tingling. Try to be as specific as possible about what you feel and where you feel it.

• Perform a physical examination by asking you to lift, rotate, extend, and move your arms and shoulders in specific patterns. They will also perform a physical examination on you as you do certain exercises.

• Order imaging if needed. Even if you already have imaging, your surgeon may want additional X-rays or an MRI of the neck and shoulder area.

What to do: Don’t agree to surgery if your surgeon hasn’t taken your history, examined you and explained why surgery is the right next step. If they request additional imaging, get it done.

3. Surgery is usually not the first step.

If you’re having weakness, a sudden loss of function, like bowel or bladder problems, or difficulty balancing — all of which are neurological warning signs — you may require urgent surgery.

But outside of those circumstances, a surgeon isn’t likely to recommend surgery as your first step.

Roughly 80% of the time, conservative treatments like physical therapy, injections and working with pain medicine specialists are enough to manage neck and shoulder pain without surgery.

If these treatments don’t improve things, “we proceed with surgical intervention if indicated,” Kissenberth said.

What to do: If you’re having weakness or a sudden loss of function (like bowel or bladder problems or difficulty balancing), tell your primary care provider immediately, as you may require more urgent surgery. Otherwise, prepare yourself to work with a physical therapist for 8-12 weeks and to possibly see a pain specialist.

4. You may see more than one surgeon.

When Kissenberth suspects that a patient’s neck might be causing their shoulder problems, he often sends them to a spine specialist for further evaluation. (This makes sense, as the neck is the top part of the spine).

The reverse is also true: Spine specialists send patients to Kissenberth to examine their shoulders.

He understands that this back-and-forth can be frustrating: “Patients just want to be fixed. They're hurting. You hate to delay them,” Kissenberth said. “But if I don’t know exactly what the problem is, it’s not responsible to do surgery.”

He encourages these patients to take a bigger picture view: They want to be a success story.

“The last thing we want to do is operate on your shoulder when your problem is really an underlying neck condition,” Kissenberth said. “If we didn't ask those questions and go ahead and operate on them anyway, then check in four months later after they’re done with their shoulder surgery recovery — the last thing you want is for the patient to say, ‘I’m not any better.’ And you have to say, ‘Oh! Turns out you had a neck problem.’”

A careful surgeon will investigate every possible cause for your pain before ever scheduling a surgery.

And if you have more than one issue causing your pain, your surgeon will likely work with another surgeon to decide the best order of possible treatments.

What to do: If your surgeon sends you to another surgeon, they aren’t pushing you off — they’re trying to understand the cause of your problem and make the best possible plan to fix it.

If you have shoulder pain that isn't improving, you deserve a thorough evaluation. Start with your primary care provider — they can assess your symptoms and refer you to the right specialist.