Radiating pain accompanied by motor or sensory change, particularly below the elbow, strongly suggests a neurologic etiology of shoulder pain. The patient's description of the pain often is misleading because the shoulder joint has a movable fulcrum, which may be the site of a secondary irritant rather than a primary site. The pain may originate medially in the spinal cord or as far distal as the axillary border of the scapula. Precise identification usually requires myelography or discography in addition to a routine careful investigation. Included in this group are spinal cord tumors, extruded intervertebral discs, foraminal root compression syndromes, scalene and cervical rib syndromes, and various clavipectoral compression syndromes. The most confusing clinical picture results from nerve and vascular involvement, such as with cervical ribs, first rib abnormalities, or scalene muscle disturbances. Identification of specific characteristics of neural and vascular pain may help in the differential diagnosis of these lesions. Persistent neurologic deficit usually requires surgical treatment. Traumatic lesions of the plexus and individual nerves represent obvious causes and also may require surgical measures.