Systemic malignancy can be manifested by musculoskeletal complaints. We review the history, physical examination, and diagnostic imaging studies of a patient whose chief complaints were neck and shoulder pain. This patient also had significant weight loss and a history of tobacco abuse. Aggressive physical therapy and appropriate medications failed to provide symptomatic relief of neck and shoulder pain. Further studies revealed lung cancer. Systemic malignancy can cause referred musculoskeletal pain without obvious metastatic involvement at the symptomatic area, and should be considered in patients with persistent symptoms.