Joint disorders are common cause of arm pain. Apart from joint disorders the majority of causes of arm pain are related to either neurological or vascular lesions which are discussed below:
● Disc lesion
● Cervical spondylosis
● Infection, e.g. osteitis, TB
● Tumours -- Spinal cord, Meninges, Nerves, Vertebral bodies
● Cervical rib
● Malignant infiltration, e.g. Pancoast’s tumour
● Thoracic inlet syndrome
● Myocardial ischaemia (left arm)
● Axillary venous thrombosis
● Subclavian artery stenosis
● Arterial thrombosis
● Repetitive strain injury
● Carpal tunnel syndrome
● Peripheral neuropathy
● Bone tumours
● Compartment syndrome
● Acute, e.g. crush injuries
● Chronic, e.g. exertional
Symptoms of cervical lesions include: pain and stiffness in the neck;
pain radiating down the arm. Cervical cord compression may occur.
Cervical spondylosis represents ‘wear and tear’ of the cervical
spine. It is common over the age of 60 years. Acute disc lesions
usually occur in the younger patient. A careful history is needed to
Brachial plexus lesions refer pain down the arm and may result
from localised lesions, e.g. a cervical rib causing extrinsic compression
will affect T1 and cause wasting of the small muscles of the hands
and paraesthesia in the dermatomal distribution, i.e. the inner aspect
of the upper arm.
Subclavian artery stenosis will result in ‘claudication’ in the arm,
i.e. pain brought on by exercise, relieved by rest, due to inadequate
blood flow. A history of cardiac problems, e.g. AF or widespread
arterial disease, will suggest embolism or thrombosis. A sudden
onset of a painful, swollen, cyanotic limb will suggest axillary vein
thrombosis. Pain radiating into the left arm brought on by exercise
and related to central chest pain and pain radiating into the neck
suggests myocardial ischaemia. Pain associated with occupation, e.g.
writing, word-processing (keyboard occupations), suggests repetitive
strain injury. A history of diabetes mellitus, renal failure, liver failure,
alcohol abuse, vitamin B12 deficiency, drugs, e.g. phenytoin or
vincristine, suggests peripheral neuropathy.
Pain, paraesthesia in the thumb, index and middle finger, which
is worse in bed at night and relieved by hanging the arm out of
bed, would suggest carpal tunnel syndrome. The latter may be
associated with pregnancy, rheumatoid arthritis, myxoedema,
anterior dislocation of the lunate, gout, acromegaly, amyloidosis and
arteriovenous fistula at the wrist created for haemodialysis.
Localised bone pain may be due to primary or secondary tumours.
The latter are most common and may result from a primary in the
breast, bronchus, thyroid, prostate or kidney. Pathological fractures
may occur. With compartment syndrome, there may be a history of
crush injury, vascular injury or vascular surgery. Chronic compartment
syndrome may result from unusual exertion, e.g. weight-lifting.
A full neurological examination should be carried out, looking for
cervical lesions, brachial plexus lesions or carpal tunnel syndrome.
There may be limitation in movements of the cervical spine. The
limbs should be examined for swelling, e.g. axillary vein thrombosis,
when there will be cyanosis and dilated veins. Examine for signs
of ischaemia and feel for pulses. The classical signs of an ischaemic
limb, i.e. pain, pallor, pulselessness, paraesthesia, ‘perishing cold’ and
paralysis, may be present. Occupation will suggest repetitive strain
injury and there will usually be little to find on examination. Horner’s
syndrome (ptosis, miosis, enophthalmos and anhidrosis) suggests
Pancoast’s tumour. With bone tumours, there will be localised swelling
and tenderness. With compartment syndrome, there will be a swollen
tender compartment in the forearm, paraesthesia and paralysis. Pulses
may be normal initially; later they are reduced or absent.
WCC ↑ infection, e.g. osteomyelitis or cervical spine TB.
ESR ↑ infection and malignancy.
Cervical spine X-ray
Cervical spondylosis, bony metastases, cervical spine fractures.
Malignancy resulting in bone secondary. Pancoast’s tumour
(apical lung tumour spreading to involve brachial plexus).
Cervical rib (13 ribs).
Cervical disc lesions, tumours.
Cervical disc lesions, tumours.
Nerve conduction studies
Brachial plexus lesions, peripheral neuropathy, carpal tunnel
Arterial or venous lesions.
Venous lesions, e.g. axillary vein thrombosis.
Angina may present only with pain in the left arm.
Take a careful history.
Paraesthesia and weakness in association with arm
pain suggests nerve compression.
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