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Arm Pain Cheat Sheet (DRAFT) by

Arm pain diagnosis + examination

This is a draft cheat sheet. It is a work in progress and is not finished yet.


- Viscera (Heart)
- Vascular disorders
- Cx Spine (refer­red­/ra­dic­ular)
- Upper limb plexop­athies
- Peripheral nerve entrap­ments
- MSK disorders
- T4 syndrome
Brachial Plexopathy: Pain + weakness radiating into the suprac­lav­icular region + upper extremity
- Causes:
Compre­ssion of the plexus (TOS)
Apical Lung Tumour (C8, T1 - Atrophy of the hand)
Direct Trauma (Burne­r/S­tinger)

Serious Disorders

- Angina
- MI
- Apical lung tumour (Panco­ast's)
- Bone Tumours
- Septic Arthritis
- Osteom­yelitis


- Entrapment syndrome of the peripheral Nerves
- Lesion of Brachial Plexus


- Myelopathy and persistent radioc­ulo­pathy
- Unreso­lving peripheral nerve entrap­ments
- Conditions not responding to treatments
- Non-me­cha­nical causes

Hx & Exam

- Hx of pain, trauma
- Onset
- Aggrev­ati­ng/­Rel­ieving
MSK Assessment of the upper limb
Cx Spine and TOS routine
Percus­sio­n/v­ibr­ation (if trauma)


- X-rays
- Nerve conduction Studies
- Electr­omy­ography
- Ultrasound

Arm Pain in Children

- Trauma - elbow
- In neonate , consider: Erb's/­Klu­mke's palsy

In elderly

- T4 syndrome
- Upper limb peripheral nerves
- Brachial Plexop­athies
- Myofascial pain syndrome

Tunnel Syndromes

Neurop­raxis: Segmental block of axonal conduction due to local demyelination
- causes conduction block (Sunde­rland Grade 1)
Axnotmesis - loss of axon with contin­uation of myelin sheath - Wallerian degene­ration of distal nerve
- loss of axon contin­uity, intact endone­urium (Sunde­rland grade 2)
Neurot­mesis - Axon and connective tissue sheath destored - severe, leads to Wallarian degene­ration , but less chance of regrowth
- loss of axon contin­uity, Disrupted endone­urim, intact perine­urium (Sunde­rland Grade 3)
Above + disrupted perineurim + intact epineurium (Sunde­rland Grade 4)
- Complete Nerve Transe­ction (Grade 5)

General S&S

- Transient Ischaemic sympto­ms/­par­aes­theisa and numbness (Compr­ession of neurov­ascular bundle)
- Chroni­cally - pain, numbness, parase­sthesia and paresis
- Dyaest­hesia may be present
- If mixed nerves are affected , sensory signs appear before motor
Negative Symptoms: Loss of conduction - Hypaes­thesia (reduced sensit­ivity to a stimulus)
Hypalgesia - Decreased sensit­ivity to cutaneous pain
Positive Symptoms: Caused by an imbalanced input
Parase­sthesia - abnormal sensations
Dysaes­thisa - unpleasant abnormal sensations
Hypera­est­hesia, Hypera­lgesia, Hyperp­athia, Allodynia


SMR, Autonomic symptoms
Nerve palpation
Tinel's sign
Neurod­ynamic tests (upper tension tests)
Tunnel compre­ssion tests
Contra­ction of muscle tissue bordering a tunnel

Further Tests



- Radicu­lopathy
- Proximal Lesion (TOS)
- CNS Lesion­/di­sease
- Diabet­ic/­alc­oholic polyne­uro­pathy
- Vascular disorders causing vasospasm


- Rule out sinster causes
- Identify aggrav­ating factors (rest/­modify activi­ties)
- Mobili­sation and manipu­lation to improve extremity joint function - "­ope­n" sites of compre­ssion
- Cryoth­erapy (decreases oedema + inflam­mation)
- Interf­ere­ntial therapy
- US (reduces oedema + adhesions)
- Stretching techhn­iques and exercises
- Ergonomic advice
- Heat in healing phase
- Vitamin B6
- NSAID advice (pharm­acist)
- Neurod­ynamic mobili­sation

Median Nerve entrapment (C6-8, T1)

Can occur at:
High median Nerve Tunnel (CTS)
Suprac­ondylar Spur and Ligament of Struther's
Pronator Teres
Anterior intero­sseous nerve tunnel syndrome

Ligament of Struthers

- Pain and tenderness above the elbow
- Weakness of pronation, wrist/­finger flexors
- Clumsiness
- Possible sensory changes in palm
- Refer to x-ray (bone spur on anterior humerus)

Ulnar nerve (C7-8,T1)

Can Occur at:
- Cubital Tunnel
- Flexor Carpi Ulnaris
- Guyon's canal

Radial Nerve

Can occur at:
- High radial Nerve Tunnel syndrome (axilla and spiral groove)
- Distal to the radial nerve hiatus (near lateral humeral condyle)
- Supinator
- Syndrome of superf­icial branch of radial nerve
- Distal posterior intero­sseous nerve syndrome


F# of humerus
Crutch Palsy
Saturday nigh palsy (falling asleep with arm hanging off chair)
Triceps lesion


Insidious Onset
Deep pain in posterior part of the forearm
Gradual Finger Weakness (Can be some wrist weakness - wrist drop)
Local discomfort at elbow (4 finger­bre­adths below lateral epicondyle - helps differ­entiate from tennis elbow)
Pain on active supination
Positive Tinels

Other Neurop­athies

Long Thoracic Nerve (C5-8):
Due to external compre­ssion; heavy backpack. Paralysis of Serratus Anterior (winging of the scapula, weakness of shoulder flexio­n/a­bdu­ction)
Manage­ment: Decomp­res­sion, then rehab exercises
Supras­capular Nerve (C5-6)
Scapular trauma­/fr­acture or repetitive stretc­hing. Pain and weakne­ss/­par­alysis of supras­pin­atous + infras­pin­atous - mimics rotator cuff
Double Crush: Two compre­ssive lesions affecting the same nerve. Look for manipu­lable lesions at segmental level to the peripheral nerve

Non-MSK causes of Arm pain

- Skin: Herpes Zoster, Cellul­itis, Contusions
- Muscles, joints, tendons, nerves: Inflam­mation, trauma
- Bones and Joints: Osteom­yel­itis, primar­y/mets bone tumours, fractu­re/­inf­lam­mation of joints
- Veins: Thromb­oph­lebitis
- Arteries: Ischaemia - risk factors (smoking, hypert­ension, raised glucose levels, systemic inflam­mation)
- Heart, lungs, subdia­phr­agmatic struct­ure­s(i­ntr­a-a­bdo­minal bleeding, gall bladder) can refer down the arm
- IHD Risks - Increasing age, Male, Family Hx, Race (south asians higher risk), Hypert­ension, DM, Hyperl­ipi­daemia, Obesity
- IHD S&S: Constr­icting discomfort in the front of the chest, neck, shoulders, jaw or arm, Precip­itated by emotio­n/e­xer­tion, relieved by rest/ GTN


- Pain related to exertion and relieved by rest? Effort over movement? Risk factors for IHD/Ca­rdiac
- Recent Viral infection? Pain affected by positi­oni­ng/­bre­athing?
- Cough? SOB? Wheeze? Haemop­tysis? Smoker? Breathing exacerbate problem? Symptoms of infection? Hx of cancer
- Intole­rance of fatty foods? Indige­stion?