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Cheatography

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.

Causes

- 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
- CRPS

Pitfalls

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

Referral

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

Hx & Exam

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

Invest­iga­tions

- X-rays
- FBC
- ESR/CRP
- 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
- CRPS
- PMR
- Myofascial pain syndrome

Tunnel Syndromes

Types:
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

Testing

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

- EEG

DDx

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

Management

- 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
- SMT
- 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

Causes:

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

S&S

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

Questions

- 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?