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 |
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? |
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