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Saturday, August 23, 2025

Arm pain


Introduction

Arm pain refers to any discomfort, ache, or pain felt in one or both arms, including the shoulder, elbow, forearm, wrist, or hand.

  • It may be localized (to muscles, joints, or nerves) or referred (from the neck, chest, or heart).

  • Severity ranges from mild and self-limiting to severe and life-threatening (e.g., myocardial infarction).

  • A structured approach is essential to distinguish benign from urgent causes.

Causes of Arm Pain

1. Musculoskeletal Causes

  • Muscle strain / overuse (sports, heavy lifting).

  • Tendinitis / Tendinopathy:

    • Rotator cuff tendinitis (shoulder).

    • Tennis elbow (lateral epicondylitis).

    • Golfer’s elbow (medial epicondylitis).

  • Bursitis: inflammation of fluid-filled sacs (shoulder, elbow).

  • Fractures and dislocations (clavicle, humerus, radius, ulna).

  • Arthritis: osteoarthritis, rheumatoid arthritis.

  • Repetitive strain injury (RSI).

  • Frozen shoulder (adhesive capsulitis).

2. Neurological Causes

  • Cervical radiculopathy (nerve compression in neck).

  • Carpal tunnel syndrome (median nerve compression).

  • Ulnar nerve entrapment (cubital tunnel).

  • Peripheral neuropathy (diabetes, alcohol, toxins).

  • Brachial plexus injury.

3. Vascular Causes

  • Peripheral arterial disease.

  • Deep vein thrombosis (DVT) of the arm.

  • Thoracic outlet syndrome (compression of vessels/nerves near collarbone).

4. Referred Pain

  • Cardiac: Angina, myocardial infarction (left arm pain, crushing, associated with chest pain, sweating).

  • Gallbladder/liver disease (occasionally referred pain to right shoulder/arm).

  • Lung tumors (Pancoast tumor).

5. Infectious / Inflammatory

  • Cellulitis, septic arthritis, osteomyelitis.

6. Other

  • Fibromyalgia.

  • Psychogenic pain (stress, anxiety).

Clinical Features

  • Pain characteristics: sharp, dull, burning, throbbing, radiating.

  • Location: shoulder, elbow, forearm, wrist, or diffuse.

  • Onset: sudden (trauma, MI) vs gradual (arthritis, tendinitis).

  • Aggravating factors: movement, exercise, posture.

  • Associated symptoms:

    • Numbness/tingling → nerve compression.

    • Weakness → nerve/muscle involvement.

    • Swelling/redness → infection, DVT.

    • Chest pain, dyspnea → cardiac cause.

Diagnostic Approach

1. History

  • Duration, onset, severity.

  • Trauma or overuse?

  • Occupation and physical activity.

  • Associated chest pain, systemic illness.

  • Medical history (diabetes, arthritis, heart disease).

2. Examination

  • Inspection: swelling, deformity, redness.

  • Palpation: tenderness, warmth, crepitus.

  • Range of motion of joints.

  • Neurological exam: sensation, reflexes, strength.

  • Cardiovascular exam (pulse, BP, heart sounds).

3. Investigations

  • Blood tests: CBC, ESR/CRP, rheumatoid factor, glucose, cardiac enzymes (if MI suspected).

  • Imaging:

    • X-ray (fracture, arthritis).

    • MRI (tendons, ligaments, nerves, spine).

    • Ultrasound (tendons, DVT, soft tissue).

  • ECG: if left arm pain and chest pain present.

  • Echocardiography / stress test: cardiac evaluation.

  • Nerve conduction studies / EMG: neuropathy, carpal tunnel.

Management and Treatment

Treatment depends on underlying cause.

A. Musculoskeletal Pain

  1. Rest and Physical Therapy

  • Rest affected arm, avoid aggravating activity.

  • Physiotherapy to strengthen muscles and improve range of motion.

  • Heat or ice packs.

  1. Medications

  • NSAIDs: Ibuprofen 400 mg orally every 8 h, or Naproxen 250–500 mg twice daily.

  • Acetaminophen (Paracetamol) 500–1000 mg orally every 6–8 h (max 4 g/day).

  • Topical NSAIDs: Diclofenac gel applied to painful area 2–3 times daily.

  1. Steroid Injections

  • For persistent tendinitis, bursitis, or arthritis.

  • Triamcinolone 20–40 mg intra-articular or intrabursal injection.

B. Neurological Causes

  • Carpal tunnel syndrome:

    • Wrist splints, physiotherapy.

    • Gabapentin 300 mg orally once daily (titrate to 300 mg TID).

    • Corticosteroid injection if severe.

    • Surgery for refractory cases.

  • Cervical radiculopathy:

    • NSAIDs, physiotherapy, cervical traction.

    • Surgery if persistent neurological deficits.

C. Vascular Causes

  • DVT of arm:

    • Anticoagulation: Enoxaparin 1 mg/kg SC every 12 h, followed by Warfarin or Apixaban.

  • Peripheral arterial disease / Thoracic outlet syndrome:

    • Risk factor control (stop smoking, control diabetes, statins).

    • Surgical decompression if severe.

D. Cardiac Causes (Red Flag!)

  • Acute coronary syndrome (ACS):

    • Admit immediately.

    • Aspirin 325 mg chewed.

    • Clopidogrel 300 mg orally loading dose.

    • Nitroglycerin 0.4 mg sublingual every 5 min up to 3 doses.

    • Morphine 2–5 mg IV if severe pain.

    • Reperfusion therapy (PCI or thrombolysis).

E. Infections

  • Cellulitis:

    • Amoxicillin-clavulanate 875/125 mg orally twice daily × 7–10 days.

  • Septic arthritis:

    • IV antibiotics (Ceftriaxone 2 g IV daily) + joint drainage.

F. Fibromyalgia / Chronic Pain

  • Multidisciplinary management.

  • Amitriptyline 10–25 mg orally at bedtime.

  • Duloxetine 30–60 mg orally daily.

  • Exercise and CBT.

Complications

  • Chronic pain and disability.

  • Loss of function if untreated fracture, arthritis, or nerve compression.

  • Missed myocardial infarction (life-threatening).

  • Pulmonary embolism from untreated DVT.

Prognosis

  • Simple strains and minor injuries: Excellent, recover with rest/therapy.

  • Nerve compression: Good if treated early, may become chronic if delayed.

  • Cardiac causes: Prognosis depends on early recognition and treatment.

  • Cancer, systemic disease: Depends on stage and underlying pathology.

Patient Education

  • Arm pain may be minor but can also be a warning sign of serious conditions (especially if associated with chest pain, shortness of breath, or dizziness).

  • Maintain good posture and ergonomics to prevent strain.

  • Regular exercise and stretching.

  • Manage chronic conditions (diabetes, hypertension).

  • Avoid smoking and excessive alcohol.

  • Seek urgent medical care if arm pain is:

    • Sudden, severe, or crushing.

    • Associated with chest pain, sweating, faintness.

    • Accompanied by swelling, redness, or weakness.




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