Arm pain

Arm pain: Excerpt from Handbook of Signs & Symptoms (Third Edition)

Arm pain usually results from musculoskeletal disorders, but it can also stem from neurovascular or cardiovascular disorders. (See Causes of local pain.) In some cases, it may be referred pain from another area, such as the chest, neck, or abdomen. Its location, onset, and character provide clues to its cause. The pain may affect the entire arm or only the upper arm or forearm. It may arise suddenly or gradually and may be constant or intermittent. Arm pain can be described as sharp or dull, burning or numbing, and shooting or penetrating. Diffuse arm pain, however, may be difficult to describe, especially if it isn’t associated with injury.

History and physical examination

If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Then quickly assess him for severe injuries requiring immediate treatment. If you’ve ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.

If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right upper quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts movement. Also ask if heat, rest, or drugs relieve it. Finally, ask about preexisting illnesses, a family history of gout or arthritis, and current drug therapy.

Next, perform a focused examination. Observe the way the patient walks, sits, and holds his arm. Inspect the entire arm, comparing it with the opposite arm for symmetry, movement, and muscle atrophy. (It’s important to know if the patient is right- or left-handed.) Palpate the entire arm for swelling, nodules, and tender areas. In both arms, compare active range of motion, muscle strength, and reflexes.

If the patient reports numbness or tingling, check his sensation to vibration, temperature, and pinprick. Compare bilateral hand grasps and shoulder strength to detect weakness.

If a patient has a cast, splint, or restrictive dressing, check for circulation, sensation, and mobility distal to the dressing. Ask the patient about edema and if the pain has worsened within the last 24 hours.

Examine the neck for pain on motion, point tenderness, muscle spasms, or arm pain when the neck is extended with the head toward the involved side. (See Arm pain: Common causes and associated findings.)

Medical causes

❑ Angina. Angina may cause inner arm pain as well as chest and jaw pain. Typically, the pain follows exertion and persists for a few minutes. Accompanied by dyspnea, diaphoresis, and apprehension, the pain is relieved by rest or vasodilators such as nitroglycerin.

❑ Biceps rupture. Rupture of the biceps after excessive weight lifting or osteoarthritic degeneration of bicipital tendon insertion at the shoulder can cause pain in the upper arm. Forearm flexion and supination aggravate the pain. Other signs and symptoms include muscle weakness, deformity, and edema.

❑ Cellulitis. Typically, cellulitis affects the legs, but it can also affect the arms. It produces pain as well as redness, tenderness, edema and, at times, fever, chills, tachycardia, headache, and hypotension. Cellulitis usually follows an injury or insect bite.

❑ Cervical nerve root compression. Compression of the cervical nerves supplying the upper arm produces chronic arm and neck pain, which may worsen with movement or prolonged sitting. The patient may also experience muscle weakness, paresthesia, and decreased reflex response.

❑ Compartment syndrome. Severe pain with passive muscle stretching is the cardinal symptom of compartment syndrome. It may also impair distal circulation and cause muscle weakness, decreased reflex response, paresthesia, and edema. Ominous signs include paralysis and an absent pulse.

❑ Fractures. In fractures of the cervical vertebrae, humerus, scapula, clavicle, radius, or ulna, pain can occur at the injury site and radiate throughout the entire arm. Pain at a fresh fracture site is intense and worsens with movement. Associated signs and symptoms include crepitus, felt and heard from bone ends rubbing together (don’t attempt to elicit this sign); deformity, if bones are misaligned; local ecchymosis and edema; impaired distal circulation; paresthesia; and decreased sensation distal to the injury site. Fractures of the small wrist bones can manifest with pain and swelling several days after the trauma.

❑ Muscle contusion. Muscle contusion may cause generalized pain in the area of injury. It may also cause local swelling and ecchymosis.

❑ Muscle strain. Acute or chronic muscle strain causes mild to severe pain with movement. The resultant reduction in arm movement may cause muscle weakness and atrophy.

❑ Myocardial infarction (MI). An MI is a life-threatening disorder in which the patient may complain of left arm pain as well as the characteristic deep and crushing chest pain. He may display weakness, pallor, nausea, vomiting, diaphoresis, altered blood pressure, tachycardia, dyspnea, and feelings of apprehension or impending doom.

❑ Neoplasms of the arm. Neoplasms of the arm produce continuous, deep, and penetrating arm pain that worsens at night. Occasionally, redness and swelling accompany arm pain; later, skin breakdown, impaired circulation, and paresthesia may occur.

❑ Osteomyelitis. Osteomyelitis typically begins with vague and evanescent localized arm pain and fever and is accompanied by local tenderness, painful and restricted movement and, later, swelling. Associated findings include malaise and tachycardia.

Special considerations

If you suspect a fracture, apply a sling or splint to immobilize the arm, and monitor the patient for worsening pain, numbness, or decreased circulation distal to the injury site. Also, monitor the patient’s vital signs, and be alert for tachycardia, hypotension, and diaphoresis. Withhold food, fluids, and analgesics until potential fractures are evaluated. Promote the patient’s comfort by elevating his arm and applying ice. Clean abrasions and lacerations and apply dry, sterile dressings, if necessary. Also, prepare the patient for X-rays or other diagnostic tests.

Pediatric pointers

In children, arm pain commonly results from fractures, muscle sprain, muscular dystrophy, or rheumatoid arthritis. In young children especially, the exact location of the pain may be difficult to establish. Watch for nonverbal clues, such as wincing or guarding.

If the child has a fracture or sprain, obtain a complete account of the injury. Closely observe interactions between the child and his family, and don’t rule out the possibility of child abuse.

Geriatric pointers

Elderly patients with osteoporosis may experience fractures from simple trauma or even from heavy lifting or unexpected movements. They’re also prone to degenerative joint disease that can involve several joints in the arm or neck.

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Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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