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Pain in the Arm: a Symptom Ofheart Disease

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Pain in the Arm: a Symptom Ofheart Disease 410 Postgrad Med J: first published as 10.1136/pgmj.35.405.410 on 1 July 1959. Downloaded from PAIN IN THE ARM: A SYMPTOM OF HEART DISEASE By WALTER SOMERVILLE, M.D., F.R.C.P. Assistant Physician, Department of Cardiology, The Middlesex Hospital Pain in the arm was mentioned in Heberden's heat lamp for his shoulder pain. A chauffeur may first description of angina pectoris, '. sometimes blame his forearm pain on heavy steering. Alert there is joined (with the chest pain) a pain about questioning in these cases may uncover a co- the middle of the left arm . .' (I772). Herrick existing chest sensation and lead to the true cause. (19I2) also referred to arm pain in his first paper Ischaemic pain in the arm is often described by on coronary occlusion, the earliest in the English the patient in similar terms to the typical chest language. When the arm and chest pain of pain. It is said to be cramp-like, squeezing, a band ischaemic heart disease occur at the same time, no around the arm or like ' having my blood pressure diagnostic problem arises. But pain confined to taken.' The arms are often said to ache or feelProtected by copyright. one or both shoulders or arms may be misleading. heavy after a severe attack of angina pectoris. Its real meaning may be missed even in well- The pain is usually felt on the ventral and informed circles. Not long ago, a professor in an medial surfaces of the arm and forearm. It may eminent medical school died suddenly from what extend down to the little finger and the ring was shown at autopsy to be a cardiac infarction. finger. The patient may demonstrate what he For the previous few weeks, he had been having feels by gripping the forearm and then the upper physiotherapy for pain in both shoulders and arms arm, pointing out two areas with a gap between which came on only when he walked. The person them. An elderly man with syphilitic angina with anginal pain mainly in the arms does not would grip the ring finger of the left hand where associate it with his heart and usually keeps his his pain began and spread upwards to the shoulder, trouble to himself until he feels the pain in the across the chest and down the right arm. Sweating chest also. localized to the arm or shoulder has been described The typical sensation of angina pectoris or but is very uncommon. http://pmj.bmj.com/ cardiac infarction has an easily-recognized quality. The terms constricting, squeezing, grzpping, vice- The Pain Pathways from the Heart like, cramp-like and tight are usually used by the All the pathways of pain from the heart have not patient. He often corrects the doctor who en- been precisely defined. The following facts, quires about pain, saying the sensation is pressure however, are generally accepted. Ischaemic pain or tightness rather than pain. Its position, too, is arises in the heart muscle and passes along pain fairly standardized. The common sites are across fibres situated in nerve plexuses in the adventitia the chest, or behind the sternum, but seldom of the coronary arteries. The pain impulses are on September 29, 2021 by guest. under the left breast. The diagnosis of a pain or carried in sympathetic nerves to the first to fourth sensationi with these two features of quality and thoracic sympathetic ganglia. From here, they site should never be in doubt. Radiation beyond pass into the corresponding segments of the cord the chest is common. The usual paths are in the (T. I-4). These fibres, transmitting visceral pain left arm or both right and left arms, and upwards from the heart, join with others bearing somatic to the throat and along the jaws. Sometimes the pain impulses from the areas of the skin supplied pain passes to the upper abdomen or the back by T. I-4, that is the mid- and upper parts of the but this is unusual. The pain combining these front of the chest and the medial aspect of the arm characteristic features of quality, site and radiation and forearm. The intimate relationship between leaves open no other diagnosis than ischaemic these two sets of sensory nerves explains, according heart disease. The referred pain may trouble the to the theory of referred pain, how sensations patient more than the chest pain. He may go to arising in the heart are perceived by the patient in his dentist because of toothache, or buy a radiant the arms as well as the chest. 412 POSTGRADUATE MEDICAL JOURNAL July 1959 Postgrad Med J: first published as 10.1136/pgmj.35.405.410 on 1 July 1959. Downloaded from The Shoulder-Hand Syndrome by the eighth cervical to the fourth thoracic spinal The shoulder-hand syndrome consists of pain, segments. stiffness and limitation of movement of the shoulder, hand and fingers, and trophic changes in Treatment the skin and other tissues of the hand, following No special treatment is needed for the pain of acute cardiac infarction. The complete picture is acute infarction referred to the arm. The mild uncommon, occurring in less than 5 per cent. of varieties of the shoulder-hand syndrome usually infarctions. Some degree of stiffness of one or yield to passive and active shoulder and arm both shoulders develops in about io per cent. of exercises. The more severe degrees are often patients within a month or six weeks of an long-lasting and resistant to treatment. If the acute infarction. infarction heals satisfactorily and pain does not In the mildest form of the syndrome, the patient recur, the shoulder stiffness may subside spon- complains of slight pain or stiffness on moving the taneously in a few months. Sometimes it may arm. Severe limitation of movement with pain still cause trouble after a year. In addition to shooting down the arm, upwards to the neck and physiotherapy the various measures used i-nclude down the side of the thorax on abduction and procaine infiltration around the shoulder joint, lateral rotation is known as a ' frozen shoulder.' steroid therapy, upper thoracic sympathetic block In some cases the hand is warm and the fingers with procaine and stellate ganglionectomy. These pulsate, reflecting vaso-dilation. These changes points are considered fully in other parts of this may be the forerunners of severe, if uncommon symposium. trophic changes, namely swelling of the fingers and hand, stretching of the skin with red-purple discoloration, trophic ulceration of the fingers or Summary hand, and thickening and contracture ofthe palmar The typical chest pain of ischaemic heartProtected by copyright. aponeurosis. The condition in any degree of disease (angina pectoris and cardiac infarction) is severity except the slightest, may be very resistant often transmitted to one or both shoulders and to treatment and sometimes the results of months arms. Occasionally, it is felt first in the forearm of painstaking physiotherapy may be disappoint- or arm and spreads upwards to the shoulder and ing. Occasionally, all stiffness and pain may across the chest. Rarely, it may be confined to the disappear spontaneously within a few weeks. arms. The correct diagnosis may be missed when The shoulder-hand syndrome has not been the pain is dominantly in the arms or shoulders. satisfactorily explained. The changes show a The shoulder-hand syndrome is an uncommon tendency to appear in joints which have been the sequela of acute cardiac infarction. It consists of seat of arthritis or peri-arthritis. The left arm is stiffness of the shoulder, and in its severe form, of the more often affected but the right arm is in- great pain on moving the arm and trophic changes volved when the ischaemic pain was right-sided. in the hand. The condition may respond only Protective disuse of the limb is responsible to slowly to treatment, and may be troublesome for http://pmj.bmj.com/ some extent, but other factors are involved, too. many months after an acute infarction. One of these is a neurovascular reflex mechanism. Pain impulses arising from the heart, reflexly pro- duce muscular spasm and neuro-vascular reac- BIBLIOGRAPHY HEBERDEN, W. (1772), Med. Trans. Roy. CoU. Phys., 2, 59. tions in the ligaments, muscles and skin, innervated HERRICK, J. B. (I9I2), Y. Amer. med. Ass., 59, 2015. on September 29, 2021 by guest. References from page 404 - H. Harold Friedman, M.D., Thomas G. Argyros, M.D., and Otto Steinbrocker. M.D. REFERENCES 7. FISKE, L. G. (I952): ' Brachial plexus irritation due to hyper- I. ADSON, A. W., and COFFEY, J. R. (1927): 'Cervical rib, trophied omohyoid muscle,' J.A.M.A., I49, 758. method of anterior approach for relief of symptoms by 8. GAMBLE, S. G. (1gsi): 'Costoclavicular syndrome,' Arch. division of scalenus anticus,' Ann. Surg., 85, 839. phys. Med., August, 5x6-522. 2. BEYER, J. A., and WRIGHT, I. S. (I95I): 'The hyper- 9. HAGGERT, G. E. (Igg8): 'Value of conservative management abduction syndrome with special reference to its relationship in cervicobrachial pain,' J.A.M.A., 137, So8-513. to Raynaud's syndrome,' Circulation (N. Y.), 4, No. 2. so. JUDOVICH, B., BATES, W., and DRAYTON, W., Jr. 3. EDEN, K. C. (1939): 'The vascular complications of cervical (1944): 'Pain in the shoulder and upper extremity due to ribs and first thoracic rib abnormalities,' Bnt. _. Surg., scalenus anticus syndrome,' Amer. J. Surg., 63, No. 3, 27, III. March. 4. EDWARDS, E. A., and LEVINE, H. D. (1942): 'Auscultation i I. LORD, J. W., Jr., and ROSATI, L. M. (5958): ' Neurovascular in the diagnosis of compression of the subclavian artery,' compression syndromes of the upper extremity,' Clin.
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