Review Article Clinical Differentiation of Upper Extremity Pain Etiologies

Abstract Ravi K. Ponnappan, MD Upper extremity pain can result from many overlapping etiologies. Mustafa Khan, MD These can be categorized into anatomic regions and specific organ systems. Anatomically, pain etiologies are classified into four major Jonas L. Matzon, MD groups: neurologic, musculoskeletal, vascular, and other (eg, tumor, Emran S. Sheikh, MD infection). Knowledge of the characteristic clinical presentation and Bradford S. Tucker, MD physical examination findings of each group can help distinguish the ’ Matthew D. Pepe, MD source of the patient s complaints quickly so that an accurate clinical diagnosis can facilitate appropriate diagnostic measures and Fotios P. Tjoumakaris, MD treatment. A focus on the neurologic causes of upper extremity pain Ahmad N. Nassr, MD (ie, cervical spine pathology, peripheral nerve compression, neuropathy) and musculoskeletal causes of shoulder and elbow pain (eg, adhesive capsulitis, calcific tendinitis, biceps tendinitis, synovitis) and the distinguishing characteristics (eg, periscapular pain, two-point discrimination, signal intensity on T2-weighted MRI) helps determine the appropriate diagnosis.

he most common etiologies of Referred Pain From Spondylotic Tupper extremity pain can be Changes categorized into one of four main Intervertebral disks are innervated by groups: neurologic, musculoskeletal, the sinuvertebral nerve, which can refer vascular, and other (eg, tumor, pain to the axial neck and upper infection). Here, we focus on differ- torso.1,2 Loss of integrity of the disk entiating between neurologic and can result in hypermobility, altered musculoskeletal etiologies. biomechanics, and subsequent abnor- mal facet joint loading and irritation Neurologic Etiologies of the sinuvertebral nerve. Referred pain from these degenerative changes Neurologic sources of upper extrem- often remains axial in nature (involv- ity pain can result from any of the From Drexel University College of ing the head and neck) and does not Medicine, Philadelphia, PA (Dr. following: cervical spine pathology, extend beyond the shoulder girdle. Ponnappan), the University of Toledo peripheral nerve compression, and Medical Center, Toledo, OH (Dr. Khan), neuropathy. Cervical the Rothman Institute, Philadelphia, PA Compression of specific cervical (Dr. Matzon, Dr. Sheikh, Dr. Tucker, Cervical Spine Pathology Dr. Pepe, Dr. Tjoumakaris), and the nerve roots can result in pain, par- Mayo Clinic, Rochester, MN (Dr. Nassr). Degenerative (ie, spondylotic) changes esthesias, dysesthesias, weakness, J Am Acad Orthop Surg 2015;23: of the cervical spine (eg, osteophytes, and loss of reflexes in a dermatomal 492-500 herniation, ligamentous hypertrophy) and myotomal distribution supplied 2,3 http://dx.doi.org/10.5435/ can lead to impingement of the neural by that particular nerve root. Cer- JAAOS-D-11-00086 structures within the spinal column, vical radiculopathy can be unilateral thus leading to a variety of syndromes, or bilateral and may involve one or Copyright 2015 by the American Academy of Orthopaedic Surgeons. such as referred pain, cervical radicu- more levels. The level of cervical lopathy, and cervical myelopathy. radiculopathy can be distinguished

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Table 1 Patterns of Symptom Distribution Seen With Cervical Radiculopathy Level Root Referred Pain Dermatome Major Muscle Groups Reflex

C2/3 C3 Occiput, upper Anterior and posterior Trapezius, Scapulohumeral posterior neck upper neck (collar) sternocleidomastoid, levator scapulae, diaphragm C3/4 C4 Middle posterior neck, Anterior and posterior Rhomboids, levator Scapulohumeral suprascapular area lower neck (cape) scapulae, trapezius, diaphragm C4/5 C5 Lower posterior neck Anterior upper chest, Deltoid, diaphragm, Biceps lateral biceps, volar biceps, brachialis, forearm (radial aspect) brachioradialis, to wrist pectoralis major (clavicular head), rotator cuff C5/6 C6 Superior angle of Lateral upper arm (deltoid), Brachialis, biceps, wrist Brachioradialis scapula radial forearm including extensors thumb and index finger (dorsum and volar) C6/7 C7 Superior angle of Posterior arm (triceps), Triceps, finger and thumb Triceps scapula elbow, and dorsal extensors, wrist flexors, forearm to middle latissimus dorsi finger (volar and dorsum) C7/T1 C8 Midscapular region Dorsal and ulnar upper Finger flexors and grip None arm and forearm to ring and little finger T1/T2 T1 Midscapular region Volar forearm (ulnar Finger abduction and None aspect), medial biceps, adduction upper chest based on the dermatomes, myotomes, side, and pain with upper limb tension progressive neurologic functional and reflexes affected (Table 1). It test away from the side of radiculop- loss (eg, gait disturbance, coordina- can also manifest in a charac- athy are highly suggestive of cervical tion deficit, weakness) with or with- teristic pattern of periscapular pain1 radiculopathy.5 Confirmation of clini- out associated pain. Patients with (Figure 1). Classic presentation of cal diagnosis can be achieved with cervical myelopathy often describe cervical radiculopathy patients in- imaging (eg, MRI, myelography), gait imbalance, spasticity, fine motor cludes a history of radiating severe electrodiagnostic testing (ie, electro- coordination difficulty with the use of arm pain, which is relieved with myography), and/or selective diagnos- their hands (eg, buttoning shirts, placement of their ipsilateral hand tic nerve root injections. handwriting). Strength loss and atro- on top of their head (ie, shoulder phy of intrinsic hand muscles, espe- abduction relief sign)4 (Figure 2). A Cervical Myelopathy cially in the first dorsal web space, positive Spurling test, decreased pain Cervical myelopathy is a clinical maybeseeninadvancedcases.A with cervical distraction (ie, stretch), syndrome arising from the compres- rapid grip-and-release test reveals decreased rotational range of motion sion of the cervical spinal cord. This spasticity and coordination difficulty, (ROM) ,60° toward the affected condition clinically manifests as and the little finger escape sign denotes

Dr. Ponnappan or an immediate family member serves as a paid consultant to or is an employee of DePuy and serves as an unpaid consultant to Biomet. Dr. Tucker or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of, and serves as a paid consultant to or is an employee of, Mitek and DePuy; serves as an unpaid consultant to Mitek and Knee Creations; has stock or stock options held in Johnson & Johnson; and has received research or institutional support from DePuy, Johnson & Johnson, and Zimmer. Dr. Pepe or an immediate family member serves as a paid consultant to or is an employee of Stryker. Dr. Nassr or an immediate family member has received research or institutional support from AO Spine and Synthes and serves as a board member, owner, officer, or committee member of the Cervical Spine Research Society and the Scoliosis Research Society. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Khan, Dr. Matzon, Dr. Sheikh, and Dr. Tjoumakaris.

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9-11 Figure 1 Figure 2 specificity. Electrodiagnostic stud- ies (eg, electromyography/nerve con- duction velocity studies) are the diagnostic gold standard.12,13 If patient history, the clinical examina- tion, and electrodiagnostic studies are equivocal, a diagnostic corticosteroid injection into the carpal tunnel may be useful.14

Anterior Interosseous Nerve Syndrome Clinical photograph demonstrating Additional potential sites for median a commonly exhibited posture of nerve compression include the liga- a patient with cervical radiculopathy (ie, shoulder abduction relief sign). ment of Struthers, the lacertus fi- brosus, the two heads of the pronator Clinical photograph demonstrating the posterior cervicothoracic area, teres muscle, the fibrous arch of the highlighting the cervical nerve root flexor digitorum superficialis origin, origins (radicular) for commonly vulnerable to compression at various and anomalous muscles. Pronator experienced periscapular pain points as they course within the upper syndrome can be differentiated from symptoms. 7 extremity, leading to well-described by the lack syndromes (Table 2). of nocturnal painful awakening, intrinsic muscle weakness in these decreased sensation over the thenar patients.6 Carpal Tunnel Syndrome eminence, and provocative findings at Although symptoms and con- Carpal tunnel syndrome is the most the forearm but not the wrist (eg, ditions of the cervical spine can common and well recognized a Tinel sign over the pronator tunnel overlap with other shoulder and , with a preva- and pain with resisted forearm pro- upper extremity pathology, exami- lence in the United States estimated to nation). Unlike pronator syndrome nation and provocative testing for be as high as 3.7%.8 Compression of and carpal tunnel syndrome, anterior associated upper extremity con- the median nerve at the wrist under interosseous nerve syndrome demon- ditions typically do not reproduce the the transverse carpal ligament pro- strates no sensory loss but presents pain associated with cervical radi- duces typical subjective reports of with weakness of the flexor pollicis culopathy. In a recent study of reli- involving the radial longus and flexor digitorum pro- ability of clinical examination tests, three and a half fingers and noctur- fundus muscles to the index finger (ie, a high probability of cervical radicul- nal awakenings (with “hand inability to make the “okay” sign). opathy diagnosis was associated with shaking” to alleviate symptoms). Patients often report ill-defined fore- the combination of a positive Spurling Diminished sensation of the palmar arm heaviness and pain. test, decreased pain with cervical side of the radial three and a half distraction (ie, stretch), decreased fingers by two-point discrimination Parsonage-Turner Syndrome , ° rotational ROM 60 toward the or Semmes-Weinstein monofilament Although it is similar to anterior inter- affected side, and pain with the upper testing on physical examination is osseous nerve syndrome, Parsonage- limb tension test away from the side a characteristic finding. Advanced Turner syndrome is typically preceded 5 of radiculopathy. Confirmation of cases may eventually result in thenar by a viral prodrome. Its exact cause clinical diagnosis can be often achieved muscle weakness or atrophy. Classic is unknown; viral, autoimmune, with imaging (ie, radiography, MRI, provocative maneuvers, such as the genetic, infectious, environmental, and myelography), electrodiagnostic test- Tinel sign (percussion over the median biomechanical etiologies have been ing (ie, electromyography), and or nerve at the wrist), the Phalen suggested.15 Patients typically present selective nerve root injections. maneuver (wrist flexion with elbow with a sudden onset of severe and extension for 60 seconds), and the unrelenting shoulder pain that radiates Peripheral Nerve Durkan carpal compression test to the arm or neck and may last for Compression (compression of the median nerve for weeks. As the pain subsides, it is fol- The three major nerves of the upper 60 seconds) are often used, but these lowed by a flaccid paralysis accom- extremity (median, ulnar, radial) are have varying degrees of sensitivity and panied by muscle fatigue, weakness,

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Table 2 Summary of Peripheral Nerve Compression Disorders and Associated Characteristics Examination Disorder Pain Parasthesias Weakness Findings Tinel Sign

Carpal tunnel Wrist/hand Palmar aspect of Thenar muscles Durkan carpal Carpal tunnel syndrome radial three and compression a half fingers test Pronator syndrome Proximal forearm Radial three and Thenar muscles Resisted forearm Pronator tunnel a half pronation pain fingers, thenar eminence Anterior Proximal forearm None Thumb IP flexion, Difficulty making the 6 Proximal interosseous index finger DIP “okay” sign volar forearm nerve syndrome flexion Medial elbow/ Ulnar one and Intrinsic muscles Froment sign and Cubital tunnel syndrome forearm a half fingers, scratch collapse dorsal ulnar hand test Ulnar tunnel Ulnar wrist/palm Ulnar one and Intrinsic muscles No sensory loss over Guyon canal syndrome a half fingers dorsal cutaneous branch Arm Radial dorsal hand Wrist, finger, Weakness or Spiral groove compression thumb extension absence of wrist extension Posterior Mobile wad None Finger MP Radial deviation with Radial tunnel interosseous extension, wrist extension nerve syndrome thumb IP extension Radial tunnel Mobile wad None None Resisted forearm None syndrome supination pain Wartenberg Radial wrist/hand Radial dorsal hand None into Radial wrist syndrome dorsal and radial forearm Thoracic outlet Neck/arm Varies Varies Adson test Scalene syndrome

DIP = distal interphalangeal, IP = interphalangeal, MP = metacarpophalangeal

and atrophy of the shoulder girdle entrapment around the elbow. The Semmes-Weinstein monofilament muscles. Bilateral brachial plexus locations most commonly noted testing. In severe cases, intrinsic mus- involvement occurs in 10% to 30% of include the arcade of Struthers, the cle weakness and/or atrophy of the cases. Electrodiagnostic studies are medial intermuscular septum, the hand is seen, which may result in typically confirmatory in patients with medial epicondyle, the arcuate liga- clawing of the little and ring fingers. Parsonage-Turner syndrome, but pri- ment, the Osborne fascia between the Provocative maneuvers include the mary shoulder or cervical spine two heads of the flexor carpi ulnaris Tinel sign over the cubital tunnel, pathology must be ruled out. MRI of muscle, and the proximal flexor dig- the elbow flexion compression test, the brachial plexus may have charac- itorum profundus arch. Classic pre- the Froment sign (weakness of thumb teristic findings (ie, diffuse high signal sentation includes paresthesias in the adduction with compensatory flexor intensity on T2-weighted images).16 ulnar one and a half fingers (exacer- pollicis longus flexion during pinch), bated by elbow flexion) and medial Wartenberg sign (little finger abduc- Cubital Tunnel Syndrome elbow pain. Physical examination tion), and the scratch collapse test (loss The is the second most findings include decreased sensation of muscle resistance secondary to commonly affected upper extremity in the ulnar one and a half fingers allodynia).17-19 Nerve conduction peripheral nerve; cubital tunnel syn- and the dorsal ulnar aspect of the velocity testing demonstrates delayed drome is caused by ulnar nerve hand by two-point discrimination or conduction velocity across the elbow

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Clinical Differentiation of Upper Extremity Pain Etiologies and denervation of the ulnar intrinsic carpophalangeal joint extension as middle fingers. Objectively, a positive muscles. well as thumb interphalangeal joint Tinel sign can often be elicited at the extension. Wrist extension occurs point of compression. Diagnosis is Ulnar Tunnel Syndrome with radial deviation because of the a clinical one, and electrodiagnostic Ulnar tunnel syndrome is the result of loss of extensor carpi ulnaris function, studies are unnecessary. However, compression of the ulnar nerve as it with the retention of the extensor Wartenberg syndrome should be dif- travels through Guyon canal at the carpi radialis longus via the radial ferentiated from DeQuervain tenosyn- wrist. History of trauma or repetitive nerve. Interphalangeal joint extension ovitis, which presents as radial-sided strain to the ulnar hand or palm is of the fingers is also possible secondary wrist pain over the first dorsal com- often reported. Symptoms are con- to the intrinsic muscles. partment without paresthesias. Pa- fined to the palmar ulnar aspect of the In contrast to PIN syndrome, radial tients with DeQuervain tenosynovitis hand and the ulnar one and a half tunnel syndrome is more controversial will typically demonstrate a positive fingers. Unlike cubital tunnel syn- because it is an isolated pain syndrome. Finkelstein test (indicated by pain drome, sensation along the dorsal Although these patients have intact over the first dorsal compartment ulnar aspect of the hand is spared PIN motor function, they often report with the thumb placed in a clenched because the dorsal cutaneous branch pain and heaviness over the radial fist and ulnar deviation of the wrist) of the ulnar nerve branches approxi- tunnel. On examination, findings can and may have a positive response to mately 8 cm proximal to the Guyon include tenderness to palpation of the a corticosteroid injection.20 canal. Nerve conduction velocity radial tunnel, pain with resisted fore- tests demonstrate pathology across arm supination, and pain with resisted the wrist with sparing of extrinsic middle finger extension. Characteristi- Compression of the brachial plexus ulnar hand musculature. cally, electrodiagnostic testing is usu- from the level of the scalene muscula- ally unrevealing. Furthermore, the ture to the interval between the clavicle diagnosis must be differentiated from and first rib results in thoracic outlet Radial neuropathy is less common lateral epicondylitis, which causes syndrome (TOS). It is divided into two than ulnar tunnel syndrome and can pain more proximal at the lateral types: vascular and neurogenic. Vascu- occur at three sites: above the elbow, epicondyle. Sequential injections of lar TOS may be diagnosed based on at the proximal elbow, and at the lidocaine into the lateral epicondyle physical examination findings—results distal forearm. Above the elbow, the and then the supinator may help to of the Adson test and Roos test, edema/ radial nerve may be injured in bony distinguish the two diagnoses. swelling, cyanosis, and claudication— trauma (eg, humerus fractures). It More distally in the forearm, the and may be confirmed by ultraso- presents with loss of wrist, finger, and superficial radial nerve (SRN) can be nography and angiography. Neuro- thumb extension, along with par- compressed, and this is known as genic TOS presents with objective esthesias in the radial nerve distribu- Wartenberg syndrome (ie, cheiralgia findings of chronic nerve compres- tion. The second site of compression paresthetica). Compression usually sion, such as weakness, atrophy, and is where the posterior interosseous occurs approximately 9 cm proxi- sensory deficits in a specific nerve nerve (PIN) can be compressed at the mal to the radial styloid, where the distribution, confirmed by nerve level of the proximal forearm, caus- SRN travels between the brachiora- conduction velocity tests. No widely ing either PIN syndrome or radial dialis and extensor carpi radialis accepted diagnostic criteria for TOS tunnel syndrome. The potential longus muscles to become sub- exist, and the diagnosis is usually compressive etiologies include ra- cutaneous. Once subcutaneous, the made on the basis of the clinical diocapitellar fascial bands, the radial SRN trifurcates into three dorsal presentation.21-24 recurrent artery/venae comitantes branches to supply sensation to the (leash of Henry), the fibrous edge of thumb, index finger, and middle the extensor carpi radialis brevis, the finger proximal to the proximal Noncompressive Peripheral proximal fascial edge of the supinator interphalangeal joint. Because of its Neuropathy (arcade of Frohse), and the distal subcutaneous position, the SRN is Peripheral nerve damage that results fascial edge of the supinator. susceptible to external compression in pain and dysfunction is referred to In PIN syndrome, symptoms are (such as wristwatches or handcuffs). as peripheral neuropathy. Periph- mostly related to motor weakness This leads to sensory complaints, eral neuropathy resulting from non- of the PIN-innervated digital extensors. specifically pain and paresthesias in compressive etiologies is a further Objective physical examination the dorsal radial forearm radiating source of upper extremity pain or dis- findings include loss of meta- into the dorsal thumb and index and comfort (Table 3). This condition is

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Ravi K. Ponnappan, MD, et al often a manifestation of systemic dis- Table 3 ease and can be differentiated from Differential Diagnosis of Peripheral Neuropathy musculoskeletal etiologies based on an accurate medical history, a unique Etiology Condition/Medication constellation of symptoms, and Metabolic/systemic Diabetes mellitus the distribution of limbs involved. Vitamin B12 deficiency Peripheral neuropathy from non- Vitamin toxicity compressive disorders should be con- Nutritional deficiency Cancer sidered in the differential diagnosis of Alcoholism upper extremity pain. Multiple myeloma Common etiologies of neuropathy Chronic renal failure include multiple metabolic, infectious, Hypothyroidism Pregnancy and genetic causes (Table 3). Neu- Obesity ropathy can involve a single nerve or Myxedema multiple nerves. Damage to the Acromegaly peripheral nerve endings can result Congestive heart failure Myeloma in pain, dysesthesias, paresthesias, Leukemia loss of sensation, and weakness in Genetic Friedreich ataxia the periphery of the upper extremity. Charcot-Marie-Tooth disease A thorough clinical history, includ- Infectious Lyme disease ing details about familial conditions, Parsonage-Turner syndrome recent travel, occupational exposure, Guillain-Barré syndrome and social history, helps to identify Hepatitis Human immunodeficiency virus potential etiologies of this condition. Syphilis Physical examination may show Inflammatory Rheumatoid arthritis a peripheral distribution (ie, stocking Sarcoidosis and glove) of the neurologic symp- Sjogren syndrome toms or, in the setting of few objec- Lupus Gout/pseudogout tive or imaging findings of nerve Dermatomyositis entrapment or compression, a diffuse Amyloidosis pattern of pain. Medication-related Cisplatin Isoniazid Paclitaxel Musculoskeletal Etiologies Vincristine Lithium Pathologic conditions of the major Ergot medications Beta blockers articulations of the upper extremity Anticoagulation medications can cause a variety of symptoms (Tables 4 and 5). Here, we discuss musculoskeletal etiologies involving the shoulder and elbow. duces focal joint tenderness, which Glenohumeral Joint and Humeral can often be localized by the Acromial Articulation Pain Shoulder patient. Traumatic injuries, direct The etiology of glenohumeral joint The shoulder region includes the falls, and dislocations may cause pain can be multifactorial and over- acromioclavicular joint, sternocla- the joint to appear swollen and lapping28 (Table 1). Patients with vicular joint, glenohumeral joint, tender. Inflammatory and osteoar- cartilage loss may report crepitus humeral acromial articulation, and thritic conditions may be identified and diffuse pain with a feeling of scapulothoracic articulation. by provocative maneuvers that deep ache within the joint, even at increase load across the joint (eg, rest. Patients with restriction in Acromioclavicular and forced cross-body adduction); how- passive ROM that is equal to active Sternoclavicular Joint Pain ever, definitive diagnosis may be made ROM may have adhesive capsulitis or Pathology of the acromioclavicular with intra-articular injection of local glenohumeral osteoarthritis. Patients and sternoclavicular joints pro- anesthetic.25-27 who demonstrate full passive ROM

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Table 4 rior), the shoulder relocation test and the Yergason test are used. The shrug Intrinsic Causes of Shoulder Pain test (80% sensitive) is sensitive for Articulation Pathologic Condition detecting motion-related disorders Glenohumeral joint Adhesive capsulitis (eg, adhesive capsulitis, osteoarthri- Calcific tendinitis tis) in addition to rotator cuff ten- Biceps tendinitis dinitis.29 Radiographic and MRI Synovitis evaluation have evolved considerably Instability (multidirectional/unidirectional) Labral tear (anterior/posterior/superior) and have significantly improved our Rotator cuff tendinopathy detection and understanding of Impingement syndrome shoulder joint pathology. Overall, Rotator cuff tear symptoms attributed to intrinsic Long head proximal biceps tendon tear Osteoarthritis/articular cartilage lesions shoulder pathology often can be dis- Osteochondritis dissecans tinguished from neurologic-mediated Osteonecrosis shoulder pain based on reproduction Heterotopic ossification of symptoms with shoulder motion Osteomyelitis Pectoralis major tear and/or resolution of symptoms with Septic arthritis local diagnostic anesthetic injections; Neoplastic disease however, as discussed, this may not Acromioclavicular joint Separation always be clear.25,30 Osteoarthritis Osteolysis Scapulothoracic Articulation Physeal injury Fracture Pain Septic arthritis The etiology of scapulothoracic pain Osteomyelitis can overlap substantially with cervi- Neoplastic disease cal referred-pain syndromes. A so- Sternoclavicular joint Osteoarthritis called snapping scapula often results Traumatic subluxation/dislocation Atraumatic subluxation from bursitis that may develop post- Septic arthritis traumatically or secondarily to bony Seronegative spondyloarthropathy overgrowth and mechanical irritation. Gout/pseudogout Scapular dyskinesia can be caused by Sternoclavicular hyperostosis Condensing osteitis palsy, resulting in Aseptic osteonecrosis (Friedreich ataxia) burning pain and winging of the Osteomyelitis scapula. Other causes include a dis- Physeal injury abled throwing shoulder or associated Fracture shoulder pathology and can be de- Scapulothoracic articulation Muscle weakness Snapping scapula syndrome tected by an abnormal scapular posi- SICK scapula syndrome tion, inferior scapular winging, Bursitis coracoid tenderness, and scapular Dissociation dyskinesis (ie, SICK scapula).31,32 Exostosis/osteochondroma Facioscapulohumeral muscular dystrophy Thoracodorsal nerve injury (ie, Sprengel deformity weakness of latissimus dorsi) and trapezius weakness from spinal SICK = abnormal scapular position, inferior scapular winging, coracoid tenderness, and scapular accessory nerve injury can result in dyskinesis shoulder weakness, atrophy, asym- metry, and dyskinesia. Suprascapular nerve entrapment and compression but a limitation in active ROM may or liftoff (subscapularis) could indi- from altered scapular anatomy, have impingement syndrome or cate a tear of the rotator cuff. For motion, or labral pathology can cause a rotator cuff tear. Weakness in diagnosing impingement, the Neer pain, periscapular dysesthesias, external rotation (infraspinatus/ test and Hawkins test are commonly weakness, and atrophy of the supra- teres minor), forward elevation (su- used. For SLAP tears (ie, superior spinatus and infraspinatus muscles, praspinatus), and internal rotation labral tear from anterior to poste- which can often appear asymmetric

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33 on physical examination. Of note, Table 5 bilateral symmetric weakness, atro- Extrinsic Causes of Shoulder Pain phy, and dysfunction may be indica- tive of muscular dystrophy. Etiology Pathologic Condition Neurologic Cervical radiculopathy Elbow Upper trunk brachial Neuralgic amyotrophy Several intrinsic elbow pathologic Focal mononeuropathy conditions can cause upper extremity Muscular dystrophy pain symptoms. These include lateral Syringomyelia and medial epicondylitis as well as Herpes zoster osteoarthritis. Cardiovascular Cardiac ischemia Thoracic outlet syndrome Aortic disease Lateral Epicondylitis Axillary thrombosis Lateral epicondylitis (ie, tennis elbow) Superior vena cava syndrome is a common intrinsic elbow disorder, Pulmonary Upper lobe pneumonia Pulmonary embolism believed to involve microtears of the Pneumothorax origin of the extensor carpi radialis Pneumoperitoneum brevis resulting from microtrauma, Malignancy Pancoast tumor inflammation, and repetitive over- Metastatic disease use.34,35 The tears eventually are re- Abdominal Diaphragmatic pathology through phrenic nerve placed by disorganized collagen, irritation (Kehr sign) Biliary disease immature fibroblasts, and neo- Hepatic disease vascularization. This degenerative Pancreatitis tissue causes pain with use of the Splenic injury affected muscle groups. Symptoms Perforated viscus typically include lateral elbow pain, Other Cervical zygapophyseal joint pain which radiates into the proximal Complex regional pain syndrome Postural pain forearm with forceful gripping activ- ities, especially with the forearm in pronation and the elbow in extension.36 Elbow Osteoarthritis care and symptom management. It is The loss of articular cartilage within also important to note that several conditions may be present at once Medial Epicondylitis the radiocapitellar or ulnotrochlear (eg, a patient aged .60 years with The pathologic changes seen in joint can result in pain and loss of 39,40 asymptomatic rotator cuff pathology medial epicondylitis are similar to motion. Most common symp- and a symptomatic cervical radic- those in lateral epicondylitis but toms include pain at terminal ulopathy) and that successful treat- involve the flexor pronator origin on flexion/extension. Painful catching ment is predicated on an accurate the medical epicondyle (ie, pronator and locking may be present in up to 41,42 diagnosis. teres and the flexor carpi radialis).37 50% of patients. Symptoms include pain along the medial elbow radiating into the Summary References forearm, which is exacerbated with resistance to forearm rotation and The differential diagnosis of upper References printed in bold type are wrist flexion. Examination findings extremity pain may include neuro- those published within the past 5 include tenderness to palpation logic, musculoskeletal, and/or vas- years. along the flexor pronator origin, just cular etiologies. Careful history and 1. Tanaka Y, Kokubun S, Sato T, Ozawa H: anterior and distal to the medial physical examination can help dis- Cervical roots as origin of pain in the neck epicondyle, as well as pain with re- tinguish hallmark characteristics of or scapular regions. Spine (Phila Pa 1976) sisted wrist flexion and forearm each, allowing for more efficient and 2006;31(17):E568-E573. pronation. Medial elbow instability accurate diagnosis. Confirmatory 2. Rao R: Neck pain, cervical radiculopathy, and cervical myelopathy: Pathophysiology, and ulnar as a source of the diagnostic tests can then be appro- natural history, and clinical evaluation. J pain, however, may coexist.38 priately used to facilitate appropriate Bone Joint Surg Am 2002;84(10):1872-1881.

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500 Journal of the American Academy of Orthopaedic Surgeons

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