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Clinical Differentiation of Upper Extremity Pain Etiologies 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 Radiculopathy 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 492 Journal of the American Academy of Orthopaedic Surgeons Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Ravi K. Ponnappan, MD, et al 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. August 2015, Vol 23, No 8 493 Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Clinical Differentiation of Upper Extremity Pain Etiologies 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 carpal tunnel syndrome 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 peripheral neuropathy, 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
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