Arm pain

Causes of anterior arm pain:

  • Biceps tendonitis
  • Biceps tendon rupture
  • Pronator (teres) syndrome
  • Radicular – C4 – 6

Biceps tendonitis

What it is: Tendinopathy of long head of biceps. Often seen in association with rotator cuff syndrome or SLAP (superior labrum, anterior to posterior) lesions.

Cause: Aging process or repetitive overhead motion (e.g. athletes).

Diagnosis:

  • Dull ache in anterior shoulder.
  • Tenderness over biceps tendon (anterior shoulder, groove between anterior deltoid & pec major)
  • Speed’s test – pain reproduced by resisted straight arm flexion/external rotation at 90 deg
  • Yergason’s test – pain reproduced by resisted supination with elbow at 90 deg (note may also be possible to feel bicipital tendon slipping out of groove during Speed’s or Yergason’s test)
  • MRI may be useful in athletes participating in throwing sports, as can pick up SLAP lesions or other intra-articular pathology.

Treatment:

  • RIAP (rest/ice/analgesia/physio)
  • Possible consideration of steroid injections or surgery, with usual caveats

Biceps tendon rupture

What it is: Usually affects long head of biceps.

Cause: Can be due to weightlifting/other rapid stresses, or to chronic inflammation such as in RA.

Diagnosis:

  • Can be a sudden painful pop when tendon loaded, or may be painless and not noticed at time.
  • May be bruising and/or obvious swelling that does not move with supination.
  • May be tenderness along course of biceps.
  • Reduced power of forearm flexion/supination.
  • Ludington’s test – clasp hands behind head, look for asymmetry in biceps muscle bulk.

What to do about it:

  • Proximal tendon ruptre in frail elderly – may be able to manage conservatively with RICE & physio. Symptoms should take 4 – 6 weeks to settle.
  • Proximal tendon rupture in younger person/athlete – consider referral for surgery.
  • Distal tendon rupture – urgent surgical referral for repair.

Pronator syndrome

What it is: Median nerve compression between two heads of pronator teres in forearm. (Rare.)

Diagnosis: Symptoms similar to CTS, but with forearm tenderness. May be weakness of flexor pollicis longus, flexor digitorum profundus of index finger, & pronator quadratus. Tinel’s test positive at tender point in forearm but not at wrist, Phalen’s test negative.

What to do about it: Physio. Consider referral for guided injection or surgical decompression if physio not working or if significant weakness.

Causes of posterior arm pain:

  • Triceps tendonitis
  • Olecranon bursitis
  • Radicular pain from C7 – 8

Not much to say about these. Olecranon bursitis is pretty obvious. Treatment of triceps tendonitis is rest followed by physio.

Causes of lateral arm pain:

  • Lateral epicondylitis
  • Radial tunnel syndrome
  • Radicular pain from C5 – C6

Lateral epicondylitis

Diagnosis:

  • Point tenderness over lateral aspect of elbow at origin of common extensor origin
  • Pain on resisted dorsiflexion of wrist (this manoeuvre is also useful for localising the common extensor origin as above)
  • Pick up the back of a chair with palm facing down – if this can be done it virtually excludes lateral epicondylitis (this is actually called the ‘pick up the back of a chair’ test, so no eponyms to remember this time)
  • Elbow itself normal – full ROM, no loss of indentations on either side olecranon (which can indicate effusion)

What to do about it:

  • Physio – eccentric lengthening
  • GTN patches – a quarter of a 5 mg patch applied to site daily, continued for 3 months and combined with eccentric loading. Can cause dizziness and headaches
  • Possibly injection of autologous blood products – evidence not currently conclusive but may be considered as per NICE
  • Consider radial tunnel syndrome as an alternative differential diagnosis in resistant cases (see below)

Radial tunnel syndrome

What it is: Entrapment of the posterior interosseous nerve in the radial tunnel

How to diagnose it:

  • Presents similarly to lateral epicondylitis (consider as differential diagnosis in ‘resistant lateral epicondylitis), but with maximal pain 4 finger-breadths distal to the common extensor origin
  • May be weakness of digital extensors
  • No sensory symptoms as the posterior interosseous nerve is purely a motor branch
  • Nerve conduction/electromyography have high specificity but low sensitivity

What to do about it:

  • Avoid aggravating factors
  • Physio
  • Refer resistant cases for decompression

Causes of medial arm pain:

  • Medial epicondylitis
  • Ulnar neuritis (cubital tunnel syndrome)
  • Medial collateral ligament injury
  • Radicular pain from T1.

Medial epicondylitis

How to diagnose it:

  • Find common flexor origin by palpating medial side of elbow with wrist held in resisted palmar flexion. Point tenderness is confirmatory.
  • Neurological examination and ROM of elbow should be unaffected.
  • Usually diagnosed clinically, but USS is investigation of choice if investigation needed
  • Nerve conduction studies may be needed to exclude cubital tunnel syndrome if this looks like a likely alternative diagnosis

What to do about it:

  • RICE, avoidance of aggravating factors, taping/bracing
  • Probably eccentric loading, but no direct evidence for this

Cubital tunnel syndrome

What it is: Entrapment of the ulnar nerve within the cubital tunnel

How to diagnose it:

  • Presents with medial elbow pain, hand weakness, and dysaesthesia/pins & needles radiating down medial forearm.
  • Tinel’s test may be positive over medial elbow
  • Froment’s sign – Grip a paper between clenched fist and straight thumb, against resistance. Flexion of the thumb is a positive test as indicates adductor pollicis weakness.
  • Wartenburg’s sign – inability to adduct little finger due to opposed action of extensor digiti minimi. (Forearm pronated, wrist neutral, fingers extended – fully abduct and then adduct all fingers.)
  • Doesn’t in itself affect elbow ROM but note may be seen in RA or OA of elbow joint and thus seen in association with joint symptoms
  • Confirm clinical diagnosis with nerve conduction study

What to do about it:

  • If no weakness (negative Froment’s and Wartenburg’s sign), and sensory symptoms mild, can be managed conservatively – physio, ergonomic advice
  • USS-guided injections can give temporary relief
  • If weakness present (positive Froment’s/Wartenburg’s), refer for decompression

Medial collateral ligament injury

Who gets it: Typically participants in overarm-throwing sports

How to diagnose it:

  • Usually comes on chronically, sometimes with long-term deterioration in throwing ability
  • Medial elbow tenderness approx 2 cm distal to medial epicondyle, +/- swelling
  • Pain can be reproduced by clenching fist or by elbow abduction stress test – putting elbow in valgus stress in 25 deg flexion
  • Compare affected side with contralateral elbow for laxity
  • Investigation not usually needed, but MRI is investigation of choice if done
  • X-ray can exclude other causes of elbow pain – OA, avulsion fractures, loose bodies

What to do about it:

  • Acute injuries – refer for surgical intervention
  • Chronic injuries – refer for physio and stop all throwing/exacerbating factors until pain free
  • Consider surgical referral of chronic injuries if not responding to conservative Rx or if elbow unstable

(Arthritis Research UK handout, Series 6 no 11, spring 2012)

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About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in Credits 2012, Orthopaedics. Bookmark the permalink.

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