Arm and Shoulder Pain
Differential Diagnosis
Common Diagnoses
- Simple Muscular Strain
- Epicondylitis (Tennis or Golfer’s Elbow)
- Subacromial Bursitis/Capsulitis
- Cervical Spondylosis
- Angina
Occasional Diagnoses
- Bicipital Tendonitis
- Acromioclavicular and Sternoclavicular Joint Pain
- Acute Calcific Tendonitis
- De Quervain’s Tenosynovitis
- Carpal Tunnel (CT) Syndrome
- Cervical Rib
- Brachial and Ulnar Neuritis (Including Post-Herpetic Pain)
- Cervical and Thoracic Disc Prolapse
Rare Diagnoses
- GORD in adults
- Malignancy: Local Bone Cancer, Spinal Cord, Spine and Lung
- Subclavian Aneurysm
- Multiple Sclerosis
- Syphilitic Aortitis
- Thoracic Outlet Syndrome
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Epicondylitis | Muscle Strain | Cervical Spondylosis | Bursitis/Capsulitis | Angina | |
|---|---|---|---|---|---|
| Worse Moving Arm/Hand | Yes | Yes | Possible | Yes | No |
| Hand Paraesthesiae | No | No | Possible | No | Possible |
| Exercise Related | Possible | Possible | No | Possible | Yes |
| Local Arm Tenderness | Yes | Possible | No | Possible | No |
| Limitation of Movement | Possible | Possible | Possible | Yes | No |
Possible Investigations
Likely:None.
Possible:FBC, ESR/CRP, TFT, ECG/secondary care cardiac investigations, nerve conduction studies, chest and neck X-ray.
Small Print:Other X-rays/bone scan, MRI scan, lumbar puncture, syphilis serology.
- FBC, ESR/CRP: May be anaemia and raised ESR/CRP ininflammatory or malignant conditions.
- TFT: Myxoedema and carpal tunnel syndrome significantly associated.
- Neck X-ray sometimes useful to confirm diagnosis of cervical spondylosis and assess its severity: But cervical spondylosis on X-ray does not correlate well with symptoms and may just be an incidental finding.
- ECG/secondary care cardiac investigations: To pursue possible diagnosis of angina.
- Nerve conduction studies: Will help confirm nerve entrapment (e.g. carpal tunnel).
- CXR: For apical tumour.
- Other X-rays/bone scans: If bony tumour (especially secondaries) suspected. Calcium deposits may be seen in acute calcific tendonitis.
- MRI scan, lumbar puncture: If MS suspected; scanning may also be helpful to visualise possible cord lesion (all likely to be arranged after specialist referral).
- Syphilis serology: In the rare case of possible syphilis.
Top Tips
- It is tempting to view arm pain as a welcome ‘quickie’; in fact, a careful history is important to exclude the more unusual serious pathologies and the examination should usually serve only to confirm an already formulated diagnosis.
- Patients with arm pain – especially if it is accompanied by intermittent paraesthesiae – are often inappropriately concerned that the diagnosis may be angina or a stroke. Make sure these fears are properly explored.
- The natural history of many of the more common problems (e.g. subacromial bursitis, epicondylitis) can be quite prolonged. Making this clear from the outset helps maintain the patient’s trust in you if the symptoms do take some time to settle.
- Getting the patient to indicate the site of pain is a useful ploy in shoulder discomfort. Diffuse pain is typical of capsulitis and subacromial bursitis, whereas, with sternoclavicular or acromioclavicular joint problems, or bicipital tendonitis, the area is more likely to be very localised.
Red Flags
- Beware of persistent paraesthesiae with arm pain, especially if the patient also complains of arm or hand weakness; either there is serious nerve compression or some other significant neurological pathology.
- Angina may present only with arm pain. Enquire carefully to establish the pattern of the pain.
- Apical lung tumour (Pancoast tumour) may cause severe arm pain long before any signs are evident. Investigate smokers with unexplained arm pain.
- Consider the other less common diagnoses if the pain is severe and persistent, the diagnosis is not obvious from the history and the patient displays unrestricted arm movements.