Arm Pain, Numbness, and Tingling: Etiologies and Treatment Steve Fowler MD Confluence Health Department of Physiatry
Education Medical School: University of Utah Residency: Mayo Clinic Work Confluence Health Wenatchee Physiatry Department Spine Clinic Director
No financial disclosures
Case 1 40 yo male complains of right medial forearm and hand numbness and tingling 3 month duration, no inciting factor No pain Affects 4th and 5th digits Wakes him at night He tends to hug a pillow when sleeping
Exam Normal appearance of upper extremity Normal strength, sensation, and reflexes Mild tenderness to palpation at the ulnar groove at the medial epicondyle
Differential?
The differential diagnosis: Ulnar neuropathy at the wrist rare Ulnar neuropathy at the elbow Medial cord/lower trunk plexopathies Lower trunk lesions would include: medial forearm sensory loss (MABC sensory deficit) ulnar motor signs (e.g. weakness of finger spreading) median motor signs (e.g. weakness on thumb abduction) radial motor signs (e.g. weakness of index finger extension) If index finger extension is normal - consider medial cord C8-T1 radiculopathy would include neck pain in addition to the above mentioned weakness Myelopathy/Syrinx - bilateral symptoms and hyperreflexia
Nerve Conduction Study NCS/EMG 80-90% sensitive if motor and sensory symptoms Ultrasound Thickening Subluxing nerve? Diagnostics
Ulnar Neuropathy Ulnar Neuropathy at the elbow is the 2nd most common entrapment neuropathy With elbow flexion => pressure at cubital tunnel doubles (9 20mmHg) Carpentry hammer hand Cycling Pillow hugging Any prolonged pressure
Ulnar Neuropathy: Management Mild cases: Avoid direct pressure Avoid flexion Elbow pad 90% effective at 3-6 months in mild cases Corticosteroids not effective
Ulnar Neuropathy: Management Severe cases: Ulnar nerve transposition No consensus when to operate Consider with: Fixed sensory loss Weakness Intractable pain Denervation on EMG
Case 2 60 y/o female fruit sorter presenting with right hand numbness and tingling Gradual and intermittent 12 months ago, now wakes her nightly Affects thumb, index and middle fingers Tends to be worse in the morning Worse with repetitive use, such as sorting fruit
Exam Mild thenar wasting compared to unaffected hand Notable weakness of thumb abduction Diminished sensation thumb, index, middle and half of ring finger Phalen s test positive at 10 seconds Tinel s mildly positive Spurling s negative
Differential diagnosis: Median neuropathy Sensory pattern could suggest C6 or C7 radiculopathy would include neck pain weakness in C6/C7 innervated muscles elbow flexion, wrist extension (C6) elbow extension and finger extension (C7) Lower trunk plexopathies lower trunk lesions would include median, radial AND ulnar motor signs and medial forearm sensory loss.? Musculoskeletal origin
Median Neuropathy/CTS The most common of all entrapment neuropathies Women more often affected than men Bilateral cases common Dominant hand more commonly affected Typically, dysesthesias affect hand and forearm, but may ascend to shoulder (not neck) Sensory changes first, motor changes to follow Common to have loss of dexterity CTS is a clinical diagnosis. One may have median neuropathy (with NCS/EMG testing) without CTS
Median Neuropathy/CTS Etiology Most cases idiopathic Compression results in ischemia, demyelination, and eventually wallerian degeneration/axonal loss DM, hypothyroidism, RA, pregnancy associated with CTS
Median Neuropathy (CTS)- Clinical Diagnosis Sensory symptoms x 1 month At least 2 digits of digits 1-4 Intermittent or if constant, previously intermittent Not pain alone Aggravating precipitants: Sleep Sustained hand/arm positioning (Phalen s test more sensitive than Tinel s) Repetitive hand movements Relieved by: Change in hand posture Shaking hand Use of wrist splint
Electrodiagnostics for CTS EMG/NCS When to order? When dx is in question Why? EMG/NCS change final clinical diagnosis ~40% of time Excludes mimickers Diagnosis of superimposed lesions Define electrophysiological severity
Median Neuropathy (CTS) Management Wrist Splints Night only 2 week trial Steroid injection US guided - variable anatomy, avoid neurovascular structures Physical Therapy Surgery
Case 3 52 y/o man with intermittent left arm pain, numbness and tingling for 2 years, now worsening No recent trauma Pain radiates from neck to wrist along lateral arm Paresthesias into 2nd and 3rd fingers Increasing difficulty performing push ups Pain worse with looking over left shoulder when driving
Exam 4/5 weakness in triceps and extensor digitorum Triceps reflex diminished compared to unaffected arm Sensory exam normal Spurling s positive for arm symptoms
Differential diagnosis Cervical radiculopathy Localization? Median or radial neuropathy Brachial plexopathy (middle trunk? posterior cord?) Neurogenic thoracic outlet syndrome a. Exceedingly rare b. Caused by cervical rib, repetitive lifting, trauma, poor posture
Diagnostics Exam, first and foremost MRI if progressive weakness or unrelenting pain, ~2-6 weeks EMG/NCS
MRI - Asymptomatic Cervical Disc Pathology ~20% men in their 20s ~12% women in their 20s ~90% both men/women over 60 years of age
EMG/NCS Clarify diagnosis Radiculopathy? Median, Ulnar or Radial Neuropathy? Brachial plexopathy? Double Crush syndrome? Correlate with Imaging High false positive rate on MRI Guide treatment ESI - what level? Surgery EMG clarifies extent of motor axon loss
MRI vs EMG Should be viewed as complementary tests MRI - Static image EMG - Physiologic function of nerve Sensitivity not as good (~75%), BUT if done correctly, specificity up to 100%
Cervical Radiculopathies ~25% of all radiculopathies are cervical ~75% are lumbar (rare thoracic) 70% C7 20% C6 10% C5, C8
Cervical Radiculopathies Etiology: 25% Herniated Disc (Age <50) 75% Neuroforaminal Stenosis
Cervical Radiculopathy Management Time PT Medication Epidural steroid injection Surgery
Cervical Radiculopathy Management Time
Cervical Radiculopathy Management PT
Cervical Radiculopathy Doctors pour drugs, of which they know little, for diseases, of which they know less, into patients of which they know nothing. Voltaire Acetaminophen NSAIDs Muscle relaxants Steroids Nerve stabilizers Opioid analgesics
Cervical Radiculopathy Epidural Steroid injection Surgery
Unusual Case of arm pain/weakness 60 year old man with 4 weeks of pain and weakness in left arm Awoke one day with severe pain in shoulder Hospitalized for pain control Pain resolved after a week Weakness in proximal left arm started after pain resolved
Unusual Case of arm pain/weakness Exam 2/5 strength shoulder abduction and elbow flexion Absent biceps reflex Reduced light touch sensation on lateral forearm
Differential Cervical Radiculopathy Brachial Plexitis Mononeuropathy Weakness in proximal left arm noticed after pain resolved
Brachial Plexitis Brachial Plexitis (Parsonage-Turner Syndrome) Severe pain (1-2 weeks) followed by weakness and muscle atrophy 1.6 people per 100,000/yr Etiology often unclear Sometimes preceded by event that triggers immune system Virus Vaccination Trauma Surgery Beghi E, Kurland LT, Mulder DW, Nicolosi A (1985). "Brachial plexus neuropathy in the population of Rochester, Minnesota, 1970-1981". Ann. Neurol. 18 (3): 320 3
Brachial Plexitis Management Symptomatic treatment Tincture of time Medication Anticonvulsants Narcotics Physical Therapy
Unusual Case of arm pain/weakness 50 year old male presents with circumferential burning pain and weakness in right forearm and hand Occasional swelling and color changes Symptoms started after carpal tunnel release
Exam Patient very guarded, holds arm closely to body, adducted, internally rotated Hand/fingers in soda-can posture Skin taut, fingers shiny, hand warm, diffuse erythema compared to contralateral limb Diffuse allodynia in forearm, hand and fingers
Differential CRPS (Complex Regional Pain Syndrome) Thrombosis Neurogenic source
Diagnostics Exam Triple Phase Bone scan
Complex Regional Pain Syndrome CRPS criteria:
Complex Regional Pain Syndrome Cause: Unknown in most cases (Type 1)? related to trauma, burn, surgery Nerve injury (Type 2) Dysregulation of sympathetic nervous system
CRPS Management Anticonvulsants, narcotics, bisphosphonates, anti-inflammatories, TCAs PT (get in early!) gentle, progressive ROM desensitization mirror box treatment Stellate ganglion or lumbar sympathetic block