Neck and upper extremity pain



Neck and upper extremity pain





Introduction

Neck pain is one of the most common pain complaints heard by primary care practitioners. After low back pain, the neck and upper extremity are the next most common sites of musculoskeletal pain (4.1)1. Neck and upper extremity pain are often disabling. A community survey of musculoskeletal pain in the Netherlands reported limitations to daily life from pain in about one in three people and work absences for one in four people with neck, shoulder, or upper extremity pain1. Interestingly, disability due to neck and upper extremity pain was similar to that for people with low back or lower extremity pain.






4.1 Community survey of musculoskeletal pain. A population-based survey of 3,664 adults ≥25 years old in the Netherlands was used to determine the prevalence of musculoskeletal pain. The most frequently reported anatomical sites for musculoskeletal pain were ranked as follows: low back, neck, shoulder, knee, and wrist/hand. People were about twice as likely to report musculoskeletal pain in the preceding year than chronic pain in each location. (Based on Picavet HJ, Schouten JG, 20031.)

A 12-month survey of general practice patients revealed that neck and upper extremity complaints resulted in 147 general practice consultations for every 1,000 registered patients2. Complaints were most commonly attributed to the neck (23.1 per 1,000 person-years) and shoulder (19.0 per 1,000 person-years). The incidence of neck and upper extremity pain was higher in women and increased until ages 40-49 (4.2).

A recent survey of 5,752 patients registered with a primary care practitioner identified hand pain in 7% of men and women between ages 16 and 44 and 13% of men and 20% of women ≥45 years old3. A similar survey of 6,038 adult primary care patients (ages 25-64 years) reported a specific hand and/or wrist pain syndrome (De Quervain’s or wrist tenosynovitis or carpal tunnel syndrome) in about 3% of patients, with nonspecific hand and/or wrist pain in about 10%4. Hand pain can significantly impair both work and leisure activities.


Assessing neck and upper extremity pain

Chronic neck and upper extremity pain is often caused by musculoskeletal or neurological conditions (Table 4.1). Myofascial pain is characterized by muscle spasm and tender muscles. Areas of discrete tenderness within the muscles, called trigger points, can be locally painful (latent trigger point) and refer pain (active trigger point). Myofascial trigger points in the neck typically refer pain to the head. Myofascial pain from the scalene and serratus anterior muscles refer pain into the upper extremity, while myofascial triggers in the levator scapulae and rhomboids refer to the shoulder (4.3). Pain may also be referred from the heart and lungs.







4.2 Lifetime epidemiology of neck and upper extremity pain. In this Dutch survey, all patient contacts for 96 general practices were evaluated for 12 consecutive months. Incidence density was calculated by determining the number of patients with a first, new episode of a neck or upper extremity complaint during the study year, divided by the sum of person-years at risk. Incidence peaked in the fifth decade, with a higher incidence in women in all age brackets (A). Among the different anatomical locations evaluated, neck and shoulder pain were the most common (B). International Classification of Primary Care (ICPC) codes are shown next to each anatomical location. (Based on Bot AM, et al., 20052.)








Table 4.1 Common causes of neck and upper extremity pain







































Pain location


Diagnosis


Neck


Arthritis



Cervical radiculopathy



Myofascial pain


Shoulder


Arthritis



Bursitis



Myofascial pain



Rotator cuff tendonitis/tear


Upper extremity


Carpal tunnel syndrome



Cervical radiculopathy



De Quervain’s tenosynovitis



Myofascial pain









Table 4.2 Evaluation for common cervical radiculopathies






























Nerve involved


Motor loss


Reflex loss


Sensory loss


C5


Biceps


Biceps


Lateral upper arm


C6


Brachioradialis


Biceps


Lateral lower arm


C7


Triceps


Triceps


Middle finger


C8


Finger flexors


None


Medial lower arm


A herniated cervical disc usually affects the nerve for the vertebra below, e.g. C5 radiculopathy occurs when the C4-C5 disc is herniated. A C8 radiculopathy occurs with a C7-T1 herniated disc.








4.3 Myofascial pain patterns in the shoulder and upper extremity. A: Scalene; B: serratus anterior; C: levator scapulae; D: rhomboids.






4.4 Motor testing for cervical radiculopathy. Arrows denote direction of movement required to test specific muscles. Test biceps strength with the palm facing up. Test brachioradialis strength with thumb pointed up.

Neurological causes of chronic neck and upper extremity pain can be diagnosed by establishing patterns of motor and sensory loss that suggest peripheral nerve or radicular dysfunction. Neurological loss in cervical radiculopathies can be localized to specific nerves by evaluating motor and sensory tests (4.4, 4.5, Table 4.2).






4.5 Sensory testing for cervical radiculopathy. Arm viewed from the anterior aspect, with palm facing toward the viewer. Skin areas served by specific cervical nerve roots are marked.




Shoulder pain

The shoulder is a complex structure (4.6). Shoulder pain can be caused by overuse in older adults or trauma in young patients (Table 4.3). Pain in the anterior shoulder often results from osteoarthritis of the true shoulder joint (glenohumeral joint) or more commonly acromioclavicular joint or biceps tendonitis. Anterior and lateral pain occur with subacromial bursitis and rotator cuff tendonitis.






4.6 Anatomy of the shoulder. The shoulder contains four articulations: the glenohumeral, sternoclavicular, acromioclavicular, and scapulothoracic joints. The rotator cuff is composed of four muscles and their tendons, providing full shoulder motion and joint stability. The subacromial bursa sits on top of the supraspinatus tendon, helping to reduce friction with tendon movement.








Table 4.3 Common causes of shoulder pain






















Adhesive capsulitis



Osteoarthritis glenohumeral or acromioclavicular joint



Rotator cuff tear



Rotator cuff tendonitis/impingement syndrome



Subacromial bursitis



Tendonitis of biceps or supraspinatus tendons


History of trauma or overuse, pain features, and physical examination can help distinguish among common causes of shoulder pain (Table 4.4). Although these features can assist in determining a diagnosis, the clinical evaluation of shoulder pain can be difficult. Several studies have compared results among clinicians when evaluating patients with shoulder pain complaints. In general, diagnostic agreement is poor to moderate. In one study, 44 patients
with shoulder pain were evaluated by three rheumatologists6. Agreement among clinicians was only 46%. When the three rheumatologists evaluated the patients together and discussed diagnostic signs and symptoms, agreement improved to 78%. In another study, diagnostic agreement between two experienced physical therapists for 201 patients with shoulder pain was only moderate (60%)7. Agreement was worse among patients with bilateral, chronic, or severe pain. Clinical tests assessing shoulder function and range of motion are also notoriously unreliable in shoulder pain patients8,9,10. For this reason, most patients with chronic shoulder pain will require radiographic studies in addition to history and physical examination (Table 4.5). Partial rotator cuff tears are best assessed with MRI or ultrasound. A comparison of both techniques against arthroscopic findings in 71 patients with rotator cuff tears showed similar good identification and size measurement for both full and partial tears11.








Table 4.4 Distinguishing features among shoulder pain diagnoses






































Diagnosis


Pain at night


Range of motion


Crepitus




Active


Passive



Osteoarthritis


No


Reduced


Reduced


Present


Rotator cuff tendonitis/impingement


Yes


Reduced


Normal


Absent


Rotator cuff tear


Yes


Reduced


Normal


Absent


Subacromial bursitis


Yes


Reduced


Reduced


Absent









Table 4.5 Radiographic studies for shoulder pain























Test priority


Imaging study


Conditions diagnosed


First-line


Plain X-ray


Osteoarthritis, complete rotator cuff tear



Arthrogram


Adhesive capsulitis, bursitis, complete rotator cuff tear


Second-line


Magnetic resonance imaging


Partial rotator cuff tear



Ultrasound


Partial rotator cuff tear



Subacromial bursitis

Inflammation of the subacromial bursa results in pain in the lateral shoulder and upper arm, aggravated with overhead activities. Pain is generally relieved by rest. There is no pain when elevating the upper extremity in front of the body or behind. Shoulder rotation and abduction, however, are painful (4.7).






4.7 Shoulder motion. Patients with subacromial bursitis report pain and weakness with shoulder abduction (A). Flexion and extension are generally not impaired (B).


Rotator cuff tendonitis

Rotator cuff tendonitis is a common cause of shoulder pain. A prospective, 1-year survey of 131 patients presenting to their primary care physicians for shoulder pain identified rotator cuff tendonopathy in 85%12. Inflammation within the rotator cuff is often combined with subacromial bursitis and termed impingement syndrome. Pain is generally
located over the anterior and lateral shoulder. Impingement syndrome can be confirmed with the Hawkins test (4.8). Rotator cuff tendonitis pain is aggravated with overhead activities and is worse at night. Clicking or popping may occur in the affected shoulder.






4.8 Hawkins test. With the elbow flexed and arm elevated in front of the body, the examiner passively internally rotates the upper extremity.


Hand pain

Hand pain is commonly caused by musculoskeletal, neurological, and vascular pathology (Table 4.6). Hand pain may occur in isolation, e.g. De Quervain’s tenosynovitis and carpal tunnel syndrome, or as part of a more diffuse pain condition, e.g. cervical radiculopathy and rheumatoid arthritis. Sensory dysfunction in the hand can help distinguish pain caused by cervical radiculopathy or compressive mononeuropathy (4.9).

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Jun 29, 2016 | Posted by in PAIN MEDICINE | Comments Off on Neck and upper extremity pain

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