Approach to upper limb pain

By : S. Khosrawi M.D. , Physiatrist

Dept. of Physical Medicine &Rehabilitation

Faculty of Medicine

Isfahan Univ. of Med. Sci.

• Upper extremity pain is a leading cause of physician visits particularly in sports and the workplace, contributing significantly to disability and lost productivity.

• This seminar describes some of the more common causes of upper limb pain , identifies potential mechanisms of injuries , and present some remedies for successful rehabilitation.

Consider:Nonmusculoskeletal problems may

presentwith musculoskeletal symptoms

Hypo(er)thyroidism Paraneoplastic Lyme Acute/subacute BE Hepatitis C

(cryoglobulinemia)

Question?

Peri-articular

Vs.

Articular Dysfunction?

◦Anatomic region◦Tendons, bursae, muscles, nerves

◦Joint swelling◦Joint abnormality

Question?Inflammatory

Vs.Degenerative

Problems?

Fatigue Fever Rash Anemia Inc ESR/CRP Morning Stiffness Weight loss Raynaud’s

phenomenon

Instrinsic Causes :Periarticular Disorders

TendinitisImpingement syndromeCalcific tendinitisTearingsAcute strainBursitisMyofascial Trigger Points

Articular DisordersInflammatory arthritisOsteoarthritisOsteonecrosisSeptic arthritisAdhesive capsulitisJoint instability

Extrinsic Causes :Regional Disorders

Cervical radiculopathyBrachial neuritisNerve entrapment syndromesReflex sympathetic dystrophyFibrositisNeoplasms

MiscellaneousGallbladder diseaseSplenic traumaSubphrenic abscessMyocardial infarctionThyroid diseaseDiabetes mellitusRenal osteodystrophy

Along the spectrum of potential conditions, musculoskeletal soft-tissue injuries are the most common.

A detailed understanding of the relevant functional anatomy and potential mechanisms of injury allows for the most accurate diagnosis and is directly related to the likelihood of successful treatment.

The soft tissues constitute a diverse group of connective tissues, including ligament, tendon, muscle, cartilage, fascia, synovium, articular cartilage, adipose tissue, and intervertebral disc.

There are numerous factors influencing the integrity of soft tissues, including age, sex, temperature, body weight, exercise, nutrition, drugs, immobilization, injury, and systemic illnesses such as inflammatory arthritis and the collagen vascular disorders.

The most common mechanisms of injury include acute trauma and repetitive overuse or overload.

Musculotendinous structures are especially vulnerable to failure from sudden overloading, as with forceful muscular contractions, particularly when weakened as a result of concurrent illness (connective tissue disorders) or medications (steroids).

Grade Signs and Symptoms Functional Implications

First degree(Mild sprains)

Minimal pain and swellingNo ligamentous instabilityMinimal localized tenderness

No significant loss of functionBracing often unnecessaryRapid return to activity

Second degree(partial rupture)

Significant pain and swellingSubtle structural instabilityOccasional joint effusion

Protective bracing indicatedSignificant activity limitationsSusceptible to recurrenceFunctional recovery within 4 to 6 weeks

Third degree Marked swelling and hemarthrosisStructural instability

Immobilization indicatedSurgery may be requiredProlonged functional limitation

Ligament Sprains

Injury Characteristics

Paratenonitis or/tenosynovitis

Inflammation of the paratenon with associated pain, swelling, and tenderness

Tendinitis Inflammation of the tendon with associated vascular disruption and inflammation

Tendinosis Intratendinous atrophy and degeneration with a relative absence of inflammation; a palpable nodule may be present over tendon

Paratenonitis with tendinosis

Partial or complete rupture

Acute inflammation superimposed on chronic tendinitis

Acute inflammation is often superimposed on chronic inflammation with tendinosis

Tendon Injuries

Muscular injuries are particularly common in sports. These are typically classified as contusions, strains, avulsions, and delayed-onset muscle soreness.

Contusions result as a direct blow and are graded as mild, moderate, or severe based on the degree of soft-tissue swelling, motion restriction, and functional impairment.

Intramuscular contusions tend to be more severe, resolve slowly, have more extensive scarring and are susceptible to developing myositis ossificans

Muscular strains result from overstretching or peak contraction of the musculotendinous unit, particularly during eccentric muscular contractions.

These injuries tend to occur more commonly at the musculotendinous junction.

The classification is similar to that of muscular contusions.

Contractile forces begin to recover as soon as 1 week after an acute strain; however, there is often prolonged and sometimes permanent loss of complete contractile ability .

Therefore, the functional ability of a patient recovering from a muscular strain may be significantly limited, and premature return to activity may increase the risk for further injury.

Delayed-onset muscle soreness typically occurs within the first 24 to 48 hours after an intense bout of exercise that often involves repeated eccentric muscular contractions.

Both inflammatory and metabolic mechanisms have been proposed for muscle damage in this condition .

In most cases, the condition is self-limiting but occasionally requires activity modification and antiinflammatory medication.

It is useful to approach the treatment and rehabilitation of soft-tissue injuries through a conceptual framework that begins with establishing the most anatomically correct diagnosis and ultimately returns the patient to normal athletic or occupational performance.

Protecting the injured site and controlling pain and inflammation set the stage for an active therapy program toward improving the flexibility, strength, and endurance of the damaged tissue.

Major Goals of Treatment in Musculoskeletal Problems

 Relieve Pain

Maximize Function