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A 33-year-old right-handed man presents to your clinic with upper extremity pain that started 2 weeks ago. The pain is worse with movement and relieved with ibuprofen. He denies antecedent trauma but began taking tennis lessons 3 weeks earlier. The pain only occurs in his serving arm and has recently progressed, prompting his visit today.

  • What additional questions would you ask to learn more about his upper extremity pain?
  • How would localizing the pain help in generating a differential diagnosis?
  • What activities put the patient at risk for specific upper extremity problems?
  • How can you use the history to identify serious diagnoses?

Pain in the upper extremities most commonly arises from musculoskeletal sources. However, pain may also result from soft tissue infection or diseases of blood vessels or peripheral nerves or be referred from embryologically linked structures in the chest. Deep pain, arising from vessels, fascia, joints, tendons, periosteum, and supporting structures, is often poorly localized and dull and may be accompanied by the perception of joint stiffness and deep tenderness. Pain arising from adjacent or supporting structures may be attributed to the joints in the absence of true joint pathology. Pain from dis-orders of proximal joints (elbow and wrist) is usually related to local inflammation from overuse syndromes or work-related activities (1% of work-related injuries affect the forearm, and 55% of work-related injuries affect the wrist). Pain in the hand joints is often a consequence of degenerative or inflammatory disease.

Painful intermittent vasospasm in the hands (Raynaud's phenomenon) is often attributable to digital artery vascular instability in young women but occurs in all age groups. It occurs less commonly in men. A variety of medications have been implicated as exacerbating this phenomenon. Athero-sclerotic narrowing of vessels occurs rarely in the upper extremity, usually in the setting of systemic vascular disease. Pain from peripheral nerve disease or entrapment neuropathies, such as carpal or ulnar tunnel entrapment, is accompanied by motor (weakness), reflex, and other sensory changes (burning or tingling).

Rarely, neuropathic pain in the upper extremity results from reflex sympathetic dystrophy/chronic regional pain syndrome (RSD/CRPS), a poorly understood condition that follows local trauma, stroke, or spinal cord injury. Irritation of the cervical nerve roots (herniated nucleus pulposus, osteoarthritis) can cause upper extremity pain. Upper extremity pain caused by compression of the nerves and blood vessels as they exit the thorax (thoracic outlet syndrome) is frequently associated with evidence of vascular compression. Referred pain, originating from structures of the chest, such as thoracic outlet syndrome, ischemic heart disease, or gastroesophageal reflux disease (GERD), may radiate to the inner surfaces of the arm.

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BursitisPain and inflammation of the structure containing the fluid that lubricates a joint or tendon sheath.
Degenerative joint diseasePainful, noninflammatory changes in a joint that result from "wear and tear" of chronic use and abuse.
Entrapment neuropathyPain and loss of function ...

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