Differentials
Vasospasm, embolism, or insufficiency
SIGNS / SYMPTOMS
Severe chest pain.
INVESTIGATIONS
Angiogram showing narrowing or occlusion of affected vessel.
Coronary artery disease
SIGNS / SYMPTOMS
Chest pain/pressure.
INVESTIGATIONS
Coronary angiogram showing narrowing or occlusion of affected vessel.
Myocardial infarction
SIGNS / SYMPTOMS
Chest pain/pressure with possible radiation to jaw/shoulder/arm, dyspnea, pallor, diaphoresis, and cardiogenic shock.
INVESTIGATIONS
ECG in ST-elevation MI: ST-segment elevation >1 mm in 2 or more anatomically contiguous leads or new left bundle branch block; ECG in non-ST-elevation MI: nonspecific changes; ST-segment depression or T-wave inversion.
Troponins: elevated.
Angina pectoris
SIGNS / SYMPTOMS
Chest pain/pressure brought on by physical exertion and relieved by rest, or present at rest in a patient with a history of coronary artery disease/angina.
INVESTIGATIONS
ECG showing nonspecific changes; ST-segment depression or T-wave inversion.
Troponins: normal.
Polymyalgia rheumatica
SIGNS / SYMPTOMS
Stiffness and pain in neck, shoulder, back, hips, thighs.
Affects adults >50 years.
INVESTIGATIONS
Elevated serum inflammatory markers (i.e., C-reactive protein, sedimentation rate).
Buerger disease
SIGNS / SYMPTOMS
Tobacco smoker.
Pain in the forearms/hands with activity.
Can have signs of ischemia/gangrene of the fingers.
INVESTIGATIONS
Diagnosis is clinical.
Henoch-Schonlein purpura
SIGNS / SYMPTOMS
Palpable purpuric rash, abdominal pain, arthralgia, features of kidney damage.
Typically occurs in children.
INVESTIGATIONS
Hematuria with or without kidney damage seen on basic metabolic panel.
Primary Raynaud phenomenon
SIGNS / SYMPTOMS
Numbness/pain and coolness of fingers when exposed to cold temperatures/stress with associated color changes of the fingers (pale/white or blue/purple during episode; red when episode is resolving).
INVESTIGATIONS
Diagnosis is clinical.
Carpal tunnel syndrome
SIGNS / SYMPTOMS
Pain and numbness primarily in the wrists; night-time worsening of symptoms.
Reproducible pain with physical exam maneuvers (i.e., positive Tinel sign and Phalen sign).
INVESTIGATIONS
Electrodiagnostic testing showing focal slowing of conduction velocity in the median sensory nerves across the carpal tunnel.
Cubital tunnel syndrome
SIGNS / SYMPTOMS
Pain and numbness primarily in the elbow through the ring and little fingers.
INVESTIGATIONS
Electrodiagnostic testing showing motor conduction velocity across the elbow is <50 m/second.
Brachial plexitis
SIGNS / SYMPTOMS
Also known as Parsonage-Turner syndrome, brachial plexopathy, and brachial neuropathy/neuritis.
Self-resolving, sudden onset, primarily unilateral piercing/sharp pain in shoulder and/or upper extremity lasting less than 7-10 days, followed by usually self-resolving upper extremity weakness.
May have a history of previous infection, injury, or surgery.
INVESTIGATIONS
Diagnosis is often clinical.
Electrodiagnostic testing shows abnormalities of the affected nerves.
Herniated or ruptured cervical intervertebral disk
SIGNS / SYMPTOMS
Pain radiating down the upper extremity.
INVESTIGATIONS
MRI cervical spine showing herniation and/or rupture of cervical intervertebral disk.
Cervical stenosis and/or degenerative joint disease
SIGNS / SYMPTOMS
Stiffness and pain in the upper neck. Possible radicular symptoms.
INVESTIGATIONS
Cervical spine x-ray showing cervical degenerative joint disease (i.e., intervertebral disk space narrowing, vertebral osteophytes, and facet hypertrophy).
Cervical dystonia
SIGNS / SYMPTOMS
Involuntary contraction of neck muscles and abnormal movements and postures of the head and neck. Rhythmic tilting, leaning, or twisting of the head is often observed, and permanent or fixed contractures may occur.
INVESTIGATIONS
Diagnosis is clinical.
Quadrilateral space syndrome
SIGNS / SYMPTOMS
Rare disorder with compression of the axillary nerve and/or posterior circumflex humeral artery in the quadrilateral space, which is bound by the lateral head of the triceps muscle, teres minor muscle, teres major muscle, and the medial border of the humerus. Compression may be due to fibrous bands or muscle hypertrophy. Symptoms include pain in the posterior shoulder, difficulty lifting the arm, and numbness over the deltoid area of the shoulder. Some patients may develop arterial thromboembolism from pathologic changes in the posterior circumflex humeral artery, which accompanies the axillary nerve through the quadrilateral space.[27][28][131]
INVESTIGATIONS
MRI may demonstrate atrophy of the teres minor and/or deltoid muscles with or without fatty infiltration.
Angiography shows occlusion or compression of the posterior circumflex artery in the quadrangular space region, more pronounced when the arm is abducted.
Suprascapular neuropathy
SIGNS / SYMPTOMS
Uncommon condition arising from compression of the suprascapular nerve as it passes through the suprascapular notch underneath the transverse scapular ligament. May occur more frequently in high-performance overhead athletes. Symptoms include shoulder pain and weakness, with exacerbated pain during adduction and internal rotation. Supraspinatus and infraspinatus muscle atrophy is considered to be pathognomonic.[132][133]
INVESTIGATIONS
Electromyography and nerve conduction studies indicate denervation of the suprascapular nerve.
Multiple sclerosis
SIGNS / SYMPTOMS
Typically relapsing-remitting neurologic symptoms that can include: numbness or weakness in extremities, radicular symptoms with neck flexion, fatigue, vision changes, tremor, unsteady gait, and/or bowel/bladder dysfunction.
INVESTIGATIONS
MRI brain and/or spine shows characteristic lesions.
Rotator cuff injury
SIGNS / SYMPTOMS
Pain in shoulder with possible arm weakness.
Provocative physical exam maneuvers.
INVESTIGATIONS
MRI shoulder showing partial or complete tearing of one or more tendons of the rotator cuff (most commonly supraspinatus).
Adhesive capsulitis
SIGNS / SYMPTOMS
Pain in shoulder with decreased range of motion in shoulder joint.
INVESTIGATIONS
Diagnosis is clinical.
Shoulder impingement
SIGNS / SYMPTOMS
Pain in shoulder with certain movements and provocative physical examination maneuvers (i.e., Neer test and Hawkins test).
INVESTIGATIONS
Diagnosis is clinical.
Glenohumeral/acromonial clavicular degenerative joint disease
SIGNS / SYMPTOMS
Pain in shoulder with movement and tenderness to palpation over joint spaces.
INVESTIGATIONS
X-rays show evidence of degenerative joint disease.
Evidence of degenerative joint disease on musculoskeletal ultrasonography of the acromioclavicular joint.
Superior/pulmonary sulcus tumor (Pancoast tumor)
SIGNS / SYMPTOMS
Severe scapular, shoulder, and/or upper extremity pain.[134]
May also develop hand muscle weakness and/or atrophy.
Horner syndrome can develop if invasion into the sympathetic ganglion occurs (e.g., ptosis, miosis, anhidrosis).
INVESTIGATIONS
CT chest or MRI neck/shoulder (if images include pulmonary sulcus) demonstrate a tumor.[135]
Trigger points
SIGNS / SYMPTOMS
Pain in neck, shoulder, or upper extremity.
Pain reproduced with palpation of specific trigger points.
INVESTIGATIONS
Diagnosis is clinical.
Fibromyalgia
SIGNS / SYMPTOMS
Chronic, widespread body pain and accompanying symptoms such as fatigue, memory difficulties, disturbance of sleep and mood.
INVESTIGATIONS
Diagnosis is clinical.
Complex regional pain syndrome (CRPS)
SIGNS / SYMPTOMS
Chronic burning or throbbing pain in the upper (or lower) extremity out of proportion to expected following an injury or illness (type 1) or surgery (type 2; causalgia).
Can also have allodynia, edema over the area of pain, changes in skin color (e.g., whitening, mottling, blueness or redness), decreased range of motion, and/or weakness.
INVESTIGATIONS
3-phase nuclear bone scan may show increased uptake/activity on delayed phase/pooling images (diagnostic utility is debated).
Radiographs may show evidence of previous injury, surgery, degenerative changes, and/or osteopenia.
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