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Right upper extremity pain

 
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Right upper extremity pain - May 25, 2007 1:55:00 PM   
buckeye

 

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Hello forum,

A patient reports right upper extremity only occurring after walking about two blocks. The pain starts at the distal arm (medial and lateral epicondyles) and after a few minutes the pain is also at the distal radius. Pain is described as deep and dull. No radiating pain - just pain at these two areas. Pain lessens shortly after stopping the walk but may take an hour or two to be abolished. He continues walking with the pain since it does not change once it starts as described above. He is active at work using hand tools and tolerates various positions of reaching, lifting, twisting, etc. without producing any symptoms at work.

Medical history is significant for cardiac problems with CABG and pacemaker several years ago. Recent cardiac stress test is negative.

Posture is with right scapula lower than the left and forward head. Pain is not reproduced with cervical, thoracic, or upper extremity movements. Strong and pain free muscle contraction - no tenderness. Neural tension tests are grossly symmetrical and do not reproduce any symptoms although some tightness with medial and radial nerve bias. 'Hands up' test produces heaviness of right arm but no change in skin color or other symptoms. After producing symptoms on treadmill, holding the right upper extremity across with right hand on top of left shoulder did not change the pain.
Currently, treating with postural reeducation and nerve glides as a trial. Plan to continue examination. Any suggestions or thoughts?

Thanks.
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Re: Right upper extremity pain - May 25, 2007 2:29:00 PM   
Tom Reeves DPT ATC

 

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Has he tried nitro when he gets the symptoms? A good friend of mine died of a massive MI because he ignored R shoulder and flank pain after playing raquetball.

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Re: Right upper extremity pain - May 25, 2007 2:47:00 PM   
buckeye

 

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To my knowledge, he has not tried nitro. However, his physicians were primarily concerned about cardiac issues and had the cardiac tests done prior to referring to PT.

Good point that cardiac referred pain does not always have to be left sided.

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Re: Right upper extremity pain - May 26, 2007 3:18:00 AM   
nari

 

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scross,

As long as the physicians are happy that the pain was not cardiac in nature, go with the nerve glides as a start.
Cardiac pain can occur on the(R)or(L)side, sternal area, throat, jawline etc. However the fact it is produced with walking only and not with reasonable regular activity at work suggests a non-cardiac cause.
When he is with you, I am sure you would keep an eye and ear out for any suspicious change in the pain pattern.

Nari

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Re: Right upper extremity pain - May 26, 2007 3:52:00 PM   
Dr.Wagner


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Wow...this is angina until proven otherwise...ie Catheterization (not a stress test). He needs a cath.

When was the bypass graft?

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Re: Right upper extremity pain - May 26, 2007 4:18:00 PM   
FLAOrthoPT

 

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TOTALLY agree with the doc here. I mean can be neural, but if he is doing RSI type things at work without symptoms, I'd say it has to be cardiac, some sort of venouos insufficiency or arterial insufficiency, you can play around with the arm over heart of you want to try to guesstimate which one, but either way this guy is NOT for PT needs to go see a cardiologist. come on guys this is why we are pushing towards DPT, we hsould recognize this without posting it on a board.

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Re: Right upper extremity pain - May 27, 2007 8:55:00 AM   
Dr.Wagner


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As stated above ...it really is heart until the patient is catheterized. There is no other answer...needs his cardiologist. Next time this occurs he needs to go to the nearest Emergency Department (after you give him an aspirin).


I posted twice to emphasize the situation.

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Re: Right upper extremity pain - May 27, 2007 9:57:00 AM   
jma

 

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I would seriously take Dr. Wagner's advice on this matter, especially if this happens again while you are working with the patient and for the patient to go to the ER if the patient has symptoms outside the clinic.

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Re: Right upper extremity pain - May 29, 2007 8:41:00 AM   
buckeye

 

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Thanks for all the replies - I have been away for the holiday. When I posted the original message, I did not have the patient record in front of me and was faulty in my memory. This patient stated he had a cardiac catheterization prior to being referred to PT. I sincerely apologize for the miscommunication.

I'll not take offense to the implication of one posting - maybe that person had some bad coffee late in the day.

Now, let's get back to the business of tackling the problem with this patient.

I am considering trying to exercise him on an upright bicycle with good trunk posture to take arm movement and trunk rotation out of the picture. Also considering treadmill with arms crossed to take out some of the trunk activity.

Anything else from my learned colleagues is greatly appreciated.

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Re: Right upper extremity pain - May 29, 2007 1:31:00 PM   
SJBird55

 

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My guess would be more in line with FLA. Could be something with the subclavian. I believe it would be better to communicate that no significant musculoskeletal findings occur and communicate the symptoms that do happen while on treadmill. If you haven't taken vitals, I'd recommend doing that also. If you attempt the treadmill again, BP and heart rate prior and after exercise.

Symptoms are on right versus left, so I'm not sure if this would be helpful?

Ital Heart J. 2004 Jul;5(7):548-50. Links
A uncommon cause of angina during upper limb exercise.Speciale G, Pristipino C, Pasceri V, Irini D, Pelliccia F, Granatelli A, Pironi B, Roncella A, Richichi G.
Interventional Cardiology, San Filippo Neri Hospital, Rome, Italy. giuliospeciale@yahoo.it

Subclavian artery stenosis or occlusion may be a cause of myocardial ischemia in patients treated using an internal mammary artery graft. Subclavian stenosis may cause myocardial ischemia during arm exercise by a coronary-subclavian steal phenomenon, with flow inversion in the graft from the coronary tree to the left subclavian artery. We here describe a case of a patient developing left subclavian occlusion after coronary artery bypass grafting with the left internal mammary artery. The lesion was successfully treated with a carotid-subclavian bypass. The article underscores the importance of an early diagnosis (possibly before bypass surgery) and discusses possible treatments. Percutaneous interventions with stent implantation appear the treatment of choice, but surgery has an important role in case of total occlusion.

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Re: Right upper extremity pain - May 29, 2007 2:22:00 PM   
Dr.Wagner


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Hold on...did you mean "stress test" or "catheterization" TWO separate tests with two completely different negative predictive values.

Stress test: treadmill provocative EKG
Cath: Groin procedure to the heart, with direct visualization of Coronary Arteries.

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Re: Right upper extremity pain - May 29, 2007 3:13:00 PM   
buckeye

 

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As noted above, this was an error in memory on the initial post. The patient stated he had a cardiac catheterization prior to being referred to PT. He stated his primary care physician and 'heart doctor' were both primarily concerned about there being a cardiac component to his arm pain.

Also of note, he mentions rarely awakening at night having pain in both shoulders and upper arms - and less frequently when he awakens the left arm will feel weak. He denies any other left UE symptoms.

Today he was on the exercise bike for five minutes with arms crossed to take away arm and upper trunk movement. He had much difficulty maintaining good posture, needing frequent cues. No symptoms reproduced. Plan to have him work more on postural strength/muscle performance then increase exercise bicycle time (and monitor pulse, SpO2, & blood pressure).

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Re: Right upper extremity pain - May 30, 2007 1:14:00 PM   
Dr.Wagner


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Do you think the patient is correct in his memory of cath prior to therapy? There seem to be some significant red flags with this patient, and some extensive concerns regarding his past medical history.
I would be VERY cautious about aerobic conditioning in this individual since he likely has angina (which is reversible) possibly due to at the very least coronary vasospasm.

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Re: Right upper extremity pain - May 31, 2007 9:55:00 AM   
buckeye

 

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The patient had a left heart catheterization in latter March 2007. The patient was told the test was OK and the heart was not the cause of his arm pain. He was referred to PT based on the results of the catheterization.

I understand the concern - as I asked the questions about his medical history, the red flags were noted. The bypass graft was in 2003. In this case, I am relying on the patient giving me accurate information that he is not told to restrict his activities and his heart cath is OK.

Perhaps I could discuss with his primary care physician a trial of nitro? Even though this may be in the best interest of the patient, such a suggestion often goes over like a lead balloon.

I tend to be the local therapist who does not blindly treat patients just because they are referred by a physician. Over the years a number of physicians have been upset because I question the need for PT or the specific type of PT treatment they are requesting.

I appreciate the responses and insight.

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Re: Right upper extremity pain - May 31, 2007 2:14:00 PM   
Dr.Wagner


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The patient should always have sublingual nitro (ie Nitrostat) around, but longer acting nitroglycerin (such as the patch variety) goes in and out of favor and certainly has some orthostatic hypotensive qualities.
Now, of course a clean cath does not mean there is no vasospasm causing anginal symptoms. Sometimes Calcium Channel blockers are used to control this.

Regardless, it seems as though you have noted the red flags and your antenna are raised.

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Re: Right upper extremity pain - June 4, 2007 2:36:00 PM   
buckeye

 

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I saw the patient earlier today and told him to return to his cardiologist or family doctor for further medical work up. I instructed him to stop his walking for exercise until he has further cardiac work-up or clearance from his cardiologist. Unfortunately, he is also confused about the roles of his physicians - he is seeing a cardiac electrophyisiologist for his rhythm and pacemaker and equates this person with the cadiologist.

I was able to get a copy of the catheterization report and spoke to the cardiologist's nurse. Although the report shows some severe limitations in circulation, the nurse stated the bypass grafts show good blood supply to the appropriate area or collateral circulation is present. After talking to the nurse for several minutes, she aggreed the pain sounds more cardiac than neural or muscular and agreed to discuss with the cardiologist a trial of nitro for the patient. She also noted the patient either canceled or failed to keep a follow-up appointment within the past two or three weeks. I am making a guess this is because he did a follow-up with the electrophysiologist and thought it was a cardiac follow-up.

Thanks again to my learned colleagues for the gray matter support

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