Upper Extremity Pain

The upper extremities, defined as the hands, wrists, forearms, upper arms and shoulders, are commonly the site of chronic pain. Any part of the upper extremity mechanism is subject to joint inflammation, bone fracture, or injury to the extensive nerve innervations which makes possible the feats of strength or fine motor movements of the upper extremities. A loss of any of these functions can be extremely disturbing to any patient.

A fracture would normally be considered an acute injury, but sometimes these fractures do not heal in a natural or complete way. The long bones of the arm may be shortened upon healing, they may be thinned or osteoporotic, or they may have various bony projections at the injury site which compromise nerve or blood vessel function. Muscles and tendons may be torn and not subject to former functional capacity. All the joints mentioned can heal with spurs which dig into the internal joint capsule upon movement. Each of these problems can lead to chronic joint pain or pain in any other of the mechanical structures of the upper extremity.

Arthritis can certainly lead to chronic pain in the upper extremity. It is perhaps more common for rheumatoid arthritis to virtually wreck the joints of the hands, but it can affect other joints, as well. There are exciting new immune modulating drugs which can halt and even reverse the damage of rheumatoid arthritis. They are very expensive, but they are out there. The chronic pain of osteoarthritis, the "wear and tear" arthritis, can often be controlled by NSAID medication, the family of which would include ibuprofen, naproxen, diclofenac, or meloxicam (Mobic). Osteoarthritis, or OA as it is called, can often be treated symptomatically with regular or extra-strength Tylenol. Physical therapy and/or splinting selectively can help with chronic pain.

Ligaments which bind the joints together are subject to tears which can disrupt joint integrity and can cause chronic pain. Of particular note is the AC joint of the shoulder where the clavicle bone across the top of the chest actually joins the acromial projection of the scapula ("wing-bone"). If this ligament is torn or stretched it can ache with use or can fall out of joint. Damaged ligaments of the elbow can interrupt the smooth rotation of the radial head upon the ulna (bones). Similar conditions can occur at the wrist, this time with the head of the ulna bone rotating upon the radius bone. The ulnar nerve has to pass through a ligamentous tunnel on the palm side of the wrist. The fit can be too small and inadequate, causing pain or numbness in the distribution of the ulnar nerve (Carpal Tunnel Syndrome.) One cause of pain in the upper extremity is stretching or other injury of the brachial plexus. This complex "junction box" of nerves lies deep to the armpit and sorts and distributes nerves of motor strength as well as sensation.

Muscle and tendon tears can be the source of chronic pain in the upper extremity. Of course there is the tendon inflammation called tendonitis which can involve any tendon. Tendonitis is often treated with NSAIDS and physical therapy, although sometimes a stronger medicine may be needed.

Chronic severe upper extremity pain may require stronger analgesics (or pain medicines.) There is a synthetic, non-narcotic drug called Tramadol, which may be combined with an NSAID for excellent pain relief. Sometimes it may be necessary to carefully prescribe a limited number and schedule of narcotic medication. The overall goal would be to continue to look for causes and treatments of the chronic pain such that it might be prescribed for a limited time. However, there are those who require it for an ongoing time if they are to normalize their activities of daily living.