Upper Limb History

Cure Arthritis Naturally

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The presenting complaints arising from hands and wrists are usually stiffness, pain and loss of function. Pain and stiffness are usually well localised to the affected joints. In early inflammatory arthritis stiffness with reduced function may be the only symptoms, and pain may be minimal or absent. The complaint of local or diffuse swelling is common, but should always be confirmed on examination. The distribution of joint involvement is critical to diagnosis. If hand pain is diffuse or poorly localised by the patient, referred pain or a neurological problem such as carpal tunnel syndrome (Fig. 8.14) should be considered. This condition also frequently causes numbness and sleep disturbance. The patient may report hanging the arm down and shaking the hand to relieve the pain.

Pain due to pathology in She elbow joint is usually exacerbated by use and may be localised or referred to l he forearm. The commonest problem is lateral epicondylitis or so-called 'tennis elbow". Symptoms of pain in the upper outer arm or shoulder region with restriction of shoulder movements suggests pathology affecting one or more of the major structures of Ihe shoulder girdle (i.e. glenohumeral, sternoclavicular or acromioclavicular joints, rotator cuff tendons or bone). Pain arising in the shoulder is felt over its anterior aspect or in the lateral aspect of the upper arm. The pain is exacerbated by lying on the shoulder and may cause sleep disturbance. Movements are likely to be both restricted and painful causing the patient to report difficulty putting on a jacket or reaching up to a shelf. Rotator cuff pathology tends to produce pain on elevating the arm. Pain which is

KEY POINTS

• Note abnormalities of posture and distinguish between structural and postural scoliosis.

• Sites of spinal tenderness help to localise pathology.

• Assess range of movement and remember that even with a rigid spine a patient can touch the toes if the hips are mobile.

• Identify local or widespread muscle tenderness.

• Perianal sensory loss and sphincter tone should be assessed If sacral nerve root involvement is suspected.

TABLE 8.8

Sites of somatic referral of limb joint pain

Shoulder

to Lateral aspect of upper arm

Elbow

to Forearm

Hip

to Anterior thigh or knee or both

— premenstrual

Sites Median Nerve Entrapment

Fig. 8.14 Causes of median nerve compression.

Synovitis of flexor tendons

Bony compression e.g. acromegaly, dislocated lunate

Increased fluid

— premenstrual

Flexor retinaculum

Median nerve

Fig. 8.14 Causes of median nerve compression.

difficult for the patient to localise, in the absence of shoulder restriction, is more likely to suggest referred pain from the neck or viscera.

A history of trauma is usually obvious and in young adults may he associated with dislocation of the shoulder, There is a tendency for this to be recurrent. Occasionally, dislocation may occur without an apparent history of trauma, such as after a nocturnal epileptic convulsion.

If the pattern of symptoms, e.g. diurnal variation, suggests an inflammatory disorder, a family history (Tabic 8.6) and symptoms of extra-articular features (Table 8.5) should be sought and close enquiry made about other joints (Table 8.2). The impact of upper limb symptoms on normal daily activities, i.e. extent of disability, should be documented (Table 8.9).

TABLE 8.9 Joints involved in performing dally activities

Pincer grip -for writing.

Hand

Opposition of thumb to

turning key

index

Gripping taps, handles,

Hand, wrist

Grasp

bottle tops

Eating, cleaning teeth and

Hand, elbow

Grasp, elbow llexion

face

Dressing, washing and

Hand, elbow,

Pinch, grasp, elbow flexion

grooming hair

shoulder

Shoulder elevation/rotation

Cleaning perineum

Hand, wrist.

Grasp, wrist and elbow

elbow,

flexion

shoulder

Forearm supination

Internal rotation shoulder

KEY POINTS

General

• Establish the site and distribution of pain and associated symptoms

• Establish the daily pattern of symptoms.

• Enquire about extra-articular features and family history il a systemic inflammatory condition is suspected.

• Distinguish whether upper limb pain is due to local pathology or referred from the neck.

« Document functional difficulties.

Hand and wrist

• If pain is poorly localised, enquire about night pain and numbness in the hand.

Shoulder

• Remember that pain in Ihe shoulder may be referred from the cervical spine, the root of the neck, pleura, diaphragm or peritoneum

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Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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