What is the most likely cause and recommended management for exertional chest pain radiating to the left arm with throat burning and left‑arm paresthesia that occurs only when walking uphill, given that cardiac causes, pulmonary embolism, and imaging studies are normal?

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Musculoskeletal Chest Pain: Cervical Radiculopathy or Thoracic Outlet Syndrome

Given the exertional nature with uphill walking only, normal cardiac workup, and combination of chest pain with left arm paresthesia, this presentation is most consistent with cervical radiculopathy (cervical angina) or thoracic outlet syndrome—both musculoskeletal conditions that mimic cardiac pain but are triggered by specific postural demands of uphill ambulation.

Clinical Reasoning

The key diagnostic features pointing away from cardiac causes and toward musculoskeletal etiology include:

  • Positional/mechanical trigger: Symptoms occur exclusively with uphill walking (requiring forward trunk flexion and increased upper extremity muscle engagement) but NOT on flat surfaces—this is atypical for true angina, which would be triggered by any exertion reaching the same metabolic threshold 1
  • Paresthesia: The presence of left arm paresthesia is a neurological symptom that does not occur with cardiac ischemia; cardiac pain involves referred pain but not true nerve distribution symptoms 2
  • Normal cardiac evaluation: With cardiac causes and PE already excluded, the differential shifts dramatically toward non-cardiac etiologies 1

Most Likely Diagnosis: Cervical Radiculopathy ("Cervical Angina")

Cervical angina is an under-recognized cause of chest pain originating from cervical spine pathology that can perfectly mimic cardiac pain 3. The condition involves:

  • Nerve root compression at cervical levels (typically C5-C8)
  • Referred pain to chest and left arm following dermatomal patterns
  • Triggered by neck position and upper extremity movements
  • Associated paresthesias in the affected arm distribution

Why uphill walking specifically? Walking uphill requires:

  • Forward neck flexion to maintain balance
  • Increased upper extremity muscle engagement for arm swing and potential handrail use
  • These mechanical factors compress already compromised cervical nerve roots 4

The burning throat sensation may represent referred pain from C4-C6 levels, which can radiate to the anterior neck and upper chest 3.

Diagnostic Confirmation

To confirm cervical radiculopathy:

  1. Cervical spine imaging: MRI cervical spine to identify disc herniation, foraminal stenosis, or spondylosis 3
  2. Provocative maneuvers:
    • Spurling's test (neck extension with rotation toward symptomatic side)
    • Upper limb tension tests
    • Assess if symptoms reproduce with cervical range of motion 3
  3. EMG/nerve conduction studies: If diagnosis remains uncertain

Management Approach

Conservative treatment is first-line 4:

Acute Phase

  • NSAIDs: Ibuprofen 400-600mg TID or naproxen 500mg BID for anti-inflammatory effect
  • Muscle relaxants: Cyclobenzaprine 5-10mg at bedtime if muscle spasm present
  • Activity modification: Avoid prolonged neck flexion, use proper ergonomics

Rehabilitation Phase

  • Physical therapy: Cervical traction, postural training, strengthening of cervical stabilizers
  • Heat therapy: For muscle relaxation
  • Cervical collar: Short-term use (days, not weeks) only if severe

Refractory Cases

  • Epidural steroid injections: For persistent radicular symptoms
  • Surgical consultation: If progressive neurological deficits or failure of 6-12 weeks conservative management

Alternative Consideration: Thoracic Outlet Syndrome

If cervical imaging is normal, consider thoracic outlet syndrome (TOS):

  • Compression of neurovascular bundle between clavicle and first rib
  • Triggered by arm elevation and specific postures (like uphill walking with arm swing)
  • Presents with arm paresthesias and chest/shoulder pain
  • Diagnosed with provocative maneuvers (Adson's test, Wright's test)
  • Managed with physical therapy focusing on shoulder girdle strengthening and postural correction

Critical Pitfall to Avoid

Do not dismiss this as "non-cardiac" without specific diagnosis and treatment plan. Patients with cervical angina often experience delayed diagnosis and unnecessary anxiety, repeated ED visits, and cardiac testing 3. The key is recognizing that:

  • Up to 20% of chest pain presentations have orthopedic causes 4
  • The exertional component mimics angina but the mechanical trigger (uphill only) and neurological symptoms (paresthesia) distinguish it
  • Once life-threatening causes are excluded, pursue musculoskeletal evaluation aggressively

Immediate Next Steps

  1. Order MRI cervical spine to identify structural pathology
  2. Refer to physical medicine/rehabilitation or orthopedic spine specialist
  3. Initiate trial of NSAIDs and activity modification
  4. Reassure patient that symptoms, while distressing, are not life-threatening once cardiac causes excluded
  5. Document specific triggers and response to conservative measures for treatment optimization

341

References

2
Research

Mechanisms of cardiac pain.

Comprehensive Physiology, 2015

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