What is the diagnosis and management for a 25-year-old patient presenting with numbness, tingling, and pain in the left arm and shoulder since January?

Diagnosis and Management of Left Arm Numbness, Tingling, and Pain in a 25-Year-Old

For a 25-year-old patient with left arm numbness, tingling, and shoulder/chest pain since January, MRI of the shoulder without contrast is the most appropriate next diagnostic step after initial radiographs to evaluate for labral tear with or without instability.

Initial Assessment

Clinical Presentation

• Numbness and tingling in left arm
• Left chest/shoulder pain
• Symptoms persisting for several months
• Young adult (25 years old)

Differential Diagnosis

1. Labral tear with or without instability - Most likely given age and symptom pattern
2. Rotator cuff pathology
3. Cervical radiculopathy
4. Thoracic outlet syndrome
5. Peripheral nerve entrapment

Diagnostic Approach

Step 1: Initial Imaging

• Standard radiographs of the shoulder should be obtained first
  • Should include anteroposterior (AP) views in internal and external rotation
  • Axillary or scapula-Y view is essential to evaluate for glenohumeral alignment 1
  • Radiographs should be performed upright to properly assess alignment 1

Step 2: Advanced Imaging (if radiographs are noncontributory)

• MRI shoulder without contrast is the recommended next step 1

  • For patients under 35 years, labral tears and instability are common causes of shoulder pain 1
  • MRI effectively diagnoses most traumatic soft-tissue pathologies including labral, rotator cuff, and glenohumeral ligament injuries 1
  • Can also assess bony morphology and bone loss 1

• Alternative options if MRI is contraindicated:

  • MR arthrography (rated 9/9 for appropriateness) 1
  • Ultrasound shoulder (rated 9/9 for appropriateness, but operator-dependent) 1

Management Approach

For Labral Tear/Instability (if confirmed)

1. Initial conservative management is appropriate for most soft-tissue injuries 1

   • Physical therapy focusing on strengthening shoulder girdle muscles
   • Gradual increase in active range of motion 1
   • NSAIDs for pain management if no contraindications 1

2. Surgical intervention may be considered if:

   • Conservative management fails
   • Significant instability is present
   • Patient has functional limitations affecting quality of life

For Shoulder Pain Management

• If pain persists:
  • Gentle stretching and mobilization techniques, focusing on external rotation and abduction 1
  • Analgesics such as acetaminophen or ibuprofen if no contraindications 1
  • Physical activity has been shown in multiple studies to improve pain 1

Clinical Pearls and Pitfalls

Important Considerations

• In patients under 35 years, shoulder instability is more common than rotator cuff disease 1
• Numbness and tingling may indicate neurological involvement - careful assessment of sensory distribution is essential 2
• Shoulder pain may mask improvement in movement and function 1

Pitfalls to Avoid

1. Missing cervical pathology - Ensure symptoms are not originating from cervical spine
2. Inadequate imaging - Failure to obtain proper radiographic views can miss dislocations 1
3. Delayed diagnosis - Persistent numbness and tingling warrant thorough evaluation to prevent chronic issues
4. Overlooking non-musculoskeletal causes - Consider systemic conditions that can present with similar symptoms

Follow-up

• Re-evaluate after 4-6 weeks of conservative management
• If symptoms persist or worsen, consider referral to orthopedic specialist
• Monitor for changes in neurological symptoms which may indicate progression

The combination of numbness, tingling, and pain in a young adult most commonly suggests a labral tear with possible instability, and MRI is the most appropriate diagnostic tool after initial radiographs to guide further management decisions.