What is the best course of management for a patient with persistent tingling, numbness, and pain in the left shoulder and arm?

Management of Persistent Unilateral Shoulder and Arm Tingling, Numbness, and Pain

This patient requires urgent cervical spine MRI without contrast to evaluate for cervical radiculopathy or nerve root compression, as the clinical presentation strongly suggests a neurological origin rather than primary shoulder pathology. 1, 2

Critical Clinical Features Pointing to Cervical Spine Pathology

The presentation has several red flags that distinguish this from primary shoulder disease:

• Dermatomal distribution: Tingling and numbness radiating from the anterior shoulder down the arm to the fingers suggests C5-C6 nerve root involvement rather than isolated shoulder pathology 1
• Bilateral symptoms: The patient reports right arm involvement occasionally, which is atypical for unilateral rotator cuff disease but consistent with cervical spine pathology 2
• Normal shoulder examination: Full active range of motion, normal strength, normal reflexes, and no focal shoulder tenderness argue strongly against primary shoulder pathology as the cause 1, 2
• Leg symptoms: The presence of any lower extremity symptoms, even if mild, raises concern for cervical myelopathy and warrants urgent evaluation 1
• Duration and progression: Five months of symptoms that have progressed from episodic to constant despite conservative measures indicates a structural problem requiring imaging 1, 2

Immediate Diagnostic Approach

Order MRI of the cervical spine without IV contrast as the next step. 1, 2

• MRI without contrast is the preferred modality for evaluating nerve root compression, disc herniation, spinal stenosis, and spinal cord pathology 1, 3
• The normal cervical spine examination does not exclude significant cervical pathology—many patients with cervical radiculopathy have normal range of motion and no tenderness 4, 5
• Cervical spine radiographs are not adequate for this presentation, as they cannot visualize soft tissue structures, discs, or nerve roots 1, 3
• The patient's occupational demands as a phlebotomist (repetitive neck positioning) increase risk for cervical disc disease 2

Conservative Management While Awaiting MRI

Initiate a multimodal pain control and neuroprotective strategy:

Pain Management:

• Acetaminophen or NSAIDs (ibuprofen) for pain control if no contraindications 1
• Consider duloxetine for neuropathic symptoms (numbness, tingling, burning pain), as it has Level IB evidence for neuropathic pain 1
• Pregabalin may be considered for neuropathic pain if duloxetine is ineffective or contraindicated, though it is FDA-approved primarily for diabetic neuropathy and postherpetic neuralgia 6

Activity Modification:

• Avoid prolonged neck flexion or extension positions during phlebotomy work 2, 7
• Educate on proper neck positioning and ergonomics 7
• Gentle cervical range of motion exercises, avoiding positions that reproduce symptoms 2, 7

Physical Therapy:

• Refer to physical therapy with emphasis on cervical spine evaluation and treatment, not shoulder-focused therapy 1
• Gentle stretching and mobilization techniques for the cervical spine 2, 7
• Strengthening of cervical paraspinal and scapular stabilizer muscles once acute symptoms improve 7

What NOT to Do (Common Pitfalls)

• Do not treat this as primary shoulder pathology (rotator cuff tendinopathy, impingement syndrome) based on the location of symptoms alone—the dermatomal distribution and normal shoulder examination indicate cervical origin 1, 2
• Do not delay imaging based on the normal cervical spine physical examination—cervical radiculopathy frequently presents with normal neck range of motion and no tenderness 4, 5
• Do not order shoulder MRI first—this would be inappropriate given the clinical presentation and would delay correct diagnosis 1, 2
• Do not rely on cervical spine radiographs alone—they are inadequate for evaluating disc disease, nerve root compression, or spinal cord pathology 1, 3
• Avoid subacromial corticosteroid injections—these are indicated for rotator cuff or bursal inflammation, not for cervical radiculopathy 2, 7

Red Flags Requiring Urgent Evaluation

Monitor closely for any of the following, which would require immediate specialist referral:

• Progressive weakness in the arms or hands 1
• Development or worsening of lower extremity symptoms (suggesting myelopathy) 1
• Bowel or bladder dysfunction 1
• Gait disturbance or balance problems 1
• Bilateral upper extremity symptoms becoming constant 2

Expected Timeline and Follow-up

• MRI should be obtained within 1-2 weeks given the chronicity and progression of symptoms 2
• If MRI demonstrates significant nerve root compression or disc herniation, refer to spine specialist (neurosurgery or orthopedic spine) for evaluation 1, 2
• If MRI is normal, reconsider peripheral nerve entrapment (thoracic outlet syndrome, brachial plexopathy) or refer to neurology 1
• Conservative treatment duration is typically 6-12 weeks if structural pathology is identified but does not require surgery 2, 7