I have left arm pain and cannot lift objects; what are the possible causes and recommended initial management?

Left Arm Pain with Inability to Lift Objects: Differential Diagnosis and Initial Management

Left arm pain with inability to lift objects requires immediate consideration of acute coronary syndrome (ACS) as a life-threatening cause, particularly if accompanied by chest discomfort, dyspnea, nausea, or diaphoresis—in which case you should call 9-1-1 immediately. 1

Critical First Step: Rule Out Life-Threatening Cardiac Causes

Chest or left arm pain as the chief symptom represents intermediate-to-high likelihood of ACS and warrants immediate emergency evaluation. 1

High-Risk Features Requiring Immediate ED Evaluation:

• Left arm pain lasting >20 minutes at rest 1
• Associated symptoms: shortness of breath, cold sweats, nausea, lightheadedness, or syncope 1
• Risk factors: known coronary artery disease, diabetes, age >70 years, male sex, or peripheral vascular disease 1
• Hemodynamic instability or recent syncope 1

Immediate Action if Cardiac Suspected:

• Call 9-1-1 immediately—do not delay for self-medication 1
• Chew aspirin 162-325 mg while awaiting EMS (if no contraindications) 1
• If previously prescribed nitroglycerin, take 1 dose sublingually; if symptoms unchanged or worsening after 5 minutes, call 9-1-1 immediately 1

Common pitfall: Women, elderly patients, and diabetics frequently present with atypical symptoms (arm pain without chest pain, nausea, fatigue) rather than classic chest discomfort, leading to underdiagnosis. 1 Always maintain high suspicion in these populations.

Musculoskeletal Causes (If Cardiac Ruled Out)

Once life-threatening cardiac causes are excluded, musculoskeletal etiologies become the primary consideration for left arm pain with lifting difficulty.

Lateral Epicondylitis (Tennis Elbow):

This is the most common cause of activity-related arm pain preventing lifting, affecting the dominant arm in 75% of cases, typically after age 40. 2, 3

Clinical features:

• Insidious onset of localized pain worsened by repetitive movements and gripping 2
• Well-localized tenderness over the lateral epicondyle on palpation 2
• Pain initially present during activity, may decrease after warming up, but progressively worsens 2
• Difficulty lifting objects due to pain with wrist extension and forearm supination 3

Initial management approach:

1. Rest and activity modification—avoid repetitive wrist extension, radial deviation, and forearm supination 3
2. NSAIDs for acute pain relief 3
3. Eccentric strengthening exercises for wrist extensors as the cornerstone of treatment 3
4. Deep transverse friction massage to reduce pain and improve function 3
5. Plain radiographs first to exclude fractures, loose bodies, or calcifications 2, 3
6. Reserve MRI or ultrasound for persistent symptoms after 6-12 weeks of conservative treatment 2

Critical pitfall: Corticosteroid injections provide short-term relief but are inferior to exercise therapy long-term and may inhibit healing. 3 Reserve for refractory cases after 6-12 weeks of conservative management.

Rotator Cuff Pathology:

Inability to lift the arm, particularly with overhead activities, suggests rotator cuff tendinitis or tear. 4

Clinical features:

• Pain with active shoulder abduction and external rotation 4
• Weakness or inability to lift arm against resistance 4
• Night pain, particularly when lying on affected side 4

Neurologic Causes

Cervical Radiculopathy:

Arm pain with weakness radiating from the neck suggests nerve root compression. 5, 4

Red flags requiring urgent evaluation:

• Bilateral symptoms with motor weakness 5
• Decreased leg strength, unsteady gait, or bowel/bladder dysfunction (suggests cervical myelopathy) 5
• Rapidly progressive or multifocal symptoms 5

Initial approach:

• MRI is most sensitive for soft tissue abnormalities but has high false-positive rates in asymptomatic individuals 5
• Most cases resolve with conservative treatment 5

Peripheral Nerve Entrapment:

Consider carpal tunnel syndrome, ulnar nerve entrapment, or radial tunnel syndrome if numbness/tingling accompanies pain. 5, 4

Diagnostic Algorithm

Step 1: Assess for cardiac risk—if ANY high-risk features present (chest discomfort, dyspnea, diaphoresis, known CAD, diabetes, age >70), activate EMS immediately. 1

Step 2: If cardiac excluded and pain is activity-related with localized elbow tenderness, treat as lateral epicondylitis with rest, NSAIDs, and eccentric exercises. 2, 3

Step 3: If shoulder-based pain with lifting weakness, consider rotator cuff pathology and obtain plain radiographs. 4

Step 4: If neurologic symptoms (numbness, tingling, radiating pain from neck), evaluate for cervical radiculopathy or peripheral nerve entrapment. 5, 4

Step 5: Obtain plain radiographs as first-line imaging to exclude fractures, loose bodies, or osseous pathology regardless of suspected etiology. 2, 3

Critical caveat: Multiple symptomatic tendons should prompt rheumatologic evaluation for systemic inflammatory conditions. 2