What is the appropriate evaluation and management for constant right arm pain in an adult?

Evaluation and Management of Constant Right Arm Pain

Begin with plain radiographs of the affected area as the initial imaging study, followed by clinical examination to localize the pain and guide further workup based on anatomical location and suspected pathology. 1

Initial Clinical Assessment

Key Historical Features to Elicit

• Pain location specificity: Determine if pain is localized to hand, wrist, forearm, elbow, or diffuse throughout the arm 2, 3
• Mechanism and onset: Sudden onset suggests acute injury or vascular event; gradual onset suggests overuse, nerve compression, or degenerative conditions 4, 5
• Aggravating factors: Pain with specific movements suggests tendinopathy or joint pathology; pain with gripping suggests hand/wrist pathology 3, 5
• Occupational factors: Repetitive activities, forceful gripping, awkward postures are linked to distal arm pain 5
• Neurological symptoms: Numbness, tingling, or weakness suggests nerve compression (carpal tunnel syndrome, cervical radiculopathy, brachial plexus tension) 2, 6, 7

Critical Red Flags to Exclude

• Cardiac origin: Right arm pain with chest discomfort, especially with wide radiation pattern, strongly suggests myocardial infarction and requires immediate cardiac evaluation 8
• Vascular compromise: Absent pulses, color changes, or acute severe pain may indicate arterial occlusion requiring emergent vascular surgery consultation
• Infection: Fever, erythema, warmth, or systemic symptoms require urgent evaluation for septic arthritis or osteomyelitis 1

Physical Examination Priorities

• Pulse assessment: Compare bilateral radial and ulnar pulses; blood pressure in both arms 1
• Neurovascular examination: Test median, ulnar, and radial nerve distributions; assess for Tinel's and Phalen's signs at wrist 2, 6
• Joint examination: Palpate for tenderness over specific joints; assess for effusion, deformity, or Heberden nodes 2
• Tendon examination: Palpate tendons for tenderness; perform Finkelstein test for De Quervain tenosynovitis 3
• Provocative maneuvers: Reproduce pain with specific movements to localize pathology 2, 3

Initial Imaging Strategy

Radiography as First-Line Study

Plain radiographs are the most appropriate initial imaging for chronic arm pain and can establish diagnoses including arthritis, fracture complications, infection, bone tumors, and instability. 1, 3, 6

• Standard views: Obtain posterior-anterior and lateral views in neutral position, supplemented by oblique views 3, 6
• Diagnostic yield: Radiographs identify osteoarthritis (joint space narrowing, osteophytes), old fractures, bone lesions, and soft tissue calcifications 2, 3
• Limitations: Normal radiographs do not exclude soft tissue pathology, ligament injury, or early inflammatory arthritis 1

Location-Specific Advanced Workup

Hand Pain with Normal/Nonspecific Radiographs

MRI without IV contrast is the next appropriate study for evaluating chronic hand pain when radiographs are unrevealing. 1

• MRI indications: Suspected tendon injury, tenosynovitis, ligament pathology, or occult fracture 1, 2
• Alternative to MRI: Ultrasound is equally appropriate for tendon pathology and can dynamically assess tendons during movement 1, 2
• Ultrasound advantages: Can identify tenosynovitis, tendon tears, ganglion cysts, and guide therapeutic injections 1, 3

Wrist Pain with Normal/Nonspecific Radiographs

Either MRI without IV contrast or MR arthrography is appropriate as the next study, with choice depending on suspected pathology. 1, 3

• Non-contrast MRI: Preferred for suspected tendinopathy, tenosynovitis, TFCC tears (central disc), carpal tunnel syndrome, or Kienböck disease 1, 3
• MR arthrography: Superior for scapholunate and lunotriquetral ligament tears, especially for determining which ligament segments are torn 1
• Ultrasound role: Appropriate for carpal tunnel syndrome (median nerve cross-sectional area measurement), De Quervain tenosynovitis, and extra-articular soft tissue masses 1, 6
• CT arthrography: May be appropriate for radial-sided pain when ligament assessment is needed and MRI is contraindicated 1

Forearm and Elbow Pain

Radiographs remain the initial study; MRI without contrast is appropriate if radiographs are normal and soft tissue injury is suspected. 1

• MRI indications: Suspected tendon tears (triceps, biceps), ligament injuries, or muscle strain 1, 4
• Ultrasound utility: Can assess tendons dynamically and identify muscle strain, though MRI provides more comprehensive evaluation 1, 4

Management Based on Suspected Etiology

Nerve Compression Syndromes

• Carpal tunnel syndrome: Ultrasound or MRI can confirm diagnosis; measure median nerve cross-sectional area on ultrasound 6
• Cervical radiculopathy or brachial plexus tension: Consider cervical spine imaging and physical therapy techniques for nerve mobilization 7

Tendinopathy and Tenosynovitis

• First-line treatment: Topical NSAIDs for mild-to-moderate pain; ergonomic modifications and joint protection 2
• Exercise regimen: Range of motion and strengthening exercises once acute inflammation subsides 2, 4
• Imaging-guided injection: Ultrasound can guide corticosteroid injection for persistent tenosynovitis 3

Inflammatory Arthritis Suspected

When inflammatory arthritis is suspected, obtain laboratory testing including ESR, CRP, rheumatoid factor, and anti-citrullinated protein antibodies. 2, 3

• MRI with IV contrast: Particularly useful for identifying active synovitis, inflammatory tenosynovitis, and bone marrow edema (osteitis) 3
• Ultrasound with power Doppler: Can identify erosions and active synovitis in rheumatoid arthritis 3
• Rheumatology referral: Indicated for suspected inflammatory arthritis for disease-modifying therapy 2

Osteoarthritis

• Treatment approach: Acetaminophen, NSAIDs, physical activity, and exercise per American College of Radiology recommendations 3
• Orthotics: Consider splints or braces if pain impedes functioning 3
• Hand surgery referral: Indicated for severe thumb base osteoarthritis or structural abnormalities 2

Common Pitfalls to Avoid

• Do not assume isolated De Quervain disease based solely on thumb-base pain; diffuse dorsal wrist involvement suggests broader extensor tendon tenosynovitis 3
• Do not order MRI directly without obtaining radiographs first unless there is specific concern for occult fracture or infection 3
• Do not overlook cardiac causes: Right arm pain with any chest symptoms requires cardiac evaluation before attributing pain to musculoskeletal causes 8
• Do not rely solely on marginally positive Finkelstein test: This does not reliably indicate De Quervain disease if other range-of-motion findings are equally pronounced 3
• Do not miss inflammatory arthritis: Normal radiographs do not exclude early rheumatoid arthritis; bone marrow edema on MRI is the best predictor of disease progression 3

Specialty Referral Indications

• Neurology: Progressive weakness, suspected focal dystonia, or signs of motor neuron disease 2
• Rheumatology: Suspected inflammatory arthritis with positive serologies or MRI findings of synovitis 2, 3
• Hand surgery: Severe structural abnormalities, persistent ganglion cysts, or failed conservative management 2
• Vascular surgery: Pulse deficits or suspected vascular compromise 1