What is the appropriate workup for a patient presenting with arm pain, paresthesia, and pressure, suggestive of a pinched nerve, lasting 3-4 days with no known injury?

From the Guidelines

For a patient presenting with arm pain described as pins and needles, pressure, and a possible pinched nerve for 3-4 days with previous similar episodes, I recommend starting with radiographs as the initial imaging for chronic elbow pain, as it may show intra-articular bodies, heterotopic ossification, osteochondral lesion, soft tissue calcification, occult fracture, or osteoarthritis, which can guide further management 1. Begin with a detailed history focusing on the exact location, radiation, aggravating and alleviating factors, and associated symptoms.

• Perform a thorough neurological examination including motor strength, sensory testing, deep tendon reflexes, and special tests like Spurling's, Tinel's, and Phalen's to evaluate for cervical radiculopathy or peripheral nerve entrapment.
• Order basic laboratory tests including complete blood count, comprehensive metabolic panel, and inflammatory markers (ESR, CRP) to rule out systemic causes. Imaging should include radiographs of the elbow to assess for degenerative changes, followed by MRI of the elbow if necessary, as radiographs complement subsequent MRI elbow examination 1. Electromyography may be necessary if symptoms persist to identify specific nerve involvement, as it assists in the workup related to nerve symptoms 1. Initial management can include NSAIDs like ibuprofen 400-600mg three times daily with food for 7-10 days, physical therapy focusing on elbow and upper extremity exercises, and activity modification. These investigations are crucial as the symptoms suggest potential nerve compression, which could be from epicondylalgia, osteoarthritis, or other neurological conditions requiring prompt diagnosis to prevent permanent nerve damage.

From the Research

Initial Assessment

The patient presents with arm pain, pins and needles, pressure, and possible pinched nerve, which has been ongoing for 3-4 days. This has happened before, but the current episode is lasting longer. There is no known injury.

Diagnostic Approach

To evaluate the patient's symptoms, the following diagnostic approaches can be considered:

• Nerve conduction studies (NCS) and electromyography (EMG) can be useful in assessing the peripheral nervous system and striated skeletal muscle 2, 3, 4.
• These studies can help identify defects in neuromuscular junction transmission, myopathic changes in muscle, and signs of denervation.
• The distribution of nerve damage can be determined as either generalized, multifocal, or focal, which can help guide further management.

Electrophysiologic Tests

Electrophysiologic tests, such as NCS and EMG, can be used to assess nerve trauma, entrapment neuropathy, and peripheral nerve surgery 3.

• These tests can provide valuable information on the function of the peripheral nervous system and can help diagnose conditions such as neuropathy or radiculopathy.
• Understanding the elements of an EMG report, including tabular data and clinical interpretation, is essential for accurate diagnosis and management 5.

Clinical Examination

A thorough clinical examination, including an assessment of consciousness, cognition, brainstem function, and motor function, is crucial in evaluating patients with neurological symptoms 6.

• The clinical examination should be guided by the patient's symptoms and medical history, and additional tests, such as neurophysiological and neuroradiological investigations, should be ordered as needed.