Dysfunction of the cervical spine (lower)
Disorders of the shoulder
Medial or lateral epicondylitis
Overuse tendonopathy of the wrist
Osteoarthritis of the thumb and DIP joints
Serious disorders not to be missed
septic arthritis (shoulder/elbow)
infections of tendon sheath and fascial spaces of hand
sporotrichosis (‘gardener’s arm’)
bone tumours (rare)
Entrapment neuropathies (e.g. median nerve, ulnar nerve)
Foreign body (e.g. elbow)
Is the patient trying to tell me something?
Highly likely, especially with the so-called RSI syndromes.
Include an analysis of the pain and a history of trauma, particularly unaccustomed activity. In children ask about pulling the child up by the arms or a fall on an outstretched arm. Ask for relationship of pain to any sleep disturbance.
Inspect the arm as a whole with both arms free of clothing and compare both sides. It may be necessary to examine a variety of joints including the cervical spine, shoulder, elbow, wrist and various joints of the hand.
Consider ECG, nerve conduction studies, plain X-ray according to rule ‘if in doubt, X-ray and compare both sides’, ultrasound for soft tissue injuries (e.g. tendonopathy)
The working rule for arm pain causing sleep disturbance:
thoracic outlet: patient cannot fall asleep
carpal tunnel syndrome: wake in middle of night then settles
cervical spondylosis: wakes patient with pain that persists.
Always keep regional pain syndrome in mind for persistent burning pain in hand following injury, trivial or severe.