Elbow shoulder hand pain symptoms

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

There are a number of conditions that may affect all three regions.

Sometimes these are separate problems and sometimes they are related. This page will discuss the many problems that may occur.

One problem that can tie together all these areas is a neck disorder where there is nerve root irritation. The pain may radiate into the shoulder, elbow, and hand. When pain begins in the neck but is felt in the shoulder and arm, it is called “referred pain.”

Another condition is reflex sympathetic dystrophy, a poorly understood condition that occurs after trauma and can cause excruciating pain and loss of function in an arm or leg.

Other types of nerve irritation or inflammation such as brachial plexus inflammation (Parsonage-Turner Syndrome), and entrapment of nerves in the elbow and wrist may also cause pain in the arm. Parsonage-Turner is a rare inflammatory disorder of the nerves of the brachial plexus. It causes severe pain and weakness in the affected arm.

Nerve entrapment of the ulnar and radial nerves near the elbow also causes significant discomfort in the arm. Entrapment may occur as a result of trauma or arthritis.

Nerve entrapment involving the median and ulnar nerve in the wrist may cause referred pain.

Shoulder pain

Shoulder bursitis and rotator cuff tendonitis both indicate there is a problem with the tendon complex in the shoulder, the bursae that cushion the tendons, or both. Sometimes the difficulty arises as a result of pinching of the rotator cuff between the head of the humerus and the acromion of the shoulder blade. This is called 'impingement syndrome.'

Normally, the rotator cuff tendons glide easily between the humeral head and the acromion. In some people, after an injury, the tendons and bursae become inflamed leading to thickening of the tendons and bursa, and this causes the space to become too narrow to accommodate the tendons and the bursa.

Common symptoms include:

o Pain with overhead activities
o Pain at night
o Pain at the lateral aspect of the shoulder/upper arm

An MRI can reveal an abnormality of the tendons of the rotator cuff and help determine if a tear is present. Diagnostic ultrasound is also a helpful diagnostic tool for rotator cuff disorders.

The most common mechanisms of a rotator cuff injury are 'repetitive use' and 'trauma.'

A rotator cuff injury due to repetitive use is more common in older individuals. Usually in younger patients, there is either a traumatic injury, or significant overuse of the shoulder, as seen in professional athletes.

As people age, the muscle and tendon tissue of the rotator cuff loses elasticity, becomes more susceptible to injuries, and is often damaged while performing everyday activities. This is the reason that rotator cuff tears are more commonly seen in older patients.

Not every rotator cuff injury causes significant pain or disability. In fact, autopsy studies have shown rotator cuff tears in up to 70% of people over the age of 80 and 30% of the population under the age of 70.

Frozen shoulder, or adhesive capsulitis, is a condition that causes pain and loss of motion in the shoulder joint.

Often people experience trauma to the shoulder prior to the onset of the frozen shoulder, and sometimes there is no known cause for developing a frozen shoulder.

Frozen shoulder is also called adhesive capsulitis (inflamed joint capsule).

The condition is characterized by a decrease in motion, primarily seen in lifting the arm. Frozen shoulder is most common in the 40-60 year old age group and it is twice as common in women as men. It is also more common in diabetics. People usually experience pain as the first symptom of frozen shoulder, followed by loss of motion and a decrease in pain. Normally a gradual return of motion will follow; however, the length of time for recovery from frozen shoulder can be prolonged, with an average duration of 18 months.

Calcific tendonitis is a condition that is due to the formation of calcium deposits in the tendons of the rotator cuff. These deposits are usually found in patients at least 30-40 years old, and have a higher incidence in diabetics.

The cause of calcium deposits within the rotator cuff tendon is not understood.

Calcific tendonitis usually progresses.

Nonoperative treatment is always the first line of treatment for calcific tendonitis. This includes physical therapy, exercises, anti-inflammatory medications, steroid injections, and ultrasound guided needle lavage. There is a good success rate with treatment.

Ultrasound guided needling with lavage is a procedure where the physician will direct a needle into the calcium deposit using ultrasound guidance and attempt to aspirate and wash out as much of the calcium deposit as possible. Patients can resume activity shortly after the procedure.

Shoulder instability is a problem that occurs when the structures that surround the glenohumeral joint do not keep the ball in the socket. Patients with shoulder instability often complain of an uncomfortable sensation that their shoulder may slide out of place. This is called "apprehension."

If patients complain of a feeling that their shoulder is loose, physical therapy with specific strengthening exercises will often help keep the shoulder in place.

If therapy fails, there are surgical options that can be considered.

If the cause of the shoulder instability is a loose shoulder joint capsule, then a procedure to tighten the capsule of the shoulder can be done with an arthroscope in a procedure called a thermal capsular shrinkage. In this surgery, a thermal probe shrinks the shoulder capsule to tighten the tissue. The other procedure is called an open capsular shift. In this surgery, the shoulder joint is opened and the capsule is tightened with sutures. The advantage of the open capsular shift is that the results are more predictable. The advantage of the arthroscopic procedure is that the recovery is faster and the incision is smaller.

A shoulder separation is an injury to the joint between the scapula and clavicle--this is called an acromioclavicular (or A-C) separation. A shoulder dislocation occurs when there is an injury to the joint between the humerus and scapula.

A Bankart lesion is an injury to a part of the shoulder joint called the labrum. The shoulder joint is a ball and socket joint; however, the socket of the shoulder joint is extremely shallow and inherently unstable.

To compensate for the shallow socket, the shoulder joint has a cuff of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move in. This cuff of cartilage confers stability, yet allows for a very wide range of movements.

A Bankart lesion happens when an individual dislocates their shoulder. As the shoulder pops out of joint, it tears the labrum. The tear is to part of the labrum called the inferior glenohumeral ligament.

Typical symptoms of a Bankart lesion include a catching, aching, and susceptibility to dislocation. MRI scans can be helpful. Patients who sustain a Bankart injury are at much higher risk for another dislocation.

A Bankart operation repairs the torn ligament. The Bankart repair can be performed through an arthroscope.

A specific type of labral tear is called a SLAP lesion; this stands for Superior Labral tear from Anterior to Posterior. The SLAP lesion occurs at the point where the tendon of the biceps tendon inserts on the superior labrum. The mechanism of injury is usually a fall onto an outstretched arm.

Typical symptoms of a SLAP lesion include a catching sensation and pain with movement, most typically overhead activities such as throwing.

Diagnosis can be difficult. MRI can be helpful. Shoulder arthroscopy can be performed, and the injury can be diagnosed and treated.

Osteoarthritis is the most common type of shoulder arthritis. It is characterized by progressive wearing away of the cartilage of the joint between the humeral head and the glenoid socket of the scapula. As the cartilage is worn away, bare bone is exposed in the joint.

Rheumatoid arthritis is a systemic condition that causes an inflammation of the lining of a joint. This inflammation can, over time, invade and destroy the cartilage and bone and may affect the shoulder.

Osteoarthritis of the shoulder typically affects patients over 50 years of age. It is more common in patients who have a history of prior shoulder injury.

There is also a genetic predisposition of this condition.

Shoulder arthritis symptoms tend to progress as the condition worsens.

The most common symptoms of shoulder arthritis are:

o Pain with activities
o Limited range of motion
o Stiffness of the shoulder
o Swelling of the joint
o Tenderness around the joint
o A feeling of grinding or catching within the joint

Limiting certain activities may be necessary. Shoulder exercises are excellent for patients who have a weak shoulder.

Preventing atrophy of the muscles is an important part of maintaining functional use.

Anti-inflammatory medications help with pain and inflammation.

Cortisone injections may help decrease inflammation and reduce pain in the joint.

Stem cell procedures have been shown to be effective in some cases. For more information contact the Arthritis Treatment Center at www.arthritistreatmentcenter.com

Total shoulder replacement surgery is reserved for end stage disease.

The biceps tendon connects the biceps tendon to bone. There is a proximal biceps tendon at the shoulder joint, and a distal biceps tendon at the elbow.

Rupture of the proximal head of the biceps tendon usually occurs in older individuals and is caused by degenerative changes in the tendon leading to rupture. The proximal biceps tendon rupture may occur during trivial activity, and some patients may experience pain relief once the damaged tendon ruptures.

Usually patients will have sudden pain associated with an audible snap in the area of their shoulder.

After the ruptured tendon retracts, patients may notice a bulge in their arm at the biceps muscle. This is the retracted muscle bunched up in the arm, and is sometimes referred to as a "Popeye Sign," because it is more pronounced than normal.

Patients usually do not notice any loss of arm or shoulder function following a proximal biceps tendon rupture. The reason is that there are actually two tendon attachments of the biceps at the shoulder joint. When the rupture occurs at the distal biceps tendon at the elbow, where there is only one attachment, surgical repair is more commonly needed.

Rupture of the distal biceps tendon at the elbow joint is much less common and accounts for less than 5% of biceps tendon ruptures. This injury is also usually found in elderly patients, although not always. There is usually some degree of tendinosus, or degenerative changes within the tendon, that predisposes the patient to rupture of the tendon.

The significance of a distal biceps tendon rupture is that without surgical repair, patients who experience complete rupture of the distal biceps tendon will notice loss of strength at the elbow.

Distal biceps tendon rupture is characterized by sudden pain over the front of the elbow after a forceful effort against a flexed elbow. Usually the patient will hear a snap and have pain where the tendon rupture occurs. Swelling and bruising around the elbow are also common symptoms of distal biceps tendon rupture.

Most patients will experience benefit if the biceps tendon is repaired surgically.

Lateral epicondylitis, also known as tennis elbow, is characterized by pain in the lateral part of the elbow and forearm. The pain is caused by damage to the extensor tendons.

Tennis elbow may be caused by the following:

• improper backhand stroke
• weak shoulder and wrist muscles
• a too tightly strung or too short tennis racket
• hitting the ball off center on the racket
• repetitive painting with a brush or roller
• operating a chain saw
• frequent use of other hand tools on a continuous basis

Specific treatment for tennis elbow will be determined based on:

• age, overall health, and medical history
• extent of the condition
• tolerance for specific medications, procedures, and therapies


Pain in the elbow joint, especially when straightening the arm
Pain when making a fist
Weak grip
Difficulties and pain when trying to grasp objects.

Treatment for tennis elbow includes stopping the activity that produces the symptoms. Treatment may include:

• ice pack application (to reduce inflammation)
• strengthening exercises
• anti-inflammatory medications
• Ultrasound-guided needle tenotomy with injection of platelet-rich plasma (PRP). For more information go to www.arthritistreatmentcenter.com

The diagnosis of tennis elbow usually can be made based on a physical examination. However, in some cases, imaging procedures such as MRI or diagnostic ultrasound may be needed.

Other conditions that cause elbow pain:

•Osteoarthritis - the joint cartilage wears away and pieces of cartilage float around inside the joint.
•Referred pain - nerve injuries to the spine (vertebrae) can irritate the nerves of the arm and cause referred pain around the elbow joint.
•Nerve entrapment - the radial nerve can be pinched at the elbow joint. It is confused with lateral epicondylitis.
•Ligament sprain

Medial epicondylitis, also known as golfer's elbow is characterized by pain in the elbow along the medial epicondyle. The pain is caused by damage to the flexor tendons.

Medial epicondylitis is caused by the excessive force used to flex the wrist toward the palm, such as swinging a golf club or pitching a baseball. Other possible causes of medial epicondylitis include the following:

•serving with a spin serve
•weak shoulder and wrist muscles
•using a too tightly strung, too short, and/or too heavy tennis racket
•throwing a javelin
•carrying a heavy suitcase
•chopping wood with an ax
•operating a chain saw
•frequent use of other hand tools on a continuous basis

The most common symptom of medial epicondylitis is pain in the elbow on the same side as the little finger. The pain can be felt when bending the wrist toward the palm against resistance.

The diagnosis of medial epicondylitis usually can be made based on a physical examination.

Specific treatment for medial epicondylitis will be based on the same criteria as that for lateral epicondylitis.

For more information on tendonitis, visit our sister site:

Tendonitis and PRP

Hand pain

The hand is composed of different bones, muscles, and ligaments thatpermit movement. There are three types of bones in the hand:

• phalanges - the 14 bones that are found in the fingers of each hand. Each finger has three phalanges (the distal, middle, and proximal); the thumb only has two.
• metacarpal bones - the five bones that comprise the middle part of the hand.
• carpal bones - the eight bones that make up the wrist. The carpal bones are connected to two bones in the arm, the ulna and the radius.

A number of muscles, ligaments, and sheaths can be found within the hand. The muscles allow movement of the bones in the hand. The ligaments are fibrous tissues that bind the joints in the hand. The sheaths are tube-like structures that surround tendons.

Common problems that can interfere with activities of daily living include the following:

Arthritis is joint inflammation and commonly occurs in the fingers and at the base of the thumb. The pain associated with arthritis may be from many different sources, including inflammation of the following:

•synovium - the lining of the joint.
•tendons - the tough tissue that connect muscles to bones.
•ligaments -flexible bands of fibrous tissue that connect various bones.

Osteoarthritis, a degenerative joint disease, is the most common type of arthritis in older people. It is a disease that primarily affects the hands and the large weight-bearing joints of the body, such as the neck, low back, knees and hips.

Osteoarthritis in the hands or hips may run in families, or be caused by injuries, overuse, muscle strain, or fatigue.

• Heberden nodes, bony abnormal enlargements of the distal interphalangeal joints.
• Bouchard nodes – bony enlargement of the proximal interphalangeal joints

Rheumatoid arthritis, psoriatic arthritis, gout, and pseudogout may also affect the hands.

Carpal tunnel syndrome is a condition in which the median nerve is compressed as it passes through the carpal tunnel in the wrist, a narrow confined space.

The following are the most common symptoms for carpal tunnel syndrome:

• difficulty making a fist
• difficulty gripping objects with the hand(s)
• pain and/or numbness in the hand(s)
• "pins and needles" feeling in the fingers
• swollen feeling in the fingers
• burning or tingling in the fingers, especially the thumb and the index and middle fingers

The symptoms of carpal tunnel syndrome may resemble other conditions such as tendonitis, bursitis, or rheumatoid arthritis.

Treatment may include:

•splinting of the wrist
•oral anti-inflammatory medications or steroids injected into the carpal tunnel
•surgery (to relieve compression on the nerves in the carpal tunnel)
•changing position of a computer keyboard, or other ergonomic changes

A new procedure, ultrasound-guided needle release, is a simple procedure with 90 % effectiveness. Down time is one day. Go to www.arthritistreatmentcenter.com to find out more.

Soft, fluid-filled cysts can develop on the front or back of the hand. These are called ganglion cysts - the most common, benign (non-cancerous), soft-tissue tumor of the hand and wrist.

The following are the most common symptoms for ganglion cysts:

•wrist pain that is aggravated with repetitive use or irritation
•a slow growing, localized swelling, with mild aching and weakness in the wrist
•a cyst that is smooth, rounded, and/or tender

Initially, when the cyst is small and painless, treatment is usually not necessary. Only when the cyst begins to grow and interferes with the function of the hand is treatment usually necessary. Treatment may include:

• rest
• splinting
• non-steroidal anti-inflammatory medications
• aspiration
• cortisone injections
• surgery

Two major problems associated with tendons include tendonitis and tenosynovitis. The term tendonitis is a misnomer. The proper term, "tendinosis" indicates there is very little inflammation but that the primary problem is tendon degeneration. When the tendons become irritated, swelling, pain, and discomfort will occur.

Tenosynovitis is inflammation of the lining of the tendon sheaths which enclose the tendons. The tendon sheath is usually the site which becomes inflamed. The cause of tenosynovitis is often unknown, but usually strain, overuse, injury, or excessive exercise may be implicated. Tendonitis may also be related to disease (i.e., diabetes or rheumatoid arthritis).

DeQuervain's tenosynovitis - the most common type of tenosynovitis disorder is characterized by tendon sheath swelling in the extensor tendons of the thumb.

Trigger finger/trigger thumb -a condition in which the tendon sheath becomes inflamed and thickened and prevents the smooth extension or flexion of the finger/thumb. The finger/thumb may lock or "trigger". Triggering can be treated with ultrasound guided hydrodissection. A large volume of fluid is injected to open up the tendon sheat. This prevents the need for surgery. Go to wsww.arthritistreatmentcenter.com to find out more.

Treatment for most tendon problems may include:

• activity modification
• splinting or immobilization
• steroid injections
• anti-inflammatory medications
• ultrasound-guided needle tenotomy with platelet-rich plasma (PRP) in jection

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