A 54-year-old man comes to the office due to right shoulder and arm pain. His symptoms began 3 days ago after playing golf for several hours. The patient states that his right arm feels weak, especially when lifting objects. He has no prior medical conditions and takes no medications. Physical examination shows spasm of the cervical paraspinal muscles. There is mild weakness of right elbow flexion, and the biceps reflex is decreased on the right. The pain improves when the patient is instructed to lift the right arm above the head and rest the hand on the top of his head. Which of the following is the most likely diagnosis?

Question

A 54-year-old man comes to the office due to right shoulder and arm pain.  His symptoms began 3 days ago after playing golf for several hours.  The patient states that his right arm feels weak, especially when lifting objects.  He has no prior medical conditions and takes no medications.  Physical examination shows spasm of the cervical paraspinal muscles.  There is mild weakness of right elbow flexion, and the biceps reflex is decreased on the right.  The pain improves when the patient is instructed to lift the right arm above the head and rest the hand on the top of his head.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d587_b449_bc81_11e1cb245e51_MD0003_00 This patient with acute right shoulder and arm pain, biceps weakness, and diminished biceps reflex associated with cervical muscle spasm most likely has a cervical radiculopathy involving the C6 nerve root. Radiculopathies typically occur due to compression of the nerve root due to disk herniation (evidenced by acute symptom onset) or progressive spinal spondylosis (evidenced by subacute or progressive symptom onset). Cervical radiculopathy occurs most commonly in middle-aged men and may develop after repetitive exercise (eg, golf). Manifestations depend on the involved nerve root but typically include pain in the neck and upper extremity associated with sensory and motor deficits and diminished reflexes. Shoulder abduction reduces tension on the impinged nerve root, and improvement of radicular symptoms when the hand is placed on the top of the head (ie, shoulder abduction relief test) is both diagnostic and therapeutic for short-term pain relief. Patients with mild deficits and low concern for malignancy or infection usually experience gradual resolution and may be managed conservatively (eg, with nonsteroidal anti-inflammatory drugs and physical therapy) without neuroimaging. Those with progressive pain should undergo further evaluation (eg, MRI) and possibly surgery. (Choice A) Cervical muscle strain can cause neck pain but would not cause arm weakness, diminished reflexes, or a positive shoulder abduction relief test. (Choice C) Rotator cuff muscle tear can cause shoulder pain but typically occurs following an injury (eg, fall on outstretched hand) and results in weakness with shoulder abduction and rotation. Arm flexion and biceps reflex would be unaffected. (Choice D) Shoulder joint capsulitis (ie, frozen shoulder) is characterized by gradual-onset shoulder stiffness with a reduction in both passive and active range of motion in multiple planes. Reflexes are unaffected. (Choice E) Thoracic outlet syndrome results from brachial plexus compression as it passes through the thoracic outlet; patients develop upper extremity weakness and paresthesia, often with swelling and exertional arm pain (due to involvement of the subclavian vessels). Raising the arm worsens compressive symptoms, as opposed to the improvement seen in this patient. Educational objective: Cervical radiculopathy is usually caused by compression of the nerve root due to disk herniation or spondylosis; manifestations depend on the involved nerve root but typically include neck pain, shoulder/arm pain, weakness, paresthesia, and diminished reflexes. Improvement of radicular symptoms when the hand is placed on the top of the head is both diagnostic and therapeutic.

A 54-Year-Old Man Comes to the Office Due to Right