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Upper-Extremity Pain

For 20 years, Tom had “no aches, no pains, no nothing.” Why was his luck changing now? Maybe his shoulder pain started because his new van didn’t have power steering, or maybe it was because he was doing a lot more wheeling on carpet. Regardless, now his shoulders hurt. Thinking that the pain might go away, he waited. But, after three or four months, the pain was so bad he couldn’t stand it anymore. A trip to the doctor left Tom with more information and some difficult choices.

Aging, Wear and Tear, and Overuse:
Tom’s story isn’t really unusual; we all expect a few more aches and pains as we grow older. After all, aging and wear and tear go together. What's different about Tom is that staying active after his spinal cord injury meant even more wear and tear on his arms and shoulders. Studies have shown that arm and shoulder pain is more frequent among SCI survivors than in the nondisabled population.

How Injuries Happen:
Pain and injury from daily overuse is a frequent cause of upper extremity pain. Overuse, however, is different for each person. An activity that causes pain for one person may not for someone else. In general though, the more frequently an activity is performed, and the more lifting or straining the activity requires, the greater the opportunity for injury and pain.
Think about the number of times you transfer from your wheelchair everyday, then consider the extra shoulder strain when you transfer to and from surfaces above or below your wheelchair – maybe into a bathtub, or a tall pickup truck. The same transfers, day in and day out can cause a lot of strain on your shoulders and wrists.
Overuse injuries can affect nearly any joint in the upper extremities, but most often affect the shoulders and wrists. Pain may be constant or may appear only during certain activities like wheeling long distances. Sometimes pain begins when daily overuse is combined with a specific injury like lifting something too heavy or too quickly. That “something” could be a grocery bag, a wheelchair, or your own body during a transfer.

Rotator Cuff Tears, Biceps Tendinitis, Carpal Tunnel Sydnrome:
Three frequent injuries among persons with spinal cord injuries are rotator cuff tears, bicipital tendonitis, and carpal tunnel syndrome.
The rotator cuff is made up of four muscles and their tendons. These muscles support
the shoulder and contribute to nearly all of its movements. Many factors, including both activity level and aging, can combine to increase pressure on these tendons and decrease their circulation. Eventually, a tear may occur – either partial or complete, depending on the amount of damage to the tendons and soft tissue. The most common symptom is pain or weakness when reaching above your head.
Bicipital tendinitis is an inflammation of the biceps tendon and is often found in people
who also have a rotator cuff tear. During normal arm movement the tendon of the biceps glides in a groove in the bone of your upper arm. Repetitive movements can cause swelling and pain in and around the tendon. Repeated use may even cause the tendon to fray. You usually feel pain near the middle of your shoulder in the front, or slightly lower on the outside of your arm. You might also have pain when you try to reach behind your back. Without treatment, you could lose some of your active shoulder movement.
Carpal tunnel syndrome occurs when a particular nerve is pinched as it passes through a narrow tunnel in your wrist. The usual symptom is pain or tingling in your thumb and first two fingers. It might awaken you from a sound sleep but then go away if you shake your hand. Bending your wrists tends to narrow the tunnel and increase the symptoms even more. And, as research already has shown, repetitive stress and strain on your bent wrist does greatly increase the risk of developing carpal tunnel syndrome. Unfortunately, SCI survivors do many daily activities with a bent wrist – transfers, weight shifts, wheeling, and using crutches are just a few examples.

Getting Help:
Upper extremity pain can begin with many different injuries; often the symptoms of one are very similar to those of another. As you evaluate the type of pain that you’re having, ask yourself: what kind of pain is it–a sharp pain with certain movements, or a dull nagging pain? Where is it–all over, or maybe one specific spot on your shoulder or your wrist? When does it hurt–all of the time or just certain times? How did it start–did it come on quickly or has it seemed to develop slowly?
Many people endure lots of pain before they seek treatment. But, ignoring pain
probably won't make it go away, so don't put off talking with your doctor. In fact, ignoring pain frequently limits recovery and function. An accurate diagnosis, and the facts about different treatments will help you make wise choices.
Be prepared to tell your doctor exactly what activities you do with your arms. Don’t just tell him or her that you use your arms for transfers. Be ready to explain, or even demonstrate, how high, how far, and how often. Not only may your daily activities be causing your pain, but some of your doctor's recommendations will involve altering those same activities.

Treatment Choices:
For most diagnoses, there probably will be more than one treatment option. What you
choose will depend on what's causing your pain, and how that treatment will affect your daily activities and independence.
Most treatments begin conservatively. “Conservative” can mean changing or decreasing your current activities, buying new equipment, increasing the assistance you get from others, or resting your joints. You may need to use some imagination. What other ways can you get the same activities done? Can some of them be done by a family member? Can you hire an attendant or housekeeper for heavy work to give your shoulders a rest? How about equipment? Some equipment changes will be expensive, like a van or an electric wheelchair. But, other, less expensive options may help too, like transfer boards, grab bars, a tub bench or nocturnal splint. An occupational or physical therapist can help you evaluate these options and choose what you need.
Your doctor may recommend medication to decrease your pain or to reduce joint swelling. Medications can be effective, especially when combined with joint rest and the elimination of the pain-causing activities. Keep in mind, though: many pain medications cause constipation and can affect your bowel program. Ask about other side effects as well. And, make sure that your doctor knows all of the other medications you're taking.
For some people, surgery is the best, or only, option. But surgery–at least in the short
term–can significantly decrease your independence. While you recover and the repaired area heals, you may need to rent a power wheelchair and arrange to have extra assistance. Make sure that you discuss the recovery period, in detail, with your doctor before surgery so that you make all the necessary arrangements.

Some Final Thoughts:
Does the possibility of shoulder pain or injury later on mean that you should do as little as possible with your arms right now, that you should be protecting your arms at all costs? No, it’s not that simple. A balance of exercise and movement is important to keep your joints healthy. But, the key word is balance. The choices you make today will impact the quality of your life as you get older. The bottom line is to pay attention and choose well.

This is one of more than 20 educational brochures developed by Craig Hospital while it was a federally-funded Rehabilitation Research & Training Center on Aging with Spinal Cord Injury. The opinions expressed here are not necessarily those of the funding agency, the National Institute on Disability and Rehabilitation Research of the US Department of Education.

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