A 48-year-old male had left-sided neck pain with intermittent left arm tingling, numbness, and aching for 2.5 months. The pain was described as a deep nagging ache on the left side of the neck with a more intense pain in the left shoulder blade that occurred without any specific activity. Also, no particular position of the neck or head changed the symptoms in the neck or left arm. The patient described having periodic episodes of neck and left arm pain/numbness four or five times over the last ten years, and he felt that this episode was similar to previous episodes. He had utilized chiropractic treatment previously with good results and was considering calling for an appointment once again.
Everything "looks and sounds" like a neck condition with an associated pinched nerve causing pain and tingling radiating down the arm, but is it?
After careful questioning, no specific date of onset could be tied to a trauma (specific injury), over-use activity, or any other identifiable cause. Similarly, he stated that no specific position of the head/neck or arm changed the intensity or length of time the pain lasted. This is unusual for a pinched nerve in the neck as the nerves are stretched when the arm hangs down at the side increasing the pain, and less stretched when the arm is raised over the head, resulting in reduced arm symptoms. Another inconsistent finding was that the whole arm rather than a specific part of the arm was symptomatic. Usually, a pinched nerve follows a specific course down the arm affecting either the 4th and 5th fingers or the thumb side of the hand, but not the whole arm and hand. The physical examination was fairly typical for neck pain sufferers: limited range of motion of the neck, and neck pain reduction with manual traction and increased pain with compression tests. However, there were no arm symptom changes during the neck ranges of motion tests, compression tests, or elevating the arm.
These history and examination findings should alert the healthcare provider of a possible "organic" cause for the symptoms rather than the "pinched nerve" diagnosis. When considering a list of possible "organic" causes, heart disease must be first on the list since it has life-threatening potential. In the case presentation above, the patient was indeed having a heart attack where the blood vessels to part of the heart wall were blocked and the blood carrying oxygen to the heart muscle couldn't get through, thus was causing the "referred pain" to the left side of the neck, shoulder blade, and down the left arm. It is important to know that this heart-related referred pain pattern never involves the right arm, only the left. Other potential symptoms can include left jaw (TMJ) pain, and the more obvious left-sided chest pain, even though these were not present in this case.
Unfortunately, this case ended sadly as the patient did not survive the heart attack. This is probably because at his young age of 48, the blood vessels around the heart had not yet developed "collateral circulation" or new branches that develop as the other arteries around heart gradually close down (atherosclerotic heart disease).
