Sudden, Severe Upper Limb Pain and Weakness in a Sleepless Man

Olusegun John Oluwole, MBBS


December 14, 2020

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us .


A 50-year-old man presents at an outpatient clinic with severe pain in his left shoulder and arm. He says the pain is particularly significant in the outer forearm. He first noticed it upon waking 4 weeks earlier. He describes the pain as severe and unlike anything he has experienced in the past. He says his shoulder and arm are aching and burning, and the pain keeps him awake at night.

He has tried over-the-counter analgesic agents, such as paracetamol and ibuprofen, with only minor and very short-lived benefits. He also says that he has noticed progressive weakness in his left shoulder over the past 2 weeks. He is now incapable of raising his left arm above his head. He believes he has true weakness in the left shoulder, rather than mere limitation of movement from pain.

He denies any previous history of trauma to his shoulder or any unaccustomed use of the shoulder prior to the onset of pain. He has had no recent upper respiratory tract infections or vaccinations and has no current or recent history of fever. He had no previous problems with his shoulders and does not suffer from neck pain. He has no weakness in any other limbs and has good control of his sphincters. He denies having any gait difficulties, double vision, facial droop, swallowing difficulties, or trouble breathing.

The patient's medical history is significant for diabetes, hypertension, and dyslipidemia, for which he takes metformin, gliclazide, valsartan/hydrochlorothiazide, and rosuvastatin, with fair control of these conditions. He has used ibuprofen and paracetamol regularly since the onset of his pain. He is a nonsmoker and does not drink alcoholic beverages. He has a brother with hypertension but has no other significant family history.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.