I have shoulder, arm, breast and neck pain. Is it musculoskeletal pain?

Question

Hello doctor,

Since last few days, I am having left sided pain in the shoulder, upper arm, the front area near the shoulder, breast, both outer sides of the neck and collarbone area. Sometimes, it pains on the back side as well. I can feel the pain when I press the body part where the pain originates. The pain aggravates when I press. There is no accompanied shortness of breath or sweating at all. Please note that pain may not be there in all the areas at the same time. Like for now, at this point in time, I only have very mild discomfort in front area near the shoulder and breast. Some of the points to consider for diagnosis. I am hypertensive. However, my BP is very well controlled (110/80) with Metoprolol and Amlodipine. I also take Atorvastatin 10 mg for cholesterol. I am now asked to stop Atorvastatin. I am on these medications since last one year. All my below tests (one year old) are normal such as EKG, chest X-ray, brain CT scan, pulmonary embolism, all blood works, 48 hours holter monitor, no murmur or gallop noticed, arterial oxygen levels and troponin levels. All my recent blood works (two months old) like lipid profiles, kidney function test, CBP, liver function test, HbA1c, vitamin profiles (vitamin D, B12, calcium, iron), sodium, potassium, urine exam are normal. I walk daily for 20 to 30 minutes. Occasionally, I run too and do not experience any pain. Sometimes, I take stairs and do not experience any shortness of breath or pain. I had a different variant of chest pain last year. I did EKG, TMT and 2D echo and results are normal findings. It was diagnosed with non-cardiac pain. I have some mild to moderate irrational anxiety (GAD) and I am not sure if the pain I am experiencing is of psychosomatic origin. I had my left shoulder dislocated some 20 years back. In last 20 years it dislocated almost 7 to 8 times of which four times, I had to go to the hospital and get it fixed non-surgically. All other times it got fixed on its own. Last time it dislocated was I am not sure if the pain is causing because of that. I was very poor in following the instructions about wearing a sling and all. I used to be sling free immediately after shoulder is replaced back. Although I never had any problem with my left shoulder or arm, I intermittently used to get some mild pain in shoulder and upper arm. My left hand is fully functional. Although, I am careful in not rotating it 360 with a fear that it might get dislocated. Currently, I do not have acidity so I think the pain does not seem to be related to GERD. 2D echo and TMT were done just one year back and returned normal, do I need to re-do these tests? Since then I believe things should have only been improved as I made a lot of lifestyle and dietary changes. BP is very much controlled. It is always 110/80, Resting heart rate is good too. 70 to 80 BPM. Lipid profile is normal. LDL (73), HDL (46), Total (145). If it is musculoskeletal pain, could you please suggest some medicine? I am looking for something that does not disturb my BP and heart rate. Is (Tramadol + Acetaminophen) good? Please suggest some potent and safe medicine that can relieve the pain and relax the muscles. One of the DMs I contacted in person is of the opinion that it may be psychosomatic in nature and prescribed a combination of Flupentixol and Escitalopram. But I am scared of the listed possible side effects like thrombosis, QT prolongation, etc. So I did not start it yet. What is your view on this combination drug? Is it safe to give it a try for four months and then wean off over next two months? Can you suggest any other anti-anxiety which is having a safest cardio-metabolic profile?

Answer 1

Hello,

Welcome to icliniq.com.

Firstly, it is not at all related to the heart. Cardiac pain usually increases on exertion and relieves with rest. It will never increase on pressing or arm movement. You do not need to repeat any test. Coming to possibilities, psychosomatic is certainly a possibility, but considering the site of pain, there is also a possibility of a cervical spine problem. Do you have any tingling, numbness in arm, neck stiffness, increase in pain on neck movements, neck trauma in the past, etc,? If yes, it suggests the possibility of cervical spondylosis. So I think, it is worthwhile to get X-ray cervical spine done anteroposterior or lateral view. Just check, sometimes during CT head, they may include neck region as well. If yes, then no need of X-ray. Regarding medicines, Tramadol is the safest as far as BP is concerned. However, it may not be that effective. You may try tablet Naproxen 250 mg two times a day after meals. Only problem is with this, in some (minor) patients, it may slightly raise BP which will come back to normal after it has stopped. So I think, it is worthwhile to try it. Also, you should try muscle relaxant tablet Myoril 4 mg whenever needed upto three times a day and look for a response. If gets a positive response then we can complete the course of five days. This should not cause any significant cardiac issues in you. Regarding, antianxiety medicine, I think there is no need to have Flupentixol, and better to avoid it. However, Escitalopram, we use very frequently and it is quite safe. Side effects like QT and all are very rare so you may have it. It comes in combination with Etizolam as Etizola plus which is a good antianxiety medicine to have during bedtime for a week or so.

Answer 2

Hi,

Welcome back to icliniq.com.

Naproxen, you need to take for five days. Muscle relaxant as I suggested above, Myoril 4 mg. In the gel, you may use Diclofenac gel for local application. All the best.

I have shoulder, arm, breast and neck pain. Is it musculoskeletal pain?

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