Contralateral Limb Pain

Scientific analysis of overuse injury and progressive disability is scantly described in the literature as it relates to children with total plexus palsy with resulting flail or near flail arm function due to its rarity and individual variability of lesions.[1] Overuse injury of the contralateral upper extremity is best described in the upper extremity amputee literature.

Contralateral upper extremity limb pain from overuse is a well known complication for those who have suffered an amputation of an upper extremity.  Despite being generally accepted in the medical community it wasn’t until 1999 that it was first described in a study of 46 persons with a unilateral upper extremity amputation, fifty percent of which report “overuse problems of varying severity and type”.[2]  Overuse injuries in the upper extremity amputee are well known and require ongoing patient counseling to make the patient aware of the risks and repercussions of overuse injuries, and counseling them on the early detection and immediate intervention of conservative treatment at the onset of symptoms, it is thought that serious injuries can be prevented or at least delayed.[3]

Resnik, et al, found in a study that contralateral limb “is prevalent and persistent in veterans and those who reported moderate to severe contralateral limb pain were associated with worse quality of life outcomes and greater disability. In addition, the authors found “the most prevalent conditions diagnosed in the contralateral limb as rotator cuff tendonitis, osteoarthritis, and carpal tunnel, nerve damage, elbow tendonitis, and wrist tendonitis”.[4]  Contralateral limb pain is reported in 71% of those in a study involving Veterans with upper-limb amputation.[5] McFarland, et al. reported in veterans from the Vietnam and Iraq conflicts described the pain “from overuse of the nonamputated limb and may include any one of the following: carpal tunnel syndrome, cubitual tunnel syndrome, tendonitis, arthritis, stiff or painful joints, or ganglion cyst” and used the term “cumulative trauma disorder”.  Delayed pain over years from overuse is supported in this study, as 60% of Vietnam veterans “who are 40 years from their limb loss” reported diagnoses that were considered cumulative trauma disorder which was significantly higher than 38% of those from the Operation Iraqui Freedom/Operation Enduring Freedom conflicts who were 3-4 years from their limb loss.[6]  In a Norwegian study,  amputees reported significantly more pain than controls in the neck/upper back and in the shoulders than in controls.[7]  Cancio, et al. found similar findings related to the increased risk of overuse conditions.[8]

OPINIONS:

  1. Within a reasonable degree of medical certainty, Moises has very poor prognosis in regaining any meaningful function at his right shoulder, right elbow, right wrist, and right hand.
  2. Within a reasonable degree of medical certainty, based on my skill, knowledge, experience, training, and literature Moises will suffer from “contralateral limb pain” caused by overuse injuries as the demands of bimanual activity are ongoing.[9]
  3. Within a reasonable degree of medical certainty Moises will have no meaningful use of the upper extremity other than cosmesis and is at great risk for significant disability and vocational loss.[10]

[1] Bahm, et al. Obstetric Brachial Plexus Palsy. Dtsch Arztebl Int, 2009 Feb: 106(6): 83-90.

[2] L.E.Jones and J. H. Davidson. Save that arm: a study of problems in the remaining arm of unilateral upper limb amputees. Prosthetics and Orthotics International, 1999, 23, 55-58.

[3] Gambrell. Overuse Syndrome and the Unilateral Upper Limb Amputee: Consequences and Prevention. JPO Journal of Prosthetics and Othotics. Vol. 20, No. 3, 2008.

[4] Resnik, et al. Contralateral Limb Pain Is Prevalent, Persistent, and Impacts Quality of Life of Veterans with Unilateral Upper-Limb Amputation. Journal of Prosthetics and Orthotics. Vol. 35, No. 11, 2023.

[5] Resnik, Ekerholm, et al. A national study of Veterans with major upper limb amputations: Survey methods, participants, and summary. PlosOne March 14, 2019.

[6] McFarland, et al. Unilateral upper-limb loss: Satisfaction and prosthetic-device use in veterans and servicemembers from Vietnam and OIF/OEF conflicts. Journal of Rehabilitation Research & Development. Vol. 47, No. 4, 2010, pgs. 299-316.

[7] Ostlie, Franklin, et al. Musculoskeletal Pain and Overuse Syndromes in Adult Acquired Major Upper-Limb Amputees. Arch Phys Med Rehabilitation. Vol. 92, December 2011.

[8] Cancio, et al. Development of overuse musculoskeletal conditions after combat-related upper journal of limb amputation: a retrospective cohort study. Journal of Hand Therapy 36 (2023) 66-73.

[9]  VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation. https://www.healthquality.va.gov/guidelines/Rehab/ULA/VADoDULACPG_Final_508.pdf

[10] Tennent, Wenke, et al. Characterisation and outcomes of upper extremity amputations. Injury, Int. J. Care Injured 45 (2014) 965-969; VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation. https://www.healthquality.va.gov/guidelines/Rehab/ULA/VADoDULACPG_Final_508.pdf 

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