Can Lyme Disease Cause Shoulder and Arm Pain?

Lyme disease can present with shoulder pain, arm weakness, and meningitis
Parsonage-Turner syndrome has also been reported with Lyme borreliosis
Severe pain followed by weakness may point to nerve involvement

Quick Answer: Lyme disease can sometimes cause shoulder and arm pain by affecting nerve roots, peripheral nerves, or the brachial plexus. One unusual presentation is Parsonage-Turner syndrome, also called neuralgic amyotrophy, which typically begins with sudden severe shoulder or arm pain followed by weakness and sometimes muscle wasting. Lyme borreliosis has been reported as an infectious association, although it is not a common cause of Parsonage-Turner syndrome.

Shoulder pain is common and usually has a musculoskeletal cause. But when severe or unexplained shoulder pain is followed by arm weakness, numbness, sensory changes, or muscle wasting, a neurologic cause may need to be considered.

Although Lyme arthritis is well recognized, Lyme disease can also affect nerve roots and peripheral nerves, producing shoulder pain, arm weakness, and sensory symptoms before joint swelling develops.

In their article, Early Lyme neuroborreliosis manifesting as brachial plexopathy and meningitis in Northwestern Ontario, Canada, Gu and colleagues describe an unusual case of early Lyme disease presenting with brachial plexopathy, meningitis, and progressive arm weakness.¹

The case highlights an important clinical lesson: patients with Lyme disease may not recall a tick bite or recognize an erythema migrans rash. Instead, they may present with painful neurologic symptoms that resemble orthopedic or spinal disorders.

These manifestations fall within the broader spectrum of neurologic Lyme disease, which can affect the brain, spinal cord, cranial nerves, nerve roots, and peripheral nerves.

A Case of Lyme Brachial Plexopathy and Meningitis

A 76-year-old man was admitted to the hospital with left arm weakness, neck pain, headaches, and a three-day history of body aches.

Several weeks earlier, he had noticed what he believed was a mosquito bite that became increasingly red and swollen. He did not recall finding an attached tick.

Because the lesion appeared inflamed, he was diagnosed with purulent cellulitis and treated with a seven-day course of cephalexin. His skin symptoms resolved completely.

At that point, Lyme disease was not suspected.

What Is Brachial Plexopathy?

The brachial plexus is a network of nerves that travels from the neck into the shoulder and arm. Damage or inflammation involving these nerves can produce:

Shoulder and neck pain
Arm weakness
Numbness or tingling
Reduced sensation
Difficulty lifting or using the arm

This condition, known as brachial plexopathy, is one form of peripheral nerve disorder and has many potential causes, including trauma, inflammatory or immune-mediated disorders, and, less commonly, infections such as Lyme disease.^2,3

Patients may initially be diagnosed with a pinched nerve, cervical radiculopathy, rotator cuff disease, or shoulder arthritis before the underlying neurologic cause becomes apparent.

What Is Parsonage-Turner Syndrome?

Parsonage-Turner syndrome, also known as neuralgic amyotrophy or acute brachial neuritis, is an uncommon peripheral nerve disorder that frequently affects nerves supplying the shoulder and upper arm.^2,4

One of its most recognizable features is the sequence of symptoms. Patients often develop sudden, intense shoulder or upper-arm pain followed by muscle weakness. Muscle wasting can develop as the affected nerves and muscles lose function.

The cause is not always known. Parsonage-Turner syndrome has been reported following infections and other events that may stimulate an immune response. Infectious associations described in the medical literature include several viral and bacterial illnesses.⁴

Lyme Disease Has Been Reported With Parsonage-Turner Syndrome

Lyme borreliosis is one of the infections that has been reported in association with Parsonage-Turner syndrome.

In 2009, Wendling and colleagues described four patients with Parsonage-Turner syndrome as the first manifestation of Lyme borreliosis.² The clinical pattern was characteristic: acute shoulder pain was followed rapidly by weakness and wasting of the shoulder-girdle muscles. Electrophysiologic testing demonstrated denervation.

All four patients had positive Lyme serology in serum, while two also had positive Lyme serology in cerebrospinal fluid. Three had cerebrospinal fluid lymphocytosis and elevated protein. Only one of the four patients reported an erythema migrans rash following a tick bite.²

The patients were treated with antibiotics and all had favorable outcomes. Two recovered completely within six months.²

This does not mean that Lyme disease is a common cause of Parsonage-Turner syndrome. Rather, the report illustrates that Lyme borreliosis may be one infectious consideration when a patient develops otherwise unexplained severe shoulder pain followed by neurologic weakness.

A Second Report Described Bilateral Neuralgic Amyotrophy

In 2018, Zhang and colleagues reported another unusual case involving a 74-year-old man with acute bilateral neuralgic amyotrophy possibly associated with Lyme disease.⁵

The illness began with sudden, severe shoulder and upper-arm pain accompanied by numbness and tingling. The patient was initially diagnosed with shoulder osteoarthritis and returned repeatedly for medical evaluation as his neurologic illness evolved.⁵

The authors ultimately described the presentation as acute bilateral neuralgic amyotrophy possibly secondary to Lyme disease. The patient made substantial functional gains during inpatient rehabilitation.⁵

This additional report does not establish Lyme disease as the cause of neuralgic amyotrophy in most patients. It does, however, add to the limited literature describing Parsonage-Turner syndrome or neuralgic amyotrophy in association with Lyme disease.

2024 Systematic Review Provides New Context

A 2024 systematic review by Al Hinai and colleagues examined 25 studies involving 950 adults with Parsonage-Turner syndrome.⁴

The review reinforces the characteristic clinical pattern of acute severe pain followed by weakness and motor deficits. Symptoms most commonly involved the brachial plexus and upper limb, although other nerves can also be affected.

The researchers found that diagnosing Parsonage-Turner syndrome may involve several approaches, including clinical history and neurologic examination, electromyography (EMG), nerve conduction studies, MRI, ultrasound, and targeted laboratory testing when another underlying condition is suspected.⁴

The review also illustrates that recovery from Parsonage-Turner syndrome can be prolonged. Across the broader PTS literature, long-term outcomes reported between 5 and 25 months included residual neuropathic pain in 60% and incomplete return of motor function in 70%.⁴

These percentages describe Parsonage-Turner syndrome overall and should not be interpreted as outcomes specifically for patients with Lyme-associated disease. The Lyme literature consists primarily of small reports and case series and does not establish the frequency, prognosis, or optimal management of Lyme-associated Parsonage-Turner syndrome.

Neurologic Symptoms Continued to Progress

In the Lyme neuroborreliosis case described by Gu and colleagues, 24 days after completing antibiotics for cellulitis, the patient returned to the emergency department with several days of persistent headache and new neurologic pain.

He described bilateral, paroxysmal “shock-like” pains radiating from his shoulders into both arms and across his chest.

Although additional testing was initiated, he was discharged while awaiting results.

Over the following several days, his condition worsened. Weakness developed in his left arm and hand, prompting another emergency department visit.

Five days later he returned once again with increasing left arm weakness, persistent neck pain, and intermittent night sweats.

The progressive neurologic symptoms suggested a process extending beyond a localized musculoskeletal injury.

MRI and Lyme Testing Revealed Early Neuroborreliosis

MRI findings demonstrated increased signal uptake along the ventral aspect of the spinal cord at T3 and along the left brachial plexus, findings that the authors considered consistent with polyradiculitis.

Given the patient’s progressive neurologic symptoms, Lyme disease testing was performed. Both the enzyme-linked immunosorbent assay (ELISA) and confirmatory Western blot were positive.

The combination of painful radiculitis, meningitis, and brachial plexus involvement led to the diagnosis of early Lyme neuroborreliosis presenting as meningoradiculitis.¹

Lyme neuroborreliosis can involve the meninges, cranial nerves, spinal nerve roots, and peripheral nerves. Although facial nerve palsy remains one of the most recognized neurologic manifestations, painful radiculitis and peripheral nervous system involvement are also described.³

Treatment Led to Complete Recovery

The patient was treated with intravenous ceftriaxone after the diagnosis of Lyme neuroborreliosis was established.

Over the following year, he experienced gradual improvement.

Muscle strength and sensation returned completely, while his neck pain and left arm pain improved more slowly before eventually resolving.¹

The outcome illustrates that substantial neurologic recovery can occur following recognition and treatment of Lyme neuroborreliosis, although recovery from nerve injury may take time.

When Should Lyme Disease Be Considered?

Most shoulder pain is not caused by Lyme disease. Rotator cuff injuries, arthritis, cervical radiculopathy, trauma, and numerous other conditions are considerably more common.

However, the clinical picture changes when severe or unexplained shoulder pain is followed by weakness, sensory changes, muscle wasting, radicular pain, headache, neck stiffness, facial weakness, or other neurologic findings.

In a patient with plausible tick exposure or who lives in or has traveled to a Lyme-endemic area, Lyme disease may deserve consideration as part of a broader differential diagnosis.

A remembered tick bite should not be required before considering the diagnosis. Patients may never see the tick, and an erythema migrans rash may be absent, overlooked, or mistaken for another skin condition.

Clinical Lessons

Lyme disease can occasionally involve the brachial plexus, nerve roots, and peripheral nerves.
Shoulder or arm pain accompanied by weakness may represent a neurologic rather than purely orthopedic problem.
Parsonage-Turner syndrome typically produces severe pain followed by weakness and sometimes muscle wasting.
Lyme borreliosis has been reported in association with Parsonage-Turner syndrome, including a four-patient series and an additional report of bilateral neuralgic amyotrophy.
The available reports do not establish Lyme disease as a common cause of Parsonage-Turner syndrome.
EMG and nerve conduction studies can help characterize peripheral nerve involvement.
Clinical history, neurologic examination, imaging, and targeted testing may be needed to distinguish among possible causes.

Frequently Asked Questions

Can Lyme disease cause shoulder pain?

Yes. Lyme disease can sometimes cause shoulder pain through arthritis or neurologic involvement, including radiculitis and inflammation affecting peripheral nerves or the brachial plexus. Nerve-related pain may be accompanied by weakness, numbness, tingling, or shooting pain.

Can Lyme disease cause arm pain?

Yes. Lyme disease can cause arm pain when inflammation affects nerve roots, peripheral nerves, or the brachial plexus. Pain may feel sharp, shooting, burning, or shock-like.

What is Parsonage-Turner syndrome?

Parsonage-Turner syndrome, also called neuralgic amyotrophy, is an uncommon peripheral nerve disorder that typically begins with sudden severe shoulder or arm pain followed by weakness. Some patients develop muscle wasting.

Is Parsonage-Turner syndrome associated with Lyme disease?

Lyme borreliosis has been reported in association with Parsonage-Turner syndrome, including a four-patient series and a separate case of bilateral neuralgic amyotrophy. However, Lyme disease should not be assumed to be the cause of most cases.

Can Lyme disease cause arm weakness?

Yes. Lyme neuroborreliosis can affect nerve roots or peripheral nerves and may result in weakness, sensory changes, or loss of muscle function.

Can Lyme shoulder pain be mistaken for a pinched nerve?

It can. Neurologic Lyme disease involving nerve roots or the brachial plexus may produce pain and weakness resembling cervical radiculopathy, a pinched nerve, or another orthopedic or neurologic condition.

Can you have neurologic Lyme disease without remembering a tick bite?

Yes. Patients with Lyme disease may not recall a tick bite, and some may not recognize an erythema migrans rash before neurologic symptoms develop.

Clinical Takeaway

Lyme disease should remain in the differential diagnosis for patients with otherwise unexplained shoulder or arm pain accompanied by neurologic findings such as weakness, sensory changes, painful radiculopathy, muscle wasting, headache, neck stiffness, or meningitis when the clinical and exposure history makes Lyme disease plausible.

Parsonage-Turner syndrome provides another example of why severe shoulder pain followed by weakness should not automatically be assumed to be an orthopedic problem. Lyme borreliosis has been reported as an infectious association, but it represents an uncommon presentation and other causes must also be considered.

Neurologic Lyme disease can affect the brain, spinal cord, nerve roots, and peripheral nerves in many different ways. These articles discuss additional neurologic manifestations and diagnostic challenges.

Neurologic Lyme Disease: Understanding the Nervous System Symptoms

Lyme Disease Brain Fog in Children: Cognitive Symptoms

Can Lyme Disease Cause Sudden Hearing Loss and Facial Palsy?

Lyme Meningitis: Symptoms, Diagnosis, and a Case of Radiculitis

Can Lyme Disease Cause Neck Pain? A Child’s Case

References

Gu K, Boodman C, Orr P, Wuerz T. Early Lyme neuroborreliosis manifesting as brachial plexopathy and meningitis in Northwestern Ontario, Canada: A case report. Medicine (Baltimore). 2022;101(45):e31576. doi:10.1097/MD.0000000000031576.
Wendling D, Sevrin P, Bouchaud-Chabot A, Chabroux A, Toussirot E, Bardin T, Michel F. Parsonage-Turner syndrome revealing Lyme borreliosis. Joint Bone Spine. 2009;76(2):202-204. doi:10.1016/j.jbspin.2008.07.013.
Koedel U, Fingerle V, Pfister HW. Lyme neuroborreliosis—epidemiology, diagnosis and management. Nat Rev Neurol. 2015;11(8):446-456. doi:10.1038/nrneurol.2015.121.
Al Hinai R, Kelly L, O’Connor M, Berman H, Abdul Jalil L, Sowa A, McDonnell JM, Dolan R. Unraveling the mysteries of Parsonage Turner syndrome: A journey towards optimal management. A systematic review. J Hand Microsurg. 2024;16(5):100142. doi:10.1016/j.jham.2024.100142.
Zhang S, Zhang LQ, Wright M, Gater DR. Challenging diagnosis and inpatient rehabilitation of acute bilateral neuralgic amyotrophy possibly attributed to Lyme disease: A case report. PM R. 2018;10(7):770-774. doi:10.1016/j.pmrj.2017.11.018.

This article is for educational purposes and is not a substitute for individualized medical evaluation, diagnosis, or treatment.

Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention

Social Converations with Dr. Daniel Cameron

Lyme disease presents as brachial plexopathy and meningitis