Recently (2 weeks), I began treating a young woman between the age of 25-30 for a 1.5 year history of bilateral wrist and hand pain with insidious onset. Besides pain, her biggest complaint was significant numbness in her ulnar nerve distribution on her left hand. Her flexibility in her bilateral wrist flexors and ulnar deviators is fair, with significantly increased tissue density in her superficial and deep anterior forearm musculature. She is left handed.
She notes 8/10 pain in her left wrist at worst, with a constant 2-3/10 at rest. She is a computer programmer who spends roughly 6 hours a day at the computer. She notes pain with continued computer work and general pain at the end of the day. She has had EMG studies as well as MRIs with no significant findings. The following is a list of special tests.
Negative: UQS, Finkelstein, Roos, Phalens, Reverse Phalens, Ulnar Tinels
Mobility: Distal Radial-Ulnar (Right:4/6, Left: 5/6), Proximal R-U (4/6 bilaterally), Carpals (4/6 bilaterally)
Strength: Grip (Right 5/5, Left 4+/5), Wrist flexion (Right 5/5, Left 5/5), Wrist extension (5/5 Bilaterally)
Endurance: 5# Repeated Repetitions (Wrist Flexion): Left fatigue with 23 reps, Right fatigue with 39 reps
- Soft Tissue Mobilization to proximal wrist flexors
- Ultrasound (Continuous, 1.0 Hz) x 7 minutes bilaterally, followed by
- Wrist flexor stretches 3-5 x 30 seconds
- 3# wrist flexion/extension/radial and ulnar deviation with eccentric focus
- Alternating isometrics for stabilization of distal R-U joint
- Basic wrist stabilization taping
- Recommended wrist/forearm padding while working at computer
I should also let you know the MD prescription was “Tendonitis; Eval and treat” (I love these scripts). The patient has also been on a certain corticosteroid for the past month which is now being tapered.
Progress to date: Pt notes decrease of L wrist pain to 4-5/10 pain and right to 2/10 pain with occasional (less than once a day) spike to 6/10 in left.
So Mike, why the hell are you writing this? I find the most interesting part of this case is that she has no positive tests, special or diagnostic imaging, for anything but continues to present with a specific pattern of pain, and in my opinion NOT tendonitis. My thought process leads me to believe ulnar nerve entrapment, but what are your thoughts about anything I have written here? In particular the script from the MD and the POC.
(Obviously certain info has been changed to keep the patient’s identity safe)