Is My Case Hopeless? Six-year Refractory Wrist Pain In An Elite Soldier - Page #1

Author: Benjamin Buchanan, MD

Patient Presentation:
34 year old elite female soldier presents with 6 years of left wrist and forearm pain.

Patient reports ventral and dorsal wrist pain as well as ventral/ulnar forearm pain. Rates the pain as a 4/10 on average and describes it as dull/achy. She denies radiation of pain outside of the pain described but reports numbness/tingling in fingers 1-3 in addition to decreased grip strength. She denies a history of trauma but says she began riding a motorcycle regularly about 6 months before the pain started. However, she has not been riding motorcycles for the last 3-4 years. She reports exercises such as push-ups and biceps curls that exacerbate the pain. Repetitive typing/pronation also exacerbate her symptoms. Symptoms are also worse in the morning after waking up. She has been through multiple rounds of wrist bracing, occupational therapy, and periods of rest without any significant improvements. She is becoming frustrated as she has seen multiple family medicine physicians, physical/occupational therapists, and an orthopedic hand specialist without improvements in her condition. She wants to avoid surgery at all costs.

Physical Exam:
Left wrist/forearm exam:
Inspection: No swelling, deformities, erythema, or atrophy
ROM: full ROM of wrist and fingers
Palpation: TTP over ventral/central aspect of the wrist, ulnar aspect of forearm approx. 3 inches proximal to the wrist
Neurovascular: fully intact
Strength: 4/5 grip strength/thumb opposition, otherwise 5/5 at wrist and digits, notable pain with wrist flexion against resistance, pain also with flexion of fingers 1-4 against resistance
Special Tests: positive carpal compression test, negative Phalen/Tinel/Finkelstein/Watson
Resisted elbow flexion with forearm supination did not reproduce symptoms
Resisted forearm pronation with elbow extended did not reproduce forearm pain

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