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32 year old with wrist pain (Science : (Evidence Based Practice…
32 year old with wrist pain
Science
:
Evidence Based Practice
Treatment
Release of the triceps and biceps will result in decreased irritation of the ulnar nerve.
Technique correction on bench press should be observed to reduce chance of further irritation.
Anantomy
The ulna nerve doesn’t pass through the carpal tunnel but passes through Guyon’s canal, so the scapholunate separation shouldn’t impact the ulnar nerve
Therefore the irritation should be either in Guyon’s canal or higher up.
Ulnar nerve can be irritated under the triceps as it passes through the arm.
Pattern Recognition
MRI didnt match with ulnar nerve irritation
nerve entrapment higher up
never seen anything similar - required problem solving
Hypo -thetico-deductive Reasoning
Subjective:
Pt tried to do bench press 3/52 ago after long absence from resistance training and felt pain on ulnar side of wrist and shoots down into finger.
AGG
: lifting, any movement
EASE
: Improves at night.
Thought
: Ulnar nerve irritation at wrist due to pain down pinky.
MRI:
Scapholunate separation of 6mm
Thought
: MRI appears to be irrelevant.
Plan
: Look for places for ulnar nerve irritation
Elbow
Objective
: ULTT ulna - pull from beginning then release. More pain with elbow bias
Thought
: ulna nerve is the problem. most likely entrapped at or above the elbow
3 more items...
Objective
: Flex, ext L=R - slight EOR pain
Hand
Objective
: AROM- UD - NSD RD - NSD
Thought
: Hand is not showing symptoms of damage.
1 more item...
Dx:
Scapholunate instability
Thought
: Scapholunate affects median nerve and not ulnar nerve
Objective:
Grip strength down. Grip N - L R, Grip sup L R, Grip pro L R
Person
Dialogiusm
Knowledge
: As pt was a electrical engineer he has good knowledge of electrical symptoms. This knowledge can be transferred into nerves as they are similar so the language used could be complex.
Fear
: Pt had a fear that his hand might not get better and moving his hand would make it worse. It was important to let him know that it will get better and movement will be a key part of treatment.
Narrative Based Reasoning
short term:
House work, Back to work
long term goal:
gym program loose weight
Outcomes needed:
Increase grip strength. start to look at and correct UL mechanics
Outcomes needed:
Increased grip streangh to functional levels. decreased Ulnar nerve irritation
Social
: Gym (mainly cardio)
Work
: Electrical engineer
Family
: Wife, daughter(20 months)
Professional Socialism
Father
: Father is GP and was interested in what was going on. It was important to call him and let him know our diagnosis and plan. This communication would also aid in reducing the fear of the pt.
MRI
: Had to read MRI report
GP:
If pain persists may need pain meds higher than neurofen? If conditioning is a goal then may need to be in contact due to medications and history of asthma.
Pt no longer needs pain medications
EP?
If pt wants to continue strength training after treatment
Seems keen to keep training
ulnar nerve.7