Bilateral Hand Numbness in an Elite Flat-Water Kayaker

Abstract

HISTORY: A 19 year old right handed female elite flat water kayaker presented with bilateral forearm and hand numbness, tingling and occasional weakness of 3 weeks duration. Symptoms started insidiously and were described as constant, but worsened in association with kayaking practice and at night. She referred improvement of symptoms with rest. Her training load had recently increased in preparation for an international competition. She denied a history of such symptoms in the past. PHYSICAL EXAM: There was no edema, asymmetry, or muscular atrophy in the upper limbs. Full active and passive range of motion was appreciated at bilateral elbows, wrists and hands. No bony tenderness to palpation was present. The vascular exam was intact bilaterally. Ulnar and median nerve compression tests were negative at elbows and wrists, respectively, but Tinel's test was positive at the elbows bilaterally. Manual muscle testing was 5/5 on bilateral upper extremities. Deep tendon reflexes were +2 and symmetric on upper extremities. Sensation was intact to soft touch and pin prick above and below the elbows. DIFFERENTIAL DIAGNOSIS: Peripheral Entrapment Neuropathy (ulnar nerve entrapment at the elbow or median nerve entrapment at the forearm) Chronic Exertional Compartment Syndrome Cervical Radiculopathy Brachial Plexopathy Thoracic Outlet Syndrome Cervical Spinal Stenosis or Myelopathy TEST AND RESULTS: Bilateral elbow musculoskeletal ultrasound: positive for bilateral ulnar nerve subluxation with active elbow flexion EMG/NCS: Bilateral ulnar conduction velocity slowing across the elbow, suggestive of a focal neuropathy at the elbow, without evidence of axonal loss. FINAL WORKING DIAGNOSIS:Bilateral ulnar neuropathy at the elbow secondary to repetitive bilateral nerve subluxation. TREATMENT AND OUTCOMES:Activity modification - decreased training volume and kayak stroke modification. Physical therapy 3 times a week with re-evaluation every 3 weeks. Physical therapy- physical modalities (Electric galvanic stimulation, Ultrasound), forearm flexor and extensor compartment stretching and strengthening program. Patient improved after 6 weeks of physical therapy without further complaints and competed in a major international competition 3 months after initial visit.