Left Arm Pain and Numbness-Recreational Athlete

Abstract

HISTORY: A 41 year old right hand dominant female presented with left arm pain and numbness of 6 months duration with progressive worsening. Symptoms started in the distal posterior medial aspect of her arm and radiated to the 4th and 5th fingers of the hand. The pain was worse with lifting, swimming, biking, and tennis, forcing her to stop her normal athletic activities. She also noticed swelling in the distal aspect of the arm where the pain originated and a palpable bump. She denied history of trauma, clicking, locking, or instability. PHYSICAL EXAM: Neck exam showed full painless range of motion, no tenderness, and a negative Spurling test. Shoulder exam showed full strength and range of motion. Her left elbow had full range of motion with pain, no instability or crepitus. She had soft tissue tenderness and swelling in the distal arm medially with palpable nodules just proximal to the medial epicondyle. Cozen’s, Speed’s, and Yergason’s tests were negative. She had 5/5 strength and full range of motion of her left hand. Neurologic exam showed decreased sensation in the ulnar nerve distribution. Capillary refill and radial pulses were intact. DIFFERENTIAL DIAGNOSIS: 1. Cubital Tunnel Syndrome 2. Ulnar Neuropathy Secondary to Mass Effect 3. Fracture/Stress Fracture 4. Cervical Radiculopathy 5. Thoracic Outlet Syndrome TESTS AND RESULTS: XR Humerus: No soft tissue swelling or acute osseous abnormality Limited Diagnostic Ultrasound: 4 hypervascular nodules adjacent to ulnar nerve, likely lymph nodes FINAL WORKING DIAGNOSIS: Ulnar neuropathy secondary to mass effect, lymphadenopathy, need to rule out malignancy. TREATMENT AND OUTCOMES: 1. MRI Left Humerus: abnormal enlarged lymph nodes. Mass effect evident along the ulnar nerve. 2. Referred to Hematology Oncology. 3. Biopsy: grade 1 follicular lymphoma. 4. PET scan: hypermetabolic lymphadenopathy above and below the diaphragm, uptake in the spleen and liver, consistent with a Stage III lymphoma. 5. Bendamustine/Rituximab (BR) was started because of its response rate and lower side effect profile compared to other chemotherapies. 6. Patient has undergone 2 cycles of BR with good response, including near resolution of her humeral disease. 7. She is restarting activities as tolerated. The expectation is that her ulnar neuropathy will improve with remission of her lymphoma.