Right Arm Dystonia In A Former Baseball Pitcher

Abstract

HISTORY: A 58-year-old right-hand dominant former baseball pitcher presented with right forearm pain. It started 1 year ago after he fell down the stairs and caught himself with his right arm. It feels like “tightness”, is localized to the ulnar side of the wrist, and radiates up the forearm. Since the fall, he also reports repetitive involuntary movements of the right upper extremity provoked by rest and improved with external rotation of the shoulder. Denies numbness, tingling, or weakness. He has a history of depression treated with fluoxetine; he was took lurasidone for this in the past but developed tic-like movements in his hands, legs, and mouth due to this medication which resolved with stopping it. PHYSICAL EXAMINATION: He is in no acute distress. He repeatedly involuntarily elevates and internally rotates the right shoulder. Cervical spine, elbow, and wrist have full range of motion; shoulder has decreased internal and external rotation. Right levator scapulae is hypertrophic; other neck muscles have normal tone. Upper and lower extremity muscle groups have 5/5 strength bilaterally. Sensation is intact to light touch bilaterally. Reflexes are 2+ in the upper extremities and at the Achilles tendons and 3+ at the patellar tendons. Spurling's and Hoffman’s signs were negative and he had no clonus. DIFFERENTIAL DIAGNOSIS: 1. Cervical myelopathy 2. Tardive dyskinesia 3. Medication-induced dystonia 4. Cervical radiculopathy TEST AND RESULTS:Right shoulder x-rays: Moderate degenerative changes of the glenohumeral and acromioclavicular joints. Cervical spine x-rays: Multilevel degenerative changes of the cervical spine. MRI cervical spine: Multilevel degenerative changes with facet arthropathy, slight retrolisthesis from C3-C7, and loss of disc height from C4-C7. Moderate-to-severe right foraminal stenosis at C3-C4 and C4-C5. Spinal cord appears normal. FINAL WORKING DIAGNOSIS: Post-traumatic dystonia TREATMENT AND OUTCOMES: 1. No structural lesion was identified to explain the patient’s symptoms. 2. He was referred to neurology for possible medication-induced dystonia. 3. Neurology diagnosed him with post-traumatic dystonia based on his history of a fall down the stairs, dystonic movements in the affected limb, and right levator scapulae hypertrophy. 4. He was treated with botox injections.