Chase Armstrong: A 32-Year-Old Male With Pain and Electric Shock–Like Sensation Radiating Into the Lateral Forearm and Ring and Little Fingers

Chase Armstrong

Chase Armstrong is a 32-year-old cycling enthusiast who I had been taking care of for the last several years. I last saw him for a hamstring strain following an ultra-endurance cycling event. His chief complaint today is “I have pain and numbness in my little finger and the outside of my ring finger.” Chase stated that over the past several months, in addition to the numbness, he began noticing a deep aching sensation in his wrist and hand. It was associated with electric shock–like pains into the ring and little fingers on the right, especially when he rode for long distances. “At first, I thought it was my seat height, so I adjusted it, but that didn’t do anything but give me a backache. So, then I thought it was the handlebars, but that wasn’t it either.”

I asked Chase if he had experienced any other symptoms, and he replied, “Doc, it’s funny that you asked, as I am having the hardest time getting my keys out of my pants pocket because my little finger keeps catching on the edge of the pocket. And after a day at work, I have begun noticing that my little finger and part of my right ring finger, the part next to my little finger, are numb!” ( Fig. 3.1 ) I asked Chase what he thought was causing his symptoms, but he had no idea. He was an iron man, and nothing ever slowed him down. I asked what he had tried to make it better, and he reported using a heating pad on his wrist at night, which “seemed to make the pain better, but the numbness worse. Tylenol PM seemed to help some, at least with sleep.” I asked Chase to describe any numbness he noticed associated with the pain, and he pointed to his right little finger and the ulnar aspect of his ring finger. “Doc, the whole little finger is numb, but just part of my ring finger goes to sleep. The pins-and-needles sensation drives me crazy!” I asked Chase about any fever, chills, or other constitutional symptoms such as weight loss, night sweats, etc., and he shook his head no. He denied any antecedent wrist trauma, but noted that sometimes the electric shock–like pain woke him up at night.

I asked Chase to point with one finger to show me where it hurt the most. He pointed to the ulnar aspect of the right wrist. He went on to say that he could live with the pain, “but the crazy way my fingers are acting kind of scares me. I have to be able to hold the handlebars.” He then asked, “Doc, my partner keeps insisting that all of this is from my cycling. That seems silly to me; I’d love to know what you think.” I said that the cycling could certainly be a factor in his pain, weakness, and numbness, but that remained to be seen.

On physical examination, Chase was afebrile. His respirations were 16, his pulse was 64 and regular, and his blood pressure was 110/68. Chase’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary exam. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of the right wrist was unremarkable. There was no ecchymosis, rubor, or color and there was no obvious infection. There was a positive Tinel sign over the right ulnar nerve at the wrist. Examination of Chase’s hands revealed no stigmata of osteoarthritis or rheumatoid arthritis. The left wrist examination was normal, but there was mild crepitus on passive flexion and extension of his right wrist. A careful neurologic examination of the upper extremities revealed decreased sensation in the distribution of the distal ulnar nerve as well as weakness of the intrinsic muscles of the right hand and weakness to the adductor pollicis brevis and flexor pollicis brevis ( Fig. 3.2 ). Deep tendon reflexes were normal. Chase exhibited a positive Froment sign as well as a little finger adduction sign ( Fig. 3.3 ). Jeanne sign was also positive ( Fig. 3.4 ).

Key Clinical Points—What’s Important and What’s Not