Marco Arco: A 22-Year-Old Male With Severe Right Wrist Pain

Marco Arco

Marco Arco is a 22-year-old tennis player with the chief complaint of “I can’t play tennis because my right wrist is killing me.” Marco stated that he recently competed in a regional tennis tournament, and since then his right wrist has been extremely painful. “Doc, the competition was really tough, and the clay courts were not up to par. My game was really off that day. I was up against this guy from Spain in the semifinals, and we were really evenly matched. He sensed my backhand was not my strongest play, so he used it against me. The game went on for what seemed like hours, and neither of us could bring the game home. I was getting tired and so was he, but I felt like if I could hang on, I could win the thing. I started returning every ball as hard as I could. I knew it was a bad idea, but I just couldn’t help myself. I wanted to win so bad! By match point, my right wrist was hurting so bad I could barely hold my racquet. I served one as hard as I could. I really put my whole body into that serve, and I knew there was no way that guy was going to return it. I won—he didn’t—but from then on, the pinky finger side of my wrist has been really hurting. Especially in the mornings when I try to pick up my coffee mug. I feel a catch and a sharp pain.”

I asked Marco about any antecedent wrist trauma, and he said he had strained his wrist several times in the past. “It always got better,” he said, “but not this time.” I asked what made the pain better, and he said that a couple of Aleves washed down with a Red Bull seemed to help. I asked Marco what made it worse, and he said the heating pad and anything that required him to move his wrist or lift anything with his right hand. I asked how he was sleeping, and he said, “Not worth a crap. I can’t lay on my right side, and that’s the side I like to sleep on. Every time I roll over, I get a sharp pain in the little finger side of my wrist and it wakes me up. I have a tough time getting back to sleep.” He denied fever and chills. I asked Marco to point with one finger where it hurt the most. He pointed to the volar-ulnar aspect of the wrist just below the base of the little finger.

On physical examination, Marco was afebrile. His respirations were 16, and his pulse was 72 and regular. He was normotensive with a blood pressure of 120/70. Marco’s head, eyes, ears, nose, throat (HEENT) exam was normal. His cardiopulmonary examination was normal. His thyroid was normal, as was his abdominal examination, which revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness or peripheral edema. Marco’s low back examination was unremarkable. Visual inspection of the right wrist was normal, specifically there was no rubor. I noted that Marco was splinting his right wrist by holding it against his abdomen. The volar-ulnar aspect of the right wrist was a little warm, but it did not appear to be infected. There was marked point tenderness 2 to 3 cm above the pisiform. Active resisted ulnar deviation of the wrist as well as active resisted wrist flexion caused Marco to wince in pain. The left wrist examination was normal, as was examination of his other major joints. A careful neurologic examination of the upper extremities revealed there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

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