Likely Diagnoses and Management
This 63-year-old man presents with three distinct conditions requiring separate evaluation and treatment: ulnar nerve compression (likely cubital or Gunn canal syndrome) causing numbness in the ulnar-sided digits, left middle finger trigger finger, and right shoulder rotator cuff tendinopathy.
Right Wrist Pain with Ulnar-Sided Numbness
Clinical Diagnosis
- Numbness and tingling in the middle, ring, and little fingers suggests ulnar nerve entrapment, NOT carpal tunnel syndrome (which affects thumb, index, middle, and radial half of ring finger only) 1, 2.
- The combination of wrist inflammation and ulnar-sided symptoms points to either cubital tunnel syndrome (compression at elbow) or ulnar tunnel syndrome (compression at wrist/Gunn canal) 1.
- Examine for decreased sensation in the little finger and ulnar aspect of ring finger, and assess for intrinsic hand muscle weakness (interossei, hypothenar muscles) 1.
Initial Workup
- Obtain standard wrist radiographs (posterior-anterior, lateral, and oblique views) immediately to exclude fracture, arthritis, bone tumors, or ganglion cysts that could compress the ulnar nerve 3, 4, 5.
- Electrophysiologic testing (nerve conduction studies and electromyography) is mandatory to confirm ulnar nerve compression, localize the site of entrapment, and assess severity 5, 6.
- If radiographs are normal but symptoms persist, obtain MRI of the wrist without IV contrast to evaluate for soft tissue masses, ganglion cysts, TFCC tears, or distal radioulnar joint pathology 3, 4.
- Ultrasound is an alternative to MRI for identifying ganglion cysts and measuring nerve size 4, 5.
Treatment
- Volar splinting in neutral position to reduce nerve compression 1.
- NSAIDs for pain control if no contraindications 3.
- Avoid repetitive wrist flexion and direct pressure on the ulnar side of the wrist 1.
- If conservative management fails after 3-6 months, surgical decompression (cubital tunnel release or Gunn canal release) is effective 3.
Left Middle Finger Trigger Finger
Clinical Diagnosis
- Trigger finger involves abnormal resistance to smooth flexion and extension ("triggering") of the affected finger due to size mismatch between the flexor tendon and the A-1 pulley 2, 7.
- Affects up to 20% of adults with diabetes and approximately 2% of the general population 2.
- Physical examination reveals palpable nodule at the A-1 pulley (metacarpophalangeal joint level) and triggering with active finger flexion/extension 7.
Initial Workup
- Clinical diagnosis based on physical examination alone—no imaging required 2, 7.
- Screen for diabetes mellitus if not already diagnosed, as trigger finger is more common and less responsive to conservative treatment in diabetic patients 2, 7.
Treatment
- First-line: corticosteroid injection into the flexor tendon sheath at the A-1 pulley level relieves symptoms in approximately 60-90% of patients 2, 7.
- Splinting the affected finger in extension may provide temporary relief 7.
- Steroid injection is less efficacious in insulin-dependent diabetics—consider early surgical A-1 pulley release in this population 2, 7.
- For recurrent symptoms after injection, surgical release of the A-1 pulley (open or percutaneous technique) is definitive treatment 2, 7.
- Important caveat: If patient has rheumatoid arthritis, tenosynovectomy is required instead of simple A-1 pulley release 7.
Right Shoulder Pain
Clinical Diagnosis
- Rotator cuff tendinopathy is the most likely diagnosis in a 63-year-old with shoulder pain, particularly if pain worsens with overhead activities 3.
- Perform Hawkins' test (forcible internal rotation with arm passively flexed forward at 90 degrees)—92% sensitive for impingement 3.
- Perform Neer's test (pain with full forward flexion between 70-120 degrees)—88% sensitive for impingement 3.
- Examine for muscle atrophy (suggests chronic condition), asymmetry, swelling, and limited range of motion 3.
- Palpation elicits well-localized tenderness over the supraspinatus tendon insertion 3.
Initial Workup
- Obtain shoulder radiographs (AP views in internal and external rotation, plus axillary or scapula-Y view) to exclude fracture, dislocation, calcific tendinosis, or acromial spur formation 3.
- If radiographs are normal or show only nonspecific findings and symptoms persist, obtain MRI without IV contrast—95% sensitive and 95% specific for detecting rotator cuff tears, degeneration, and partial tears 3.
- Ultrasound is an alternative for detecting moderate to full-thickness tears but has limited ability to detect small tears 3.
Treatment
- Relative rest: reduce overhead activities and repetitive loading of the damaged tendon 3.
- NSAIDs for pain control during the acute phase 3.
- Corticosteroid injection is more effective than NSAIDs in the acute phase but does not change long-term outcomes 3.
- Physical therapy with eccentric strengthening exercises to promote tendon healing 3.
- Deep transverse friction massage may reduce pain 3.
- If conservative management fails after 3-6 months, surgical intervention (subacromial decompression or rotator cuff repair) is effective in carefully selected patients 3.
Key Clinical Pitfalls
- Do not assume carpal tunnel syndrome based on "wrist tingling"—the distribution of numbness (middle, ring, little fingers) indicates ulnar nerve pathology, not median nerve 1, 2.
- Do not delay electrophysiologic testing—it is mandatory to confirm nerve compression and guide treatment 5, 6.
- In diabetic patients with trigger finger, consider early surgical referral as steroid injections are less effective 2, 7.
- Do not inject corticosteroids into the shoulder without establishing a diagnosis first—imaging should be obtained if the diagnosis is unclear 3.
- Multiple symptomatic tendons should prompt evaluation for rheumatic disease (rheumatoid arthritis, inflammatory arthritis) with laboratory testing (RF, anti-CCP, ESR, CRP) 3, 8.