What are the likely diagnoses and initial treatment recommendations for a 63‑year‑old man presenting with right‑wrist pain, swelling, median‑nerve numbness in the thumb, index and middle fingers, a left‑hand middle‑digit trigger finger, and right‑shoulder pain?

Clinical Presentation and Likely Diagnoses

This 63-year-old man presents with three distinct clinical entities: right-hand carpal tunnel syndrome (CTS), left-hand trigger finger, and right shoulder pain, each requiring separate diagnostic and therapeutic approaches.

Right Wrist: Carpal Tunnel Syndrome

Clinical Diagnosis

• The constellation of constant numbness and tingling in the thumb, index, and middle fingers with wrist inflammation strongly indicates carpal tunnel syndrome 1, 2
• The Durkan compression test (firm digital pressure across the carpal tunnel reproducing symptoms) should be performed, as it is 64% sensitive and 83% specific for CTS 1
• The flick sign and Phalen maneuver are additional confirmatory physical examination findings 2

Diagnostic Workup

• Begin with plain radiographs of the right wrist (PA, lateral, and oblique views) to exclude bony pathology, though radiographs are typically normal in isolated CTS 3, 4
• Electrodiagnostic studies (nerve conduction studies) are indicated if surgical decompression is planned, to determine severity and surgical prognosis 2
• Electrodiagnostic testing is approximately 80% sensitive and 95% specific for CTS 1
• Ultrasound can measure median nerve cross-sectional area and is highly sensitive and specific for CTS diagnosis, though the 2016 American Academy of Orthopedic Surgeons guidelines report limited evidence for routine use 3
• MRI is not routinely indicated for suspected CTS unless atypical features suggest alternative diagnoses 3

Treatment Algorithm

• For mild to moderate CTS, initiate conservative treatment with wrist splinting (especially at night) and consider local corticosteroid injection 2
• Corticosteroid injection provides relief for more than one month and delays surgery at one year 2
• NSAIDs, diuretics, and vitamin B6 are not effective therapies 2
• Patients with severe CTS (thenar atrophy, constant numbness, weakness of thumb opposition) or those failing 4-6 months of conservative therapy should be offered surgical decompression 1, 2
• Endoscopic and open carpal tunnel release are equally effective, though patients return to work one week earlier with endoscopic repair 2

Left Hand: Trigger Finger (Middle Digit)

Clinical Diagnosis

• Trigger finger represents stenosing flexor tenosynovitis of the A1 pulley, causing clicking, catching, or locking during finger flexion and extension 5, 6
• This condition affects up to 20% of adults with diabetes and approximately 2% of the general population 1
• The diagnosis is clinical, based on palpable clicking or visible catching of the affected finger 6

Diagnostic Workup

• Plain radiographs are not routinely necessary for isolated trigger finger unless there is concern for fracture, tumor, or other traumatic injury 6
• No advanced imaging is typically required for straightforward trigger finger 5, 6

Treatment Algorithm

• First-line therapy consists of corticosteroid injection into the A1 pulley, which relieves symptoms in approximately 72% of patients 1
• Activity modification and splinting are alternative conservative options 5, 6
• Steroid injection is less efficacious in patients with insulin-dependent diabetes, who may benefit from early surgical release 1
• For patients with recurrent symptoms or those unresponsive to injection, surgical A1 pulley release (open or percutaneous) is safe and effective 5, 1
• Excision of a slip of flexor digitorum superficialis is reserved for persistent triggering despite A1 release 5

Right Shoulder Pain

Diagnostic Approach

• Obtain plain radiographs of the right shoulder (AP, lateral, and axillary views) as the initial imaging study to evaluate for bony pathology, calcific tendinosis, or osteoarthritis 3
• A focused history should determine if pain is activity-related, present at rest, or associated with specific movements (overhead activities suggest rotator cuff pathology) 3
• Physical examination should assess range of motion, strength testing, and provocative maneuvers for rotator cuff or impingement 3

Further Workup if Radiographs Normal

• If radiographs are normal or show nonspecific findings and symptoms persist, MRI without IV contrast is the next appropriate study to evaluate rotator cuff, labrum, and other soft-tissue structures 3, 4
• Ultrasound can evaluate rotator cuff tendons and is useful for guiding therapeutic injections 3

Treatment Considerations

• For suspected tendinopathy, initiate relative rest, activity modification, NSAIDs for pain control, and physical therapy with eccentric exercises 3
• Corticosteroid injections are more effective than NSAIDs in the acute phase but do not change long-term outcomes 3
• Consider orthopedic referral if pain persists despite 3-6 months of conservative management 3

Critical Pitfalls to Avoid

• Do not delay electrodiagnostic studies if severe CTS is suspected (thenar atrophy, constant numbness, weakness), as these patients require urgent surgical evaluation 1, 2
• Do not assume all three conditions are related—each represents a distinct pathology requiring separate management 5, 6, 1
• In diabetic patients with trigger finger, recognize that steroid injection is less effective and early surgical referral may be appropriate 1
• Do not order MRI for straightforward CTS or trigger finger, as these are clinical diagnoses 3, 5