Sport: Field Hockey Progressive Numbness of Distal Lower & Upper Extremities

Jason J. Brucker, Christiana Care Sports Medicine Center, Wilmington, DE e-mail: jbrucker@christianacare.org (Sponsor: Bradley Sandella) HISTORY: 21 year old collegiate field hockey player who initially presented with 6 months of exercise-induced numbness & pain in her distal lower extremities. Testing consistent with exertional compartment syndrome. Diagnosis ultimately was nerve entrapment of multiple nerves bilaterally underwent subsequent surgical decompression & nerve release. Now presents with numbness & tingling of her distal aspects of her hands one year later. All 5 digits on both hands affected equally sparing the palms. No pain, radiation, or involvement beyond the digits. Symptoms not exercise-induced although 1 episode of self-limited hand weakness following practice was reported; otherwise no motor deficits noted. There is accompanying hyperemia with areas of blanching over both palms that are not affected by temperature. Denies any antecedent injury although completed a 6 week course of minocycline for acne treatment 3 weeks prior to the onset of symptoms. PHYSICAL EXAMINATION: Cranial nerve & visual acuity testing normal. Deep tendon reflexes intact. Strength testing 4/5 weakness in bilateral triceps, wrist extension & finger abduction but intact for remainder of upper extremities. Slight decreased sensation to light touch over left thumb, 3rd digit & 5th digit compared to right hand. Hyperemia with areas of blanching on palms but capillary refill & distal pulses both intact & equal bilaterally. Tinel’s testing was equivocal, negative at cubital tunnel. Romberg & coordination testing normal. Allen’s test & Lhermitte’s sign both negative. DIFFERENTIAL DIAGNOSIS: 1. Subacute Carpal Tunnel; 2. Polyneuropathy; 3. Mononeuritis Multiplex; 4. Vasculitis; 5.Charcot-Marie-Tooth variant. 6. Multiple Sclerosis TEST & RESULTS: MRI Brain – Negative; MRI Cervical Spine – Minimal degen changes at C5-C6 without cord signal abnormality; EMG/NCS upper extremities – consistent with very mild & early left carpal tunnel syndrome. No evidence of radiculopathy, peripheral polyneuropathy or myopathy; Labs – slight lymphocytosis on CBC; normal Vitamin B12, Folate, TSH, BMP & iron studies. FINAL/WORKING DIAGNOSIS: Mild Carpal Tunnel syndrome vs. occult systemic autoimmune illness. TREATMENT & OUTCOMES: 1. Field hockey as tolerated. 2. Regular follow up visits. 3. Follow up with neurologist & obtain MRI Neurography of lower extremities