A Case of Bilateral Elbow Pain and Paresthesia in a Young Baker
Case at a Glance
A 23-year-old transgender male, recently employed as a baker, presented with a several-week history of worsening bilateral elbow pain and paresthesia. His symptoms, which were exacerbated by his new occupation and worse at night, pointed towards significant nerve compression in both upper extremities.
Patient's Story
The patient, a 23-year-old transgender male on testosterone therapy, presented with concerns about escalating pain and numbness in both arms. He reported that for several weeks, certain positions involving elbow flexion would cause his hands, particularly the middle and ring fingers, to 'fall asleep.' The symptoms were accompanied by pain in both elbows and were particularly disruptive at night, prompting him to sleep with his arms propped on pillows to maintain extension. His condition had been significantly aggravated by his new physically demanding job in a bakery, which involves repetitive arm and wrist movements.
The patient noted a similar, though less severe, episode approximately one year prior, which affected only his right arm. That incident involved elbow pain, forearm swelling, and a purplish discoloration of his hand. At that time, he underwent physical therapy and dry needling. An urgent care physician had attributed the issue to a past tennis injury, specifically a diagnosis of rotator cuff tendinosis from several years ago, and recommended ibuprofen.
Initial Assessment
Upon initial consultation, the patient was alert and oriented, though visibly uncomfortable. He described the paresthesia as primarily affecting the middle and ring fingers of both hands, an atypical distribution that suggests potential involvement of both the median and ulnar nerves, or a more complex etiology.
Physical examination revealed tenderness to palpation over both medial epicondyles. A positive Tinel's sign was elicited over the cubital tunnel of both elbows, reproducing the tingling sensation in his reported finger distribution. The elbow flexion test was also positive bilaterally, worsening the numbness within 30 seconds. Strength was grossly 5/5 in all major muscle groups of the upper extremities, with no visible muscle atrophy in the hands. Range of motion in the shoulders, elbows, and wrists was full but provoked pain at the end ranges of elbow flexion.
The Diagnostic Journey
The primary clinical suspicion was bilateral ulnar neuropathy at the elbow (Cubital Tunnel Syndrome), given the location of pain and provocation of symptoms with elbow flexion. The atypical sensory distribution (middle and ring fingers) raised the possibility of concurrent median nerve compression (Carpal Tunnel Syndrome) or a proximal issue such as cervical radiculopathy.
The patient's history of a sports-related rotator cuff injury was noted but considered less likely to be the primary cause of his current neuropathic symptoms. Differential diagnoses included: bilateral cubital tunnel syndrome, bilateral carpal tunnel syndrome, cervical radiculopathy, and thoracic outlet syndrome.
To differentiate these possibilities and quantify the extent of nerve damage, a referral for nerve conduction studies (NCS) and electromyography (EMG) of both upper extremities was recommended. However, the patient expressed significant concern about the cost, as he was in a five-month waiting period for health insurance at his new job. This socioeconomic factor became a critical component in planning the next steps.
Final Diagnosis
Bilateral Ulnar Neuropathy at the Elbow (Cubital Tunnel Syndrome), with clinical suspicion of possible mild concurrent Median Neuropathy.
Treatment Plan
Given the patient's financial constraints and lack of insurance, the initial treatment plan was conservative and aimed at symptom management and preventing further nerve irritation.
- Patient Education & Activity Modification: The patient was counseled to avoid activities involving sustained elbow flexion, such as propping his elbows on surfaces or holding a phone to his ear for long periods. Ergonomic adjustments at his baking job were discussed.
- Nighttime Splinting: He was advised to use nighttime elbow extension splints (or a rolled towel to passively keep the arm straight) to prevent flexion during sleep.
- Pharmacotherapy: Continued use of over-the-counter NSAIDs (ibuprofen) as needed for pain and inflammation.
- Referral Deferment: The referral for definitive NCS/EMG testing was placed on hold until the patient's insurance became active.
Outcome and Follow-up
The patient agreed to follow the conservative management plan. He was scheduled for a follow-up appointment in 4-6 weeks to assess his response to conservative therapy. A formal referral to Neurology for NCS/EMG and a potential consultation with an Orthopedic Hand Specialist would be initiated once his insurance coverage began in approximately five months. The long-term plan will depend on the results of the nerve studies; if conservative measures fail or if the studies show significant nerve compression, surgical intervention such as an ulnar nerve decompression may be considered to provide definitive relief and prevent permanent nerve damage.