Case Study: Unilateral Elbow Pain and Neurological Symptoms in an Adolescent Male Following a Change in Workout Routine

Case at a Glance

A 15-year-old male presents with left-sided posterior elbow pain, bicep and tricep tendon tenderness, and concerning neurological symptoms including hand weakness, numbness, and tremor, which are acutely exacerbated by resistance exercises, particularly chin-ups.

Patient's Story

The patient, a 15-year-old male who engages in regular weight training, presented with a new onset of left arm pain. He stated, 'Whenever I do a bicep curl or tricep exercise, the first repetition causes a sharp pain right at the back of my elbow joint.' He noted that upon self-palpation, both his bicep and tricep tendons on the left arm were tender to the touch. The symptoms began after he incorporated new exercises, specifically chin-ups and lat pull-downs, into his routine. His right arm remains completely asymptomatic. The patient reported that after performing chin-ups, his left arm experiences significant diffuse pain and a fine tremor, making it difficult to perform tasks like holding a pencil. He later added, 'I also feel numb or weak when I grip with my left hand. It feels like I'm not squeezing my fist all the way, although it doesn't hurt to try.'

Initial Assessment

The patient is a 15-year-old male presenting with a chief complaint of unilateral left arm pain and weakness. The symptoms are activity-dependent, specifically triggered by elbow flexion/extension exercises under load. Key reported findings include:

Pain: Localized to the posterior elbow, particularly on the initial repetition of a movement. Tenderness is also noted over the distal biceps and triceps tendons.
Post-Exertional Symptoms: Following more strenuous activities like chin-ups, the patient experiences diffuse, poorly localized pain throughout the left arm.
Neurological Deficits: The patient reports subjective left-hand grip weakness (paresis), numbness (paresthesia), and a post-exertional fine motor tremor. These symptoms indicate potential nerve involvement.

The Diagnostic Journey

The presentation of localized musculoskeletal pain combined with neurological symptoms prompted a broad differential diagnosis. The initial overuse injury, likely a distal triceps tendinopathy, may be complicated by or co-occurring with a nerve compression syndrome.

Differential diagnoses considered included:

Ulnar Neuropathy (Cubital Tunnel Syndrome): The location of pain at the posterior/medial elbow and symptoms of grip weakness and numbness are highly suggestive. Repetitive elbow flexion can irritate the ulnar nerve.
Cervical Radiculopathy: The introduction of chin-ups and lat pull-downs could have strained the cervical spine, leading to nerve root compression (e.g., C7, C8, T1) that refers pain and causes neurological deficits in the arm and hand.
Radial Nerve Entrapment: While less common, this could explain weakness in wrist/finger extensors, which might be perceived as poor grip control or difficulty with fine motor tasks.
Thoracic Outlet Syndrome (TOS): Overhead movements like chin-ups can compress the neurovascular bundle in the thoracic outlet, causing diffuse arm pain, weakness, and numbness.
Primary Tendinopathy: Distal biceps and/or triceps tendinopathy from overuse, leading to pain and secondary muscle inhibition.

Final Diagnosis

Pending Clinical Evaluation. The constellation of symptoms is highly suspicious for a nerve entrapment syndrome, with Ulnar Neuropathy (Cubital Tunnel Syndrome) being a primary differential, potentially exacerbated by an underlying overuse tendinopathy. Cervical Radiculopathy is also a key consideration that requires exclusion. A definitive diagnosis requires a thorough physical examination and likely further diagnostic testing.

Treatment Plan

The recommended course of action involves a multi-step approach:

Immediate Management: The patient was advised to cease all aggravating activities, particularly bicep curls, tricep extensions, and chin-ups. Application of ice to the posterior elbow for 15-20 minutes several times a day was recommended for pain and inflammation.
Referral and Workup: Urgent referral to a sports medicine physician or orthopedist for a comprehensive evaluation. The clinical workup should include a detailed neurological exam assessing motor strength, sensation, and reflexes, along with provocative tests (e.g., Tinel's sign at the elbow, Spurling's test).
Diagnostic Imaging/Testing: Based on the physical exam, nerve conduction studies (NCS) and electromyography (EMG) would be the definitive tests to diagnose and localize any nerve pathology. An MRI of the elbow or cervical spine might also be considered to evaluate for structural causes of compression.

Outcome and Follow-up

The patient was strongly counseled on the importance of obtaining a professional medical diagnosis before returning to any form of resistance training. The presence of neurological symptoms like weakness and numbness warrants a cautious approach to prevent permanent nerve damage. Follow-up will be guided by the results of the specialist consultation and diagnostic tests. A course of physical therapy focusing on nerve gliding, postural correction, and strengthening of supporting musculature is anticipated as a core component of the recovery plan.