Right Wrist Pain- Esports

HISTORY: A 36-year-old right hand dominant esports athlete presented to the Sports Medicine Clinic for right volar wrist pain of 7 month duration. The pain was associated with paresthesia from wrist to all digits. Symptoms increased when playing video games and improved with rest. He denied any inciting trauma, infection or vaccinations, neck pain, right upper extremity (RUE) weakness, or hand edema. PHYSICAL EXAMINATION: He had normal RUE strength, sensation, reflexes, muscle bulk, and tone. There was no thenar or hypothenar atrophy. Tinel’s test was positive at the wrist and elbow. Phalen’s sign, Durkin's compression test, Finkelstein test, Froment’s sign, and Spurling’s test were negative. DIFFERENTIAL DIAGNOSIS: Carpal tunnel syndrome (CTS)Cubital tunnel syndrome Cervical radiculopathy Pronator syndrome Brachial plexopathy TEST AND RESULTS: 1. Normal motor and sensory nerve conduction studies for the right median and ulnar nerves. Patient deferred the electromyography component.2. RUE ultrasound revealed a bifid median nerve dividing proximal to the wrist by a persistent median artery. The summed cross sectional area of the bifid nerve was 17 mm2, consistent with compressive neuropathy of the median nerve. FINAL/WORKING DIAGNOSIS: Carpal tunnel syndrome secondary to bifid median nerve hypertrophy and persistent median artery. TREATMENT AND OUTCOMES 1. Educated patient on activity modification and gaming ergonomics. 2. Prescribed nightly cockup wrist splint and ibuprofen 600 mg every 6 hours, as needed for pain.3. Discussed if symptoms don't improve, he may consider nerve hydrodissection or possible carpal tunnel release surgery with technical modifications in light of the structural anomaly.4. The patient had complete resolution of symptoms at the 3 month follow-up and had gradually returned to play prior to the visit. 5. The prevalence of bifid median nerve is 1-16%, and persistent median artery is 4-27%. These anatomic anomalies may contribute to compressive forces within the carpal tunnel. This case demonstrates the role of diagnostic ultrasound in assessing and guiding management of musculoskeletal disorders.