Presenting Problem
51-year-old female.
HPC:
- Thumb joint pain: 1-year history of bilateral thumb joint pain.
- Investigations: X-ray shows early OA of the thumb CMCJ.
- AGGs: Desk-based work, gripping, and thumb use.
- Ease: Rest.
- 24-hour pattern: Symptoms worsen as the day progresses but do not disrupt sleep.
- Paraesthesia: Bilateral paraesthesia in the thumb, index, and middle fingers for a few months.
- AGGs: Sleeping.
- Ease: Moving the hands in the morning relieves the symptoms.
- 24-hour pattern: Often wakes at night due to symptoms; paraesthesia can sometimes be severe enough to disrupt sleep.
Neurological Examination NAD.
Special Questions:
- No symptoms of CxS (e.g., dizziness, diplopia, dysphasia/dysarthria, double vision, drop attacks, nausea, nystagmus).
- No swelling, heat, or redness.
- Denies fever, weight loss, unremitting night pain, or malaise.
PMH:
- Medications: HRT, Levothyroxine, Utrogestan.
- THREADs: Hypothyroidism,
- General Health: ME, and Fibromyalgia.
- Fibromyalgia diagnosed in 2018. Reports generalised pain and restless legs, managed with Zapain.
SH:
- Works as a veterinary receptionist with reduced hours. Currently struggling with work and pain, signed off due to stomach issues.
Objective Assessment
- Thumb: Full range of motion with some pain during full opposition.
- Wrist: Full range of movement reported.
- Special tests: Positive Phalen’s test and positive Tinel’s sign
Impression:
- Carpal tunnel syndrome (CTS) and thumb osteoarthritis (OA).
Follow-up Appointment (eight weeks post initial appointment)
Follow-Up Progress (8 weeks post-initial assessment):
- The patient reports improvement in symptoms of both CTS and thumb OA after following treatment advice and the prescribed HEP. She feels confident in managing these conditions with the resources provided.
- The patient wanted guidance on managing Fibromyalgia, noting she was prescribed Zapain but lacked information on its use and overall condition management.
- During a phone consultation, pacing and lifestyle management strategies were discussed. Resources on Fibromyalgia were shared for additional support.
Future Appointments:
- A follow-up appointment was booked 2 weeks later to discuss her return to work.
- The patient highlighted challenges with desk-hopping between four positions at work, noting difficulty in resetting ergonomic desk positions. Incorrect setups were aggravating her pain.
- As limited evidence was available for desk assessments, a functional and physiotherapy-based approach was taken:
- Ensure proper chair and desk height to avoid aggravating positions.
- Use keyboard and mouse pad supports to reduce wrist pressure.
- Incorporate regular movement and exercise breaks into the workday.
Differential Diagnoses & Clinical Reasoning
The recommendations are that education, information, and strategies to manage fibromyalgia are all the first line of treatment. In this case study, this was most beneficial to the patient, and this first step in management had not been previously covered with other healthcare workers.
CTS may improve spontaneously in up to one-third of patients over a 10–15-month period.
Treatment options depend on severity. Non-surgical management (splinting or injection) should be considered in cases of mild to moderate disease, whereby pain and numbness are intermittent and there is no wasting or weakness of the thenar muscles.
Summary
This patient has been a great learning experience in bringing together chronic pain and multiple conditions. It really highlighted the importance of education/information and how valuable this is to a patient.
Spending time explaining the background on conditions and providing information to a patient like this proved to be so important. Instead of just overlooking the Fibromyalgia and treating the MSK presentations of thumb OA and CTS, we discussed a lot about her management of this chronic condition. By allowing the patient to openly discuss these issues, we then got onto the conversation about her return to work.
Simply writing a MED3 and return to work plan with her goals in mind meant she returned to work with some simple modifications that helped her manage her pain.
The MED3 gave her the confidence to address these issues with her line manager and initiate a return to work plan that supported this.
