Problem refinement
Problem refinement
To help your thinking, you could perform a physical examination. Various tests can be carried out that help to differentiate between carpal tunnel and ulnar entrapment. These include Phalen’s test, Tinel’s sign and the Tourniquet test. These might be currently outside the scope of most community pharmacists, but those with an independent prescribing qualification may be competent to perform them.
| Phalen's test | Dorsal side of hands brought together for one minute | If causes a tingling sensation, suggest carpal tunnel syndrome |
| Tinel's sign | Tapping the finger over the ulnar nerve at the wrist | If causes a tingling sensation, suggests ulnar entrapment |
| Tourniquet test | An inflated blood pressure cuff is placed on the upper arm | Development of numbness and tingling in the fingers suggests carpal tunnel syndrome |
You observe no obvious swelling or tenderness but Tinel’s sign is positive as she reports tingling in her little finger. You are now reasonably confident that you are dealing with ulnar nerve entrapment.
Red flags
It is important to consider any nerve involvement in the entire limb, including the neck. As ulnar nerve entrapment is your working diagnosis, it would be prudent to exclude nerve compression at the elbow (cubital tunnel). Also check if symptoms are worse at any given time or for any precipitating activities that worsen symptoms.
Victoria reports only wrist pain and has not noticed any other symptoms. This seems to rule out OA, RA, gout and tendinopathy, especially as the location of her pain would be unusual for these conditions.
Management: Self-care options
Treatment of ulnar nerve entrapment is aimed at relieving the underlying cause. In many cases the cause of the compression can be identified (e.g. through work-related behaviours or sports activities).
Victoria works mostly at a desk and has not had any changes in her work practices. It might be worth advising her to ask for an occupational assessment of her work environment to see if this is an underlying reason for her symptoms.
Prescribing options
NSAIDs could be offered to ease the pain and if symptoms persist you could suggest physiotherapy.
Safety netting
You tell Victoria that you believe her problem is due to one of the nerves in her wrist being trapped and explain to her that the prognosis of most ulnar neuropathies is good, although symptoms often take weeks, if not months, to resolve. A follow-up appointment with Victoria could be made in six weeks unless her symptoms worsen.