The nerve of it all

Tuesday, January 26, 2010

Tennis’ Australian Open is an endurance event lasting two weeks with no breaks to allow a player to recover from any injury. Winning requires skill, poise and the luck to avoid damaging body parts that are needed to hit balls more than 130 mph. For Andy Roddick, an injured shoulder made that task too tough to beat his opponent in the quarterfinals. In his match, two days previous, Roddick began feeling pain in his right shoulder radiating to his hand, making it difficult to hold his racquet. As well, his ring and little fingers went numb. He was able to finish and for the rest day worked with trainers to sort out the problem and get ready for the match he ultimately lost.

Pain is the body’s way of telling a person that something is not quite right. When it comes to muscles, tendons ligaments, bones and joints, irritation for whatever cause begins a cascade of inflammatory responses. This ultimately leads to pain, the signal to quit the activity that caused the problem. The body is wired in strange and unusual ways making the source of the pain difficult to diagnose, even with the technical capabilities of x-ray, CT and MRI.

In medicine, the doctor’s goal is to find one diagnosis that can explain all the patient’s symptoms. Roddick’s complaint of shoulder pain might be due to overuse or tear of the muscles that move the joint, or it may be due to irritation of joint surface due to arthritis. But the numbness of the fingers gives a potential clue.

The nerves that supply the hand with feeling and that control the muscles that move it begin in the neck, Nerve roots leave the spinal cord at a variety of levels and exit the neck through the spaces between the vertebrae. They travel into the armpit where the roots combine to form the brachial plexus and then exit down the arm ultimately to form the radial, median and ulnar nerves that control the hand.

The radial nerve helps control the thumb and small muscles of the hand and fingers while the medical nerves works on the index, middle finger and the palm of the hand. It is the nerve that is compressed in carpal tunnel syndrome where it is inflamed as it passes across the wrist into the hand. The ulnar nerve controls sensation to the ring and little finger and is vulnerable to injury at a variety of places on its journey down the arm. Most people have hit their funny bone, causing shooting pains to the hand and temporary numbness. In reality, the ulnar nerve is exposed on the inside part of the elbow and can be inadvertently bumped. It’s also at risk for damage at the wrist.

So how do we approach Mr. Roddick ‘s shoulder pain? If he had a shoulder joint or muscle injury, then he performed heroically in playing five sets. Each stroke taking the shoulder through its range of motion should have aggravated it to no end. And what about the ulnar nerve numbness and pain in the hand? Perhaps the answer is in his neck and not his shoulder. A “pinched nerve” could cause the shoulder to hurt with any range of motion and it could also explain the numbness. The question becomes, what is irritating the nerve. It could be muscle spasm that affects the nerve as it leaves the neck; it could be a bulging disk that touches or it could be a bony spur of arthritis that is at issue. Cervical radiculopathy describes the situation; a nerve that leaves the neck has malfunctioned.

Elite athletes live in a different world than the rest of us. Time is critical for diagnosis and rehabilitation since their career is measured in years, not decades and the ability to compete requires a body that answers the call. Once the doctor hones in on the problem, they are exposed to the high tech method of medicine. For the rest of us, high tough often replaces high tech. The initial clinical diagnosis may be followed by physical therapy, medication and observation. Most people get better in time and need nothing further, aside from understanding why the injury happened and trying to get the body strong to prevent the next one.

Eventually, we may find out the cause of Mr. Roddick’s injury but the key to his diagnosis is rooted in understanding anatomy and physiology, the study of body function. Hopefully, his road to recovery is as swift as his serve.

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