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Dr Subbanna MD
Dr Subbanna MD, Neurologist (MD)
Category: Neurology
Satisfied Customers: 6683
Experience:  American Board Certified Neurologist, Internal Medicine
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Thank you for assisting me today. My question that I have is

Customer Question

Hello, thank you for assisting me today. My question that I have is I have been dealing with pain/ strain in my inner elbow , forearm, and wrist. The pain/ strain occurs most frequently in the morning when I first wake up and does occur throughout the day. For the last 7 years I have been working in a sales position at a company which requires me to utilize the computer to perform most of my work. Three months ago I started waking up nervous and my arms were the center of attention- shaking hands and arms, pain in the forearms and wrists. Whenever I went to start typing or texting someone I would get an uneasy feeling in my arms like I was going to perform a task that will cause pain and strain. This also caused my anxiety and depression to rise.It got persistently worst to the point where I ended up taking a leave of absence from work and going to a therapist/ psychiatrist because it was effecting my anxiety and thought that anxiety that causing the pain/ strain and nervousness. After being prescribed SSRI's ( Zoloft and Lexapro)-took Lexapro for 5 weeks with a 10mg-20mg increase, then stopped and took Zoloft for 6 weeks- 50mg to a 100mg increase, I found no relief from the pain/strain and nervousness in my arms. I am now off of the antidepressants and currently taking beta blockers which started 7 days ago ( 10mg 3x a day) and Gabapentin ( 100mg 3x a day). It seems to help somewhat with the general anxiety that I have especially in social situations, but the arm pain is still persistent, especially first thing in the morning. Could it be that I may have a repetitive strain injury that can cause my anxiety to rise, is there a link? Would the current medicines help with eleviating the arm pain/ strain as well as address anxiety symptoms? Also, what are your recommendations on seeing a Primary care or a specialist physician versus continuing to go to a psychiatrist? I do apologize for the long winded explanation, hoping
JA: How long have you been dealing with this? Is there anything in particular that seems to make the symptoms better or worse?
Customer: I have been dealing with this since November 2017. I am a fairly active person and since this started to occur I have been trying everything to relief the pain ( yoga, Massages, arm stretches and light weight training, cold and hot compresses, therapy- for anxiety, cardiovascular workouts- running and walking. I have also decided to wake up in the middle of the night and take the bets blocker and Gabapentin in hopes that it will kick in when I wake up so my arms do not feel strained/ in pain. These things have helped with my anxiety, but never greatly reduced the pain/ strain and nervousness in my arms. Also, I wanted to mention that I have had anxiety all of my life, I have always coped with it in a way to perform tasks and stay organized. I have always excelled and pushed through any situation that may cause anxiety. I have made public speeches, visited and meet with professionals, and have been in situations which would cause anyone to be nervous but I always have overcame the anxiety and accomplished the task. Within the last few months it seems like my arms have become the focal point of my anxiety and Im thinking that it may be related to repetitive stress injury from typing and performing tasks quickly and not in the most ergonomic way which caused strain.
JA: Anything else in your medical history you think the doctor should know?
Customer: No other medical history, always been healthy and active
Submitted: 8 months ago.
Category: Neurology
Expert:  Dr Subbanna MD replied 8 months ago.

Hi, I am an American Board Certified Neurologist with vast experience in diagnosing & treating all neurological as well as all other health/medical conditions, and I am very glad to help you with your health concerns.

I am sorry to hear about your health as you have described above. As a Neurologist I frequently diagnose & treat this type of health situation, and I can certainly help you in this regard.

I see the pain that has been involving the inner elbow, forearm and wrist regions is not responding to the treatments you have tried so far.

While it appears there is some anxiety component too, but the primary issue appears as you have also put it correctly this is due to repetitive strain injury secondary to the nature of the job you have been doing. This type of pain is not uncommon in individuals who use their upper limbs a lot at their work place especially for repetitive tasks such as using computer, performing quick tasks, and also not working in the most ergonomic way etc.

If possible try to see a specialist such as a neurologist in the clinic so that you will receive a thorough clinical examination followed by certain relevant investigations that may include some of the following;

A) An X ray of the elbow, forearm and wrist regions

B) An MRI scan of the same regions mentioned above

C) A nerve and muscle test called as EMG/Nerve conduction test of the upper limbs

D) Certain blood tests such as the following;

1) Thyroid

2) Vitamin levels

3) ESR, CRP, ANA, RA factor, SSA (Anti Ro), SSB (Anti La)

4) Lyme titer – if risk factors are present

5) Comprehensive metabolic panel etc

Not necessarily all the above investigations may be necessary, the neurologist will be in a position to decide which ones among the above mentioned investigations are required in your case after conducting a thorough neurological examination in the clinic. And also if any of the above investigations have already been done then there is no need to repeat them. The precise & specific treatment plan will depend upon the results of the above mentioned investigations and in the meantime you may try some of the following general home remedies, as well as certain more specific therapeutic measures to help with the symptoms;

Adequate rest

Maintaining good hydration

Healthy, Nutritious & balanced diet

Daily exercises

Nutritional supplements such as Methyl Guard Plus (which is a combination of active forms of vitamin b12, vitamin b9/folate, vitamin b6, vitamin b2)

Elbow splint or brace

Customized physical therapy including gradual stretching

OT (Occupational therapist) consultation for ergonomic modifications at work place

Cold or heat compresses

Epsom salt compresses

Pain relieving skin creams/ointments such as Biofreeze, or Myoflex

Strong prescription NSAID pain killers such as Diclofenac oral, or Tramadol oral

Diclofenac pain patches over the painful areas

Diclofenac pain creams over the painful area

Lidoderm anesthetic skin patches over the painful areas

Nerve pain pills like Gabapentin (you are already on, but dose 100 mg three times/day is small dose so dose can be gradually optimized), or Pregabalin, or Amitriptyline

TENS (Transcutaneous Electrical Nerve Stimulation)

Interferential therapy

Cortisone shots

Inotophoresis

PRP (Platelet Rich Plasma) injection to elbow region

Prolotherapy injection to elbow region

Autologus whole blood injection to elbow region

ESWT (Extracorporeal shockwave therapy) etc

If above mentioned non-surgical-conservative measures fail then surgical treatments too are available (epicondylar debridement etc), but most patients do not require any surgical treatments, rather one or more of the above mentioned non-surgical treatments are sufficient to help with obtaining relief from this type of repetitive strain related pain.

To summarize once again;

1) Yes, this does appear secondary to repetitive strain or stress related injury to the elbow, forearm and wrist regions, especially the elbow region

2) A thorough evaluation and clinical examination in the clinic by a neurologist followed by certain relevant neurological investigations as mentioned above (X ray, MRI scan, Nerve & Muscle test, certain specific blood tests etc) can help us in confirming the diagnosis, and also in ruling out any other explanations for this refractory pain

3) The specific treatment will depend upon the particular diagnosis that will be made after the above investigations, and in the meantime please consider trying some of the above mentioned treatments

4) And very importantly please see this does not appear secondary to any serious or irreversible condition or permanent damage etc, rather this type of health condition can be diagnosed and successfully treated, so please not to be scared.

Wishing you a quick & complete recovery! And also Wishing you the best health!

All the very best!

Please let me know if you have any additional questions or if you want to discuss this further.

Assuring you the best services!

Best Regards!

Dr Subbanna MD

Expert:  Dr Subbanna MD replied 8 months ago.

Hi, how are you feeling now, and how are your symptoms?

Do you want to discuss further the health concerns you have expressed above, or are there any other health concerns that you want to discuss?

Please let me know

Assuring you the best services!

Best Regards!

Dr Subbanna MD