Case of the Month #3: Burning pain in both hands

Author: Dr Helen Laycock

A 47-year-old man presented to the chronic pain clinic with severe constant burning pain in both hands. 

He described an 8-year history of slowly increasing intensity of burning sensation in his hands. It was present constantly, with no alleviating or exacerbating factors. He had associated numbness, finding it difficult to test bath water temperature with his hands and described experiencing occasional pins and needles in his fingers. He had noticed a loss of strength and ability to perform fine movements such as doing up buttons, in both his hands. Over the last year he has noticed this pain was now occurring up his arms and along his back, in a cape-like distribution. Additionally he felt his arm strength was reduced from a year ago, although he hadn’t mentioned this weakness to his GP.   

He did not have any other medical conditions. He was not taking any regular medicines and did not have any drug allergies. He had tried simple analgesia including paracetamol and ibuprofen for the pain but was not taking it as he had experienced no benefit.  He had fallen off a climbing frame as a teenager and sustained a neck and upper back injury, that required surgery, but was unable to give many details about this. Following surgery he had no residual weakness or neurology and had been discharged from surgical follow up when he reached 18-years-old. 

He worked as a car mechanic and had noticed his symptoms worsened after lifting heavy equipment around the garage.  He lived with his wife and two children.  He had stopped smoking 10 years ago and drank alcohol only at the weekend with friends, although had drunk heavily in his early 20’s.  He denied any use of illicit substances.  He said overall his mood was good, but his sleeping was affected by the pain. 

On examination he had a BMI of 28 and vital signs within normal range.  He had an old, well healed scar over the thoracic spine approximately 10cm long. He had wasting of the intrinsic muscles of both hands and his skin was cold and pale. He had normal muscle tone throughout his upper limbs however had reduced strength 4/5 for wrist and elbow flexion and extension, finger abduction, adduction and thumb abduction. There was reduced temperature sensation in his hands bilaterally, but preserved touch, vibration and proprioception.  Neurological examination of his lower limbs were normal.