THE CASE
A 31-year-old right-handed college baseball coach presented to his family physician (FP) with concerns about the “yips” in his right arm. His ability to throw a baseball had been gradually deteriorating. Involuntary upper right arm muscle contractions and spasms, which began intermittently when he was a teenager, were now a real problem for him as an adult. (See the video below.) The patient was having difficulty rolling a baseball underhand to players as part of infield practice and he was experiencing muscle spasms when lifting his right arm over his head. “Twitches” in the patient’s upper arm were making drinking difficult, but he had no problems feeding himself, writing, or performing other basic activities of daily living.
The patient experienced the same symptoms whether it was baseball season or not. He hadn’t noticed a change in symptoms with caffeine and denied use of any other stimulants in the last 4 years. His symptoms didn’t improve or worsen with greater or lesser quantity or quality of sleep or when he concentrated on stifling the involuntary movements. He had attempted to learn to throw left-handed to overcome the impairment, but was concerned that the same problem would occur in his left arm.
The patient had previously worked with a sports psychologist and hypnotherapist to overcome any potential subconscious performance anxiety, but this hadn’t helped. Stretching and strengthening with a physical therapist and numerous sessions with an acupuncturist hadn’t helped either. Despite this, he believed the problem to be primarily psychological.
The patient’s history included mild attention deficit disorder and exercise-induced asthma; his family history was negative for any movement or psychiatric disorders. He had 2 dislocation repairs on his left, non-throwing shoulder in his early twenties. His medications included fluticasone-salmeterol twice daily and albuterol, as needed.
The patient denied myalgia or arthralgia, decreased passive range of motion, shoulder or arm weakness, swelling, or muscle atrophy. He also didn’t have paresthesias in his right arm or hand, a resting tremor, difficulty moving (other than drinking from a cup), difficulty moving other extremities, dizziness, imbalance, or seizures.
The patient’s vital signs were normal. He had full range of motion and 5 out of 5 strength without pain during right shoulder abduction, external and internal rotation, an empty can test, a lower back lift off (Gerber’s) test, and a test of bicep and tricep strength, along with negative Neer and Hawkins tests.
There was no evidence of muscle wasting or asymmetry in the bilateral upper extremities. The patient’s deep tendon reflex grade was 2+ out of 4 in both of his arms. He didn’t have a sensory deficit to light touch in areas of C5 to T1 and he had normal cranial nerves II to XII. He had normal rapid alternating movements, heel-to-shin testing, and finger-to-nose testing, as well as a normal gait and Romberg test.
The patient provided a video showing the abnormal involuntary flexion of his shoulder when attempting to throw a baseball.