You are examining a 42-year-old string player with complaints of numbness, paresthesias, dysesthesia, pain, and clumsiness in the right ulnar three digits that occurs toward the end of long practice sessions and which is now beginning to compromise her performance. The patient reports occasional complaints of nocturnal pain that are relieved if he sits up in bed but coincides with the nights he follows a disciplined weight training regimen. Symptoms also appear when she blow dries her hair. Despite being a long-term smoker, the patient's apical chess radiographs are clear, and there is no evidence of cervical rib presence or an abnormally long C7 transverse process. Nor is there any sign of cervical spine disease. An electromyogram (EMG) and nerve conduction velocity (NCV) tests proved negative, and the patient denies any color changes, hyperhidrosis, swelling, trauma, joint pain, dry eyes, dry mouth, or photophobia.

 Upon observation, you note a forward head posture with rounded shoulders, minor atrophy of the right interossei, thenar and hypothenar eminences, and portions of the medial forearm. In contrast, there is apparent hypertrophy of the pectoralis major, pectoralis minor, and all of the anterolateral neck muscles seem to be very prominent.

 There is no point tenderness over the neck or upper extremity and no evidence of redness or warmth anywhere.

 There is full and painless range of motion in both upper extremities, and her strength is normal throughout

 The joint play assessment reveals hypermobility in the lower cervical spine and hypomobility in the sternoclavicular joint, particularly with the anterior and inferior glides.

 Sensation is diminished to light touch in the proximal and middle portions of the medial forearm, but the C5, C6, and C7 reflexes are normal.

 Compression and distraction of the cervical spine do not produce any symptoms, and there is a negative Tinel sign at the ulnar groove adjacent to the medial epicondyle. The Adson maneuver is negative, as is the costoclavicular maneuver, but there is a positive hyperabduction test though no bruit is auscultated over the supraclavicular fossa.

 Which of the following disorder is the most likely cause of this patient's symptoms?

1. Ulnar nerve entrapment
2. Thoracic outlet syndrome
3. Carpal tunnel syndrome
4. Pronator teres syndrome

 The solution will be posted in a few days.