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Orthopedic Specialist Offers Tips on Management of Common Hand, Wrist, and Elbow Problems
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Posted on: 11/30/1999
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Elbow, wrist, thumb, and hand problems are fairly common -- and they affect people of all ages from young to old. Many are the result of overuse syndromes. Overuse syndromes refers to pain, tenderness, and dysfunction from tissue damage caused by repetitive, prolonged, or forceful use of the thumb, hand, wrist, or elbow. Additionally, assuming awkward positions repeatedly can also contribute to the problem.
Athletes participating in sports activities come to mind first, but half of all repetitive overuse injuries actually occur in workers. Dentists, phlebotomists, nurses, musicians, keyboard operators, grocery store checkers, even short order cooks are just a few of the people affected. In this updated review, Dr. A.C. Rettig, an orthopedic specialist in upper extremity disorders offers tips for the diagnosis and management of several hand and wrist and elbow conditions.
Most people are familiar with carpal tunnel syndrome (CTS), a nerve entrapment syndrome affecting the median nerve as it passes through a tunnel formed by the wrist bones. Before a treatment plan can be determined, the cause of the problem must be identified. That's because carpal tunnel syndrome can be caused by overuse (repetitive movements). But it can also develop when there is an underlying pathologic problem. Diabetes, pregnancy, cancer, and rheumatoid arthritis are just a few of the possible systemic causes of carpal tunnel syndrome.
Treating the systemic problem is the first-line of treatment for carpal tunnel syndrome of this type. But when it's forceful, repetitive, loading motions that cause compression of the nerve leading to carpal tunnel syndrome, then treatment is aimed at reducing the symptoms of pain, parenthesis, and loss of strength. Evidence supports the use of oral antiinflammatories and injections of cortisone for repetitive overuse, musculoskeletal causes of carpal tunnel syndrome. Splinting, exercise, and vitamin B6 are often prescribed as well. Research has not been able to prove that vitamin B6 is helpful. Splinting offers short-term results. Exercise is still being investigated as an effective treatment tool for carpal tunnel syndrome.
Two other common causes of wrist pain include scapolunate ligament insufficiency and dorsal wrist syndrome. Both involve the middle of the wrist joint felt as pain on the back of the wrist. Two wrist bones are affected: the scaphoid and the lunate. These two bones are held together by the scapholunate ligament. Injury of the ligament is the underlying problem. In cases of ligament insufficiency, enough damage has been done to the ligament that it no longer holds the bones together in a stable position.
The examiner making the diagnosis can perform a test called the scaphoid shift or Watson test. Without an intact ligament, the scaphoid bone can be moved up and down as the wrist moves back and forth (when it should hold steady). A positive test is a sign that there is scapholunate insufficiency. With dorsal wrist syndrome, pain along the back of the wrist as the patient bends or dorsiflexes the wrist points to injury of the scaphoid bone.
There are several other wrist problems that might develop as a result of repetitive use of the wrist and hand. Tendonitis, ulnar impaction syndrome, and intersection syndrome must be considered as potential causes. Depending on the type of work and repetitive motion required, wrist tendonitis can affect a couple of different tendons at the wrist, such as the extensor carpi ulnaris or flexor carpi radialis. Conservative care is always advised first before ever considering surgery. Rest, modifying activities, icing, and stretching seem to help the most with wrist tendonitis. If there are no results or insufficient response with these efforts, then splinting and steroid injection may be tried next.
Ulnar impaction syndrome occurs when a person is born with one forearm bone (ulna) longer than the other (radius). This might not pose a problem until the affected individual injures the wrist or engages in repetitive wrist motions. The extra load on the ulnar side of the wrist can tear the ligaments and cartilage on that side of the wrist. X-rays are needed to make the diagnosis. If changing the way the person uses the wrist and hand doesn't help, surgery may be needed to even the bones out and take the stress off the ulnar side of the wrist.
You may not have heard of intersection syndrome but it's actually fairly common. It occurs when tendons in the forearm cross over tendons in the wrist and rub against them causing inflammation and of course, pain. The problem affects manual laborers and athletes who bend and/or extend the wrist over and over. Sometimes you can hear a crunching or snapping sound called crepitus as the wrist moves creating friction between the soft tissues. A program of conservative care works best with rest, splinting, and steroid injection when needed.
Some less common problems such as stress fractures of the wrist complete the discussion of overuse syndromes of the wrist. Golfers, tennis players, and baseball players share this problem. What do they have in common? The golf club, tennis racket, and baseball bat all come in contact with the fat pad along the base of the wrist on the little finger side. A bone underneath that area (the hamate) can develop a tiny fracture from the chronic impact at that point. The player ends up with pain and can't grip his or her club, racket, or bat. Stress reactions don't show up on X-rays during the acute phase, so CT or bone scans are needed to confirm the diagnosis.
That takes us to thumb pain. Most of the time, thumb pain from overuse syndromes develops at the base of the thumb. This could be caused by damage to the joint called arthrosis, tendon lining inflammation called de Quervain syndrome, or trigger thumb when thickening of the tendon in the palm area catches the tendon as it moves through its channel. The tendon gets stuck and thumb remains in a permanently flexed position. As you can imagine, without being able to extend the thumb, hand function can become severely affected. Treatment for all three of these problems begins with a hand therapist and moves to surgery only if conservative care is unsuccessful in restoring motion and strength without pain.
And finally, the author turned his attention to overuse syndromes of the elbow. The most commonly reported problem is elbow tendonitis called epicondylitis. Tendons on the inside of the elbow (medial epicondylitis or tennis elbow) can be affected or the lateral (outside) elbow (lateral epicondylitis or golfer's elbow).
Elbow tendinitis has been around for a long time. Management begins with ice, stretching, and splinting at night when needed. Activity modification is a key to successful treatment but often takes months up to even a year to recover. That's not usually very satisfactory to an avid golfer or professional tennis player. Steroid injections are not recommended. Although there is short-term relief of symptoms, as soon as the player goes back to the game, the symptoms often come back. Research efforts are being made to find better, faster ways to treat elbow tendonitis more effectively.
The one time injections are especially useful is in diagnosing the specific soft tissues (nerves, muscles, tendons, ligaments) that are being pinched, compressed, or overloaded. If injecting a numbing agent at the suspected site of dysfunction reduces or eliminates the pain, then the diagnosis is often confirmed. Although there are some diagnostic tests for each of the conditions discussed, the results aren't always reliable. Diagnostic injections have fewer false positive or false negative responses compared to other more subjective tests.
Since the last time the author reviewed overuse syndromes five years ago, there has been an increase in the number of children affected. Increased participation in organized sports seems to be at the center of this phenomenon. Primary care physicians report that up to half of the sports injuries they see in children and adolescents are from overuse. Keeping up with common problems and evidence-based solutions remains the focus of review articles like this one.
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References:
Arthur C. Rettig, MD. Tests and Treatments of Overuse Syndromes: 20 Clinical Pearls. In The Journal of Musculoskeletal Medicine. July 2009. Vol. 26. No. 7. Pp. 263-271.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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