Hand and Wrist Pain - Ask Dr. P

The 30 Day Pain Relief Challenge Kick Off

by Pain Doc | Jan 4, 2021 | Foot and Ankle Pain, Hand and Wrist Pain, Hip Pain, Knee Pain, Leg Pain, Low Back Pain, Neck Pain

It’s 2021 and time to kick off the 30 Day Pain Relief Challenge!

But first I want to acknowledge what’s on everyone’s mind.

2020 began with an unexpected crisis, the COVID-19 pandemic. A new corona virus strain emerged; highly contagious and deadly for certain individuals, and for which there was no vaccine. As of this writing, over 85 million people worldwide have contracted the virus, with 1.85 million dying from it. The United States is being hit the hardest, with 20.8 million cases and 352,000 dead. The numbers are expected to spike following the holiday season, thanks to many people choosing to get together in large groups and ignoring the risk. So please, remain extra vigilant the next two weeks because chances are, there are more viruses around you than there were a month ago, ready to find a new host.

As we navigate through COVID-19 in 2021, life must still go on. I know many have been hurt economically, and their number-one priority is to find a way to get back on their feet. It is not an easy thing to do, especially if you lost your job and the life skills you possess are in an industry that has been permanently impacted by the pandemic. If this describes your situation, I sincerely hope you find a way to re-position or re-invent yourself, to get back to earning a living.

While COVID-19 dominates the news and peoples’ attention, we must not lose focus on the many other challenges life presents that also need our attention. How would you rate your health at the start of the new year? How about your energy levels and endurance?

Quarantining and social distancing have a way of discouraging exercising and promoting over-eating, a terrible combination to health. When one is restricted from going outside and going to a gym (although a gym is not necessary for staying fit, but I digress…) and constantly bombarded by news of doom and gloom, the tendency is to stay home, surf the web, and eat, more than you typically do (what else is there to do in such a scenario?). And for many, the choice is high-calorie comfort food. This can lead to unwanted weight gain, muscle atrophy, joint pain, and so on.

If you are not feeling 100%, then I encourage you to open all the emails I’ll be sending over the next 30 days—the 30 Day Pain Relief Challenge is about to kick off, and email is how it will be executed.

And what exactly is the challenge? It’s about challenging yourself to get out of your comfort zone and do all the things I will suggest in the coming days so that you can get out of pain, or significantly knock it down to levels you haven’t experienced in a long time.

The other reward may be that you will lose 10 pounds or more; will have more energy, and will notice that your mind/ thinking is clearer. This is because the methods I’ll go over target your body and all its systems; not just the area of pain. It is wholistic.

But first let me explain how you will be measuring your results. After all, pain is subjective. You need some kind of tool to quantify your improvement, so read on.

Pain, aches, discomfort or whatever you want to call it affects your health. There is mental health and physical health; both important to happiness in different ways. Your physical and mental health are impacted, even just a little and perhaps unnoticeable to you, if you have chronic pain/aches/discomfort. Less-than-optimal physical and mental health impacts quality of life. Quality of life in this sense refers to your ability to physically do what you need or want to do; whether it be your job; recreational activity such as playing golf or swimming; or activities of daily living; i.e. taking care of yourself and your personal needs.

Why You Might Have a Disability if You Have Pain

If you live with chronic pain, you likely have some degree of disability.

“Me disabled?” you might be thinking. “No way!”

The word “disability” is often misconstrued. Disability doesn’t necessarily mean “disabled” and in a wheel chair. It simply means not being able to perform a certain task without some degree of difficulty or impediment; or not being able to do it at all.

Doctors (medical examiners) who issue disability certificates or write medical-legal reports are tasked to determine the degree to which someone is disabled. Their findings determine the patient’s disability compensation from the insurance company or government agency. They use observation, physical exam procedures, diagnostic tests like X-rays and nerve conduction; and instruments to measure strength, pain perception, reflexes, coordination, and range of motion. Any deficiency is expressed as a percent disabled, and there are laws that define levels of disability.

For example, in the insurance industry, the loss of both eyes, or the loss of two limbs equates to “100% disability.” Not being able to maintain a tight grip could be rated as 20% disability if the person’s occupation requires power gripping machinery.

Disability can also be subjectively quantified using Disability questionnaires where the patient rates his/ her ability to perform certain tasks on a scale of zero to some number; and the level of pain. In some questionnaires, the zero rating means you have zero difficulty doing the task (best score), while in others the zero rating means you cannot do the task at all (worst score).

For example, the following is one section of the Oswestry Low Back Pain Disability Questionnaire. Imagine having low back pain and rating yourself (0 to 5) on your ability to lift things:

LIFTING:

0 – I can lift heavy weights without extra pain

1 – I can lift heavy weights but it gives extra pain

2 – Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, i.e. on a table

3 – Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned

4 – I can lift very light weights

5 – I cannot lift or carry anything at all

When rating yourself, you must try to be as objective as possible—don’t over rate your ability; nor under rate it. Give each question some thought.

Then, you add up the numbers, divide it by the total number of points and multiply by 100 to get a percentage score.

If the zero rating is assigned to “full ability to do the task” (like the Oswestry above), then the score is interpreted as “percent disabled.” So, an individual with no low back disability whatsoever will score zero out of 50 and his rating will therefore be zero percent disabled; i.e. 100% functional. If his score is 30, then 30/50 x (100) = 60% disabled.

Below is an example of an Oswestry Low Back Pain Disability Questionnaire completely filled out:

oswestry low back pain disability questionnaire

In the above example, the total points out of all ten questions is 19, which is considered a Moderate disability, out of No, Mild, Moderate, Severe and Total Disability. In this case, 19/50 x 100 = 38% disabled due to low back pain. Now this person has a baseline for his condition, and can set goals to lower it each time; perhaps to 20% after a month, then 10% after three months of therapy.

If the zero rating is instead assigned to “no ability to do the task,” the score is interpreted as “percent functional.” This is how the Upper and Lower Extremity Disability questionnaires are designed. So a score of zero in this case means zero percent functional (totally disabled), and 30% means you are 30% functional (you lost 70% function in that limb).

Please note that Disability questionnaires are used as tools to quantify and set baselines for pain and functional capacity; your scores do not officially establish any disability you may have, they simply provide a more tangible interpretation of pain.

Quantifying pain/disability, even if subjective, gives you a sense of how significant it is; i.e. how much it affects your life. Secondly, it can be used as a tool to measure your improvement over time, after doing some therapy and/or rehabilitation (strength and coordination exercises). This lets you know if what you did works for your condition, and therefore, whether to continue or discontinue it.

For example, if your baseline Oswestry score was 60%, and you were prescribed some McKenzie exercises for one week and a follow- up score was 40%, it suggests that those exercises improved your condition and you should continue or progress to the next level. If it was 60% or higher, you should discontinue the exercises and try another approach.

You don’t have to see a doctor to use Disability questionnaires to subjectively assess your disability. They are fairly straightforward to use and you can download the forms from the internet (see below; I’ve done it for you).

Determine Your Pain/Disability Baseline

If you have low back pain, neck pain, shoulder pain, or lower or upper limb pain then I suggest monitoring your condition using the appropriate disability questionnaire. If you are getting therapy, your doctor should be having you fill these forms (or something similar) out each visit and going over the results with you. It’s substandard care if you don’t know if the therapy you are getting or exercises you are doing is helping; these questionnaires will prompt you to think about the change or lack of change in your functional capacity, and will help you assess your care so that you can take appropriate action.

Below you will find forms to assess any musculoskeletal pain you are having. If you wish to participate in the 30 Day Pain Relief Challenge, print out the appropriate disability questionnaire; rate your abilities as objectively as you can and calculate your score; set it aside, and be ready to fill out a new questionnaire after 30 days of diligently doing the things I will cover over the next 30 days.

My goal is for participants to experience at least a 50% improvement in their pain/ disability scores. If you have any friends who might be interested in participating, please refer them to my site, https://PainandInjuryDoctor.com and have them enter their email in the opt in form.

Download the Low Back Pain Disability Questionnaire

Download the Neck Pain Disability Questionnaire

Download the Shoulder Pain and Disability Index Questionnaire

Download the Upper Extremity Disability Questionnaire

Download the Lower Extremity Disability Questionnaire

How I Got Trigger Finger and What I Did to Treat It

by Pain Doc | Oct 2, 2020 | Hand and Wrist Pain

It’s been a while since my last article. Between the weekly-changing COVID restrictions in my area and major house renovations, I have been delinquent with my life mission of helping others manage and heal their pain and injuries, on their own. But today, I’m back on track. Today, I’ll talk about a peculiar condition known as Trigger Finger.

But first, a little background:

For those who ever engaged in do-it-yourself home renovations such as landscaping, fence building, paver-laying and bathroom and kitchen remodeling you know how much stress it can put on your body. This is my story of how I developed trigger finger for the first time in my life, and serves as a “lessons learned” opportunity for others so that they can be spared the inconveniences of this condition..

For the last 10 years, I would categorize my daily physical activity as “moderate.” I would go the gym and lift free weights (reps over max); do various cardio fitness classes such as the Les Mills classes and Bootcamp; and run 3 miles about 3x/week. My average time in the gym I would say was 60-90 minutes, with about half of that actual exercising. At home, I would be working on my website and producing videos. This did require prolonged sitting, but I would get up every 30 minutes or so to walk around to relieve pressure to my lumbar spine.

Starting the second week of this past July, I started the aforementioned home renovation projects. I basically went straight from moderate activity to short bursts of sustained intense activity, daily for over four weeks. Since I didn’t have any major musculoskeletal impediments other than a chronic right AC (acromioclavicular) joint sprain, I moved freely as though I was in my 20s, which wasn’t such a good idea. The combination of the intense movement patterns my body wasn’t used to, plus my age, took a significant toll after four weeks.

Here are some of the heavy labor activities that I engaged in:

Carrying heavy lumber from Home Depot and loading into a pickup truck, about 10 trips
Carrying 50 and 80 pound bags of concrete mix and sand, for my paver project, about 5 trips.
Used a 2-person auger (about 120 pounds; gasoline powered) to drill several 3’ deep post holes
Shoveled piles and piles of dirt (pickup truck loads—about 10x)
Hauled away bulk trash to the dumpster
Carried 100 clay 12”x12” paver squares (bricks) from a truck to my yard and positioned them carefully
Used hand tools that required hard gripping and/or twisting including various types of saws, wrenches and screwdrivers
Used vibrational tools including a miter saw, reciprocating saw, drill, and nail gun

By the third week, I was starting to feel pain at my right AC joint, my left wrist, and both hands especially my right, dominant hand. Thankfully, despite frequent bending at the waist my lower back wasn’t affected. I attributed the AC join pain to aggravation of the old strain (I rate it a Grade 2 or 3 sprain – partial tearing, but intact). What happened is the heavy lifting placed a repetitious load on that unstable joint, causing the acromion and distal clavicle to aggravate surrounding soft tissues, particularly the supraspinatous tendon, and the insertion points of the ligament. My doctor suggested my pain was impingement syndrome—compression of the supraspinatous tendon where it passes below the acromion– which could be occurring, but I’m certain most of the pain is emanating from the joint itself because I can reproduce the pain simply by pressing it with my fingertip. I’ll tell you how I’m treating this in the next article.

I believe my left wrist pain is a Grade 2 strain of the flexor ulnaris tendon where it inserts into the distal ulnar’s styloid process; caused when I lost control of the auger. The auger is a very powerful machine that requires two people to operate (see picture above). Not being familiar with using one, I wasn’t prepared for the powerful torque it generated, and lost control of it, hurting my wrist.

The third problem that I’m dealing with is trigger finger. This is the first time I’ve had it and let me tell you, it’s not very pleasant.

Trigger finger is so named because as you attempt to straighten out your finger after closing your hand, the finger “catches” mid-way, and pain is felt in one or several joint capsules usually on the palmar side. Then, as you power through the restriction the pain increases and a popping/snapping sensation occurs right before it straightens out, just like how a gun trigger offers gradual resistance then suddenly releases at a point. See the short video below of my actual trigger finger taken this morning that explains this.

Trigger finger is a stenosing tenosynovitis disorder. Stenosing means narrowing of a passageway in the body; tenosynovitis refers to inflammation of the tendon and synovium. The synovium is a specialized layer of tissue surrounding the tendon in areas where it rubs against other structures in the body. Synovium secretes synovial fluid, a biological lubricant that helps reduce friction where the tendon moves. Synovium also lines the synovial joints of the body which include the hips, knees, shoulders, elbows, spine and joints of the hands and feet.

There are three, main populations of trigger finger sufferers: young children (up to 8 years old); trigger finger as a comorbidity to a primary disease; and adults experiencing trauma/ stress to the hands, typically in the 40s-50s. It tends to affect women more, and the most common finger is the thumb although it can occur in any finger, and in multiple fingers at the same time.

In children, trigger finger is believed to be due to uneven growth rates of the hand flexor tendons and the ligaments, where the tendon growth outpaces the growth of the ligaments that hold them against the finger bones.

Trigger finger is observed to often occur alongside certain other diseases such as carpal tunnel syndrome, diabetes, hypothyroidism, gout, rheumatoid arthritis, and amyloidosis; each probably having different etiologies involving the dysfunction causing the primary disease. Diabetics seem to be affected by trigger finger at a higher rate than the regular population, and it is uncertain why. With diabetes mellitus, there are high levels of glucose in the blood, and usually high insulin levels. Insulin is considered an anabolic hormone associated with tissue growth, so this may be a possible explanation for the increased incidence of trigger finger in diabetics, if the growth leads to tendon hypertrophy (enlargement).

For the third group, which the rest of this article will address, trigger finger is caused by hypertrophy and inflammation of the finger flexor tendons at the synovial sheath, typically from repetitious hand movements, especially those involving power gripping and vibration, making them chafe against the ligaments that hold them down to the finger bones (phalanges). (Remember, ligaments connect two bones, while tendons connect a muscle to a bone; both are components of all moveable joints). Imagine these ligaments as slips of Scotch tape forming a tunnel over the bone. As the hypertrophied (enlarged) section of the tendon enters the narrow tunnel during extension (straightening out of the finger), it gets stuck in that tunnel momentarily; much like how a big person trying to climb out of a small bathroom window can get stuck before being able to make it through. Then, as the tendon makes it past that entrance, it causes the popping sensation.

Orthopedic specialists identify the tendon-ligament structures involved in hand movement as pulleys. Remember from basic physics, a pulley is one of the simple machines (the others being a lever, plane and gear). This is an appropriate name because the tendons and ligaments accomplish work just like the cables and pulleys used in cranes.

Image courtesy of OrthoBullets.com

The A1 pulley is at the metacarpo-phalangeal joint, commonly called the knuckles. It’s where the proximal phalanx connects to the respective metacarpal bone. This is where trigger finger usually occurs. Those who have it here feel the pain and popping/snapping on the palmar side of the knuckle.

The A2 pulley encircles the proximal phalanx, or first finger bone, from the knuckle.

The A3 pulley is at the PIP, or proximal interphalangeal joint—the first joint from the knuckle connecting the proximal and intermediate phalanges (first and second bones of the finger). This is also a common area of trigger finger.

The A4 pulley encircles the intermediate phalanx (second bone of the finger from the knuckle).

The A5 pulley is at the DIP, or distal interphalangeal joint, the furthest joint of the finger connecting the intermediate and distal phalanges (second and third bones of the finger, from the knuckle). Although triggering can happen here, it is less common.

Since the thumb is comprised of only two phalanges, it has an A1 and A2 pulley only. Trigger finger affecting the thumb almost always occurs at the A1 pulley. Unlike the other fingers, your thumb can move in multiple planes, much like the shoulder joint. It has a unique pulley called the oblique pulley that allows it to touch the pinky, a movement called thumb opposition.

Image courtesy of OrthoBullets.com

In my case, I have trigger finger in the middle and ring fingers of my right hand, mostly in the A1 and A2 pulley, and less in the A3, with the middle finger being more problematic. Pain is most pronounced in the middle of the night and upon waking, then gets better rather quickly in my case, in the first waking hour of the day. This is because as you sleep, there is less movement of the joints and less synovium produced, causing them to be stiffer.

I have the classic symptom where there is locking of those fingers when I move them from the natural, half-open relaxed hand to fully extending the fingers. As I force them past the locked angle, they snap at the A1 and A2 pulleys, then straighten out. It’s momentarily painful, but tolerable. But for some people, it’s a lot worse. All those weeks of sustained power gripping and twisting caused the flexor tendons and synovium to rub excessively against the ligaments holding them in place, causing microtears and initiating the inflammatory response.

TREATMENT FOR TRIGGER FINGER

The medical standard of care for trigger finger is corticosteroid injection below the affected ligament. This quickly knocks down the inflammation, and in some cases, symptomatic improvement happens within seconds. However, some patients report pain following the injection, and slower or no results.

Splinting is sometimes attempted. The idea is that if you immobilize the tendon, inflammation will stop and the tendon will shrink and heal, bringing things back to normal. However, this is not always the case. Sometimes inflammation takes a life of its own, and prolongs long after the injurious event ceases.

If neither corticosteroid injection nor finger splinting fail to correct the problem, surgery is an option. Direct, open surgery and percutaneous (minimal incision, special surgical tools) surgery are the two options, with direct surgery usually having better results. This is where the ligament is cut to provide more room for the tendon to move. This is possible because the adjacent ligament serves as a backup; for example, the A2 can back up A1 if A1 needs to be cut/ split apart. However, as you can imagine such destruction of a functional component means some strength and stability are sacrificed. I’m sure those having this kind of surgery lose some power in their grip.

MY TREATMENT STRATEGY

As I write this article, my trigger fingers have improved about 75%, from their worst presentation. It could be that my connective tissues are in pretty good shape; my healing capacity is strong; my injury was not very severe; or my treatment regimen is helping accelerate healing. Some sufferers don’t see such a quick pace of resolution.

Here is what I’m doing: as I mentioned, the symptoms are most pronounced in the middle of the night (when I get up to use the bathroom) and upon waking. In the middle of the night, I simply don’t move my fingers, and go back to sleep.

In the morning, I run cold water over my hand for 2 minutes, and gently move my fingers. I get the snapping, but it dissipates shortly after. I still feel some stiffness and soreness in my knuckles throughout the day, but no snapping.

I get localized cryotherapy done on my fingers. Cryotherapy is extremely cold air, as in sub-zero, for 3 minutes. The cold not only slows inflammation, it is said to cause a shock to the sensory nerves, which causes the central nervous system to respond by increasing blood flow, fibroblast activity, and nutrients to the area.

Note: the image above is a localized cryotherapy session on my hand, for a previous complaint. The red dot is not red light therapy; it is a laser thermometer the technician uses to measure my skin temperature so that it doesn’t too low (his hand is visible in the picture). Localized cryotherapy can reach temperatures of -30 degrees F.

Lastly, I apply red light therapy. I’m an advocate of this therapeutic technology and have written articles about it. Red light therapy is actually an electromagnetic waveform (600-880 nanometer wavelengths) that appears red to the human eye. It’s not the red you get from shining a light through a red lens; it’s a specific waveform in the electromagnetic spectrum generated from an LED (light-emitting diode). The device I use uses three LEDs, one of which emits a waveform closer to infrared and therefore does not appear to be red as it is invisible. The electromagnetic energy is at a frequency that gets absorbed by cell mitochondria and other structures, which can result in changed oxidative states that lead to cell signaling that initiates reparative processes, such as increased ATP production and increased membrane permeability. This lessens inflammation and stimulates healing.

I anticipate my trigger fingers to fully recover, to pre-injury status. I will continue to do these therapies, as I feel they are partly responsible for my good results.

BOTTOM LINE

Prevention is the best cure: if you know you are going to be using your hands a lot, such as starting on a do-it-yourself project involving power tools and hard gripping, know that this can cause trigger finger. Do what you can to minimize the stress to your hands—take frequent breaks; don’t overdo it/ don’t hold a power grip for more than a few seconds; and rest and stretch your hands often. Don’t rush it. Trigger finger creeps up on you, and by the time you notice it, it is too late. The presentations are different from person to person, depending on age, health, fitness and so on. I am lucky as my condition is resolving; others are not so lucky and wind up getting surgery and permanent percent loss of hand function. So make sure you keep prevention in mind. If you do get it, try the treatment methods for trigger finger described here that have worked for me.

What Causes Radiating Arm Pain?

by Pain Doc | Aug 31, 2015 | Hand and Wrist Pain

Just like how sciatica/ leg pain is usually caused by a bulging disc in the lower back or by a muscle pinching the nerve, arm pain and/or numbness & tingling is usually caused by a bulging disc in the neck or by a muscle pinching a cervical (neck) nerve root or plexus.

The nerve roots that come out from between your cervical vertebrae converge to form three main nerves that service the arm: the ulnar, median and radial nerves. If any of these nerve roots are pressed by a bulging disc, a bone spur or thickened ligament, it usually causes radiating (traveling) pain from the neck down the arm; usually all the way down to the fingertips.

The specific area of pain/tingling depends on which nerve root is being pinched. In fact, that is how doctors diagnose the precise problem area. For example, numbness down the medial (inner) side of the forearm down to the pinkie and ring finger can be produced by compression of the C8 & T1 nerve roots. Numbness in the outer forearm, thumb and first two fingers is associated with the C6 & C7 nerve roots.

arm dermatomes

Radiating arm pain can also be caused by thoracic outlet syndrome, where muscles near the neck and upper shoulder pinch the nerve plexus (where the roots converge). This will be next week’s topic.

Self Treatment for Radiating Arm Pain

If you have significant neck pain accompanying your arm symptoms, then it is likely you have a bulging disc in your neck. It feels like a focused, sharp pain deep inside the neck on one side. Massage does not help this kind of pain.

Most mild to moderate cases of cervical disc bulges resolve with exercises and manual therapy. The severe cases usually require surgery to remove the disc portion that is pressing against the nerve. If you have a severe case, get a consultation from a spinal surgeon and a second opinion. If done in time, surgery can resolve the arm pain, but if the entire disc is removed the surgeon will fuse the vertebrae above and below the disc which will reduce your neck range of motion somewhat.

If the disc bulge or offending structure is allowed to compress the nerve root for an extended period it may result in permanent injury to the nerve. This means after surgically removing the bulge, you still may have numbness down the arm. This is why, for nerve compression conditions, time is of the essence.

Non-surgical candidates can do exercises to reduce the bulge size. For typical posterior bulges (bulges that protrude towards the back and one side of the vertebral body) try this: while standing, use your posterior neck muscles to pull your neck straight back, as far as you can; hold for 3 seconds. It may feel uncomfortable if your disc bulge is acute. Keep your chin tucked in so that the top of your head is level. Do eight times, twice a day for a couple of weeks; note changes in your neck pain and arm pain. Discontinue if it aggravates your condition. This movement gently presses the backs of the vertebral bodies together, which pumps the disc bulge back to center.

If the exercises help but you hit a plateau, try side bending your neck towards the side of the pain, very slowly; repeat six times. Again, note changes; discontinue if it aggravates the pain.

Recommended Lifestyle Changes

Forward bending of the neck and anterior weight bearing of the head (forward head posture) tends to make the cervical discs more vulnerable to bulging because in this position the vertebrae press the front part of the discs, pushing the jelly center (nucleus) towards the back.

Axial forces (straight down through the spine) to the neck can also make disc bulges worse. Any activity that involves jumping creates axial forces — running, basketball, gymnastics, mountain bike riding, sky diving, etc. It’s not a concern unless you do it frequently.

If you have a bulging disc in your neck with arm pain, here are some suggested lifestyle changes:

Use a contoured neck pillow and sleep on your back.
Work on improving your posture: eliminate forward head posture.
Get a standing desk if your job requires a lot of sitting– it’s better for your back and neck.
Use the Cervical PosturePump device to hydrate your cervical discs
Strengthen your neck muscles so they offer more support to your neck.
Avoid excessive jumping. If you like running, consider getting Z-coil or Gravity Defyer shoes (see below).

Treatment Accessories to Reduce Arm Pain from Disc Bulge

PosturePump Disc Rehydrator

This device uses specially designed air bladders, inflated by a hand pump to spread apart and extend neck vertebrae. This expands the discs, drawing in fluids and nutrients and also stretches the neck into its normal, ideal curvature.

Anti-Shock Specialty Shoes

These specially designed shoes have powerful springs in the heel that significantly dampen the forces generated from running. Less shock to your feet, ankles, knees, hips, low back and neck.

Vari-Desk Height Adjustable Portable Desk

Place this lightweight desk on your traditional sit-down desk and switch its height between standing and sitting in less than five seconds. Choose to stand for as long as you like, then switch back– great for easing into standing while working, if you’ve been a desk sitter for many years.

The Origins of Musculoskeletal Pain – Which Describes Yours?

by Pain Doc | Mar 7, 2014 | Hand and Wrist Pain, Low Back Pain, Myofascial Pain

Musculoskeletal pain refers to pain affecting the muscles, ligaments, tendons, joints and sometimes bones. Sometimes it is straight-forward; other times it is not. Before you convince yourself that you know the origin/cause of your musculoskeletal pain, consider the following:

Pain can be due to trauma/injury where the tissue itself is generating the pain due to ruptured cells and the effects of inflammation. This is the most unambiguous case because it is connected to an identifiable event. This pain can be acute, meaning relatively recent onset; sub-acute, referring to a state where the injury still is healing but pain and some swelling is still present; and chronic, which basically means symptoms that remain after the body has done all it can at the moment to heal the injury.

Pain can manifest in one area of your body due to abnormal movement in a distal location. The abnormal movement might be caused by a previous trauma event like a car accident or sports injury, it can be congenital (developed at birth) and it can be from repetitive movements required by a certain occupation or hobby/sport. Abnormal movement (called dyskinesia) can also arise from muscle imbalances, where one muscle loses strength due to inactivity, decreasing joint stability and facilitating excessive, restricted, or other abnormal movement of that joint, forcing distal joints to make up the difference in lost movement or compensate to create more stabilization. The distal muscle(s)/joint(s) then work in a fashion that they were not designed for, leading to strain, spasm and even injury to the muscle or joint.

This is the most tricky type of pain manifestation because it is often mis-diagnosed resulting in the wrong treatment approach and lack of resolution. An example of this is sciatica (pain in the buttock) from a spasmed piriformis muscle scissoring the sciatic nerve due to an unlevel pelvis coming from hyperactive same-side erector spinae musculature. If the back muscle and pelvic imbalance is not corrected and the patient simply gets massage to the piriformis muscle, you can see how this pain will never go away with this type of treatment.

Pain can be referred pain. In referred pain, the brain senses the pain to be in one area of the body when the abnormal site is actually in another area. Despite an increasing amount of literature on the subject, the mechanism of referred pain is still unknown. Going back to the heart attack example, myocardial infarction can cause referred pain to the left jaw and left arm. The image below illustrates commonly observed types of referred pain and their true source (credit to Wikipedia).

Pain can arise from hypoxia (insufficient oxygen to the tissues). An extreme example of this kind of pain is a myocardial infarction, or “heart attack” where a major artery to the heart muscle is blocked, preventing oxygen from reaching a section of the heart. Biochemical reactions take place when this happens, which generate pain.

Thoracic outlet syndrome is a condition where the nerves and blood vessels supplying the arm get compressed in the neck region by tight scalene muscles or the collar bone. The resulting hypoxia can contribute to pain in the arms and hands.

Pain can come from trigger points, also known as trigger sites or muscle knots, are described as “hyper-irritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers.” Trigger points are usually only a few centimeters in diameter.

Clinical textbooks on the subject establish the following requirements to meet the definition of trigger points:

Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection.
The painful point can be felt as a nodule or band in the muscle, and a twitch response can be elicited on stimulation of the trigger point.
Palpation of the trigger point reproduces the patient’s complaint of pain, and the pain radiates in a distribution typical of the specific muscle harboring the trigger point.
The pain cannot be explained by findings on neurological examination.

As in referred pain, the mechanism of trigger points is still being debated. Trigger point tissues have been biopsied, and findings indicate the presence of hyperactive muscle spindles, special cells whose function is to detect the rate of lengthening in a contracting skeletal muscle and initiating the firing of complementary muscles to complete the desired goal.

Wikipedia gives a nice summary of what causes trigger points to form:

Activation of trigger points may be caused by a number of factors, including acute or chronic muscle overload, activation by other trigger points (key/satellite, primary/secondary), disease, psychological distress (via systemic inflammation), homeostatic imbalances, direct trauma to the region, collision trauma (such as a car crash which stresses many muscles and causes instant trigger points) radiculopathy, infections and health issues such as smoking.

Finally, there are more highly-complex causes of pain related to dysfunction of the central nervous system, sympathetic nerves, biochemical and hormonal issues, and even psychosomatic. These types of cases are difficult to diagnose and are often treated using pharmacological agents, and on the other side of the spectrum, holistic approaches with mixed results.

NO MATTER what pain you may be experiencing, know that it always, always helps to detoxify your body as best you can via a nutritionally-dense diet centered on naturally-occurring, non-GMO, organic unprocessed food sources; reducing your processed sugar and grain intake; regular exercise, getting enough sunshine to your body; targeted supplementation, meditation or other relaxation methods, and even nurturing social support. This is the theme of this blog, because there is no shortage of treatment methods for pain and not enough emphasis coming from doctors or the government on prevention, wellness and health optimization; i.e. Healthy Lifestyle Education.

In the next couple of blog posts, I will talk about real, practical ways you can reduce your pain without the help of your doctor by making strategic lifestyle modifications. Your body has a potent array of disease-fighting systems and has an innate ability to repair and regenerate itself. The problem is that in many pain sufferers, these systems are burdened by unhealthy habits and are not running at their full potential. Imagine what can happen if those systems were brought back on line, constantly doing what they are naturally programmed to do– protect you and keep you alive; fighting germs, cancer cells and developing diseases; and repairing injured sites so that you can function better. Isn’t this a goal worthy of your efforts?

More to come, stay tuned!

Dr. Perez

Simple Exercise to Combat Hand Pain and Fatigue

by Pain Doc | Apr 1, 2011 | Hand and Wrist Pain

If you use your hands in a repetitive fashion at work or at play and notice your hands and wrists are feeling achey and fatigued, it’s partly because the muscles in your hand are out of balance. Usage of the hands is predominantly a flexion action, where the flexor muscles of the arm contract to bend the fingers inward. This is true for gripping and typing.

So what happens is that the extensor muscles of the arm, which are the ones that straighten out the fingers and bend the wrist upwards, are “overwhelmed” by the action of their reciprocal muscles, the flexors (flexor digitorum, flexor carpi ulnaris and radialis). The action of the joints in a flexor-dominated repetitive activity puts excessive wear to the same, small area on the joint surfaces and can gradually lead to stiffness and pain in the hands. And, it de-conditions the extensor muscles over time; meaning, makes them weak and less responsive. That explains the fatigue factor.

The solution is to do exercises for the extensor muscles to counteract the amount of flexion you do. A simple yet effective exercise is to use a thick rubber band (like the ones that hold together broccoli in the grocery store) and place it around your fingertips and thumb. Open your hand (extend your fingers till they are straight at the knuckles), about one repetition per second. Do about 50 every hour, four hours per day; depending on how much you use your hands. What you’re trying to do is work the extensors as much as your flexors to ensure both groups are getting an equal amount of work out. This will keep the hands strong and resistant to weakness and pain from frequent use.

Thoracic Outlet Syndrome Exercise

by Pain Doc | Mar 15, 2011 | Hand and Wrist Pain

Thoracic outlet syndrome is a condition where the neurovascular (nerves, blood) structures that service the arm get compressed outside of the spine (a peripheral neuropathy). The compression can come the collarbone, the scalene muscles at the base of the neck, an apical tumor or other mass. Thoracic outlet syndrome can be unilateral (one side) or bilateral (both sides).

The brachial plexus is a bundle of nerves that eventually form the major nerves of the arm: median, radial, and ulnar. It passes directly underneath the center of the collarbone. The subclavian artery, which becomes the brachial artery, is right next to it and supplies blood to the arm. The collarbone (clavicle) connects your shoulder blade (scapula) to your breastbone (sternum). There is only a few millimeters clearance between the bottom of the collarbone and the ribcage, so proper alignment of these structures is absolutely critical for the nerves and blood vessels to work unobstructed.

Trauma to the shoulder complex, repetitive shoulder movements (like a baseball pitch), a long history of sleeping on your side, and a habit of carrying a heavy bag with a strap over your shoulder, or a history of carrying any other heavy objects on the shoulder such as a 5-gallon water bottle are some of the things that can cause the collarbone to close down on the neurovascular bundle. Symptoms can include numbness down the arm; hand numbness, arm and hand weakness, pins and needles sensation in the fingertips, and poor circulation in the arms (feeling of swelling or fullness).

A cervical rib can predispose one to thoracic outlet syndrome. A cervical rib is a congenital anomaly where a small rib branches from the lower neck vertebrae. A cervical rib can easily obstruct the brachial plexus on that side.

A syringomyelia or syrinx is a slowly expanding fluid filled sac in the spinal cord, usually at the neck level, that places dangerous pressure to the cord; enough to cause muscle atrophy (wasting) of the areas served by the affected neurons. Although syringomyelias are rare, they must be ruled out first.

If you are experiencing upper extremity numbness, see your doctor. You should get referred to an orthopedic specialist who can do some tests to properly diagnose your condition. If thoracic outlet syndrome is suspected, your doctor may order a nerve conduction or needle electromyograph (EMG) study to determine if the nerve is compromised. Typically, physical therapy is prescribed for several weeks. If there is no improvement, surgery may be recommended.

The exercise below can be helpful for some sufferers of thoracic outlet syndrome, especially the type that involves the collarbone pressing down on the neurovascular bundle. It is simple to do, and generally safe. This exercise attempts to lift the collarbone repeatedly off the ribcage, creating more space for the brachial plexus and subclavian artery. Do at least 100 per day for a week; if relief is felt, continue doing as needed. If at any point your symptoms feel worse, stop immediately.