Hand and Wrist Pain - Ask Dr. P - The Pain Doc

Stenosing Tenosynovitis

by Pain Doc | Sep 22, 2010 | Hand and Wrist Pain

Stenosing tenosynovitis translates to “tendon inflammation due to narrowing passageways.” It is entrapment and inflammation of the extensor pollicus longus tendon, the muscle that moves the thumb up in a “hitchhiker sign.” It is also known as DeQuervain’s Syndrome.

The passageway in question is a tunnel formed by ligaments that hold the extensor pollicus longus tendon to the distal radius (lateral wrist), one of the two bones of the forearm.

The onset is gradual over a few days. There is a very sharp, unrelenting pain at the radial styloid, the bony prominence at the lateral wrist right below the wrist crease. There is no loss of muscle strength in the thumb. Bending the affected thumb inward towards the palm while bending the wrist sideways towards the ulna (in direction away from the pain) makes the pain much worse.

Causation is believed to be related to overusing the thumbs, such as BlackBerry use, or frequent bending of the wrist while carrying weight, such as in cradling a baby several times a day. However, there are documented cases of stenosing tenosynovitis occurring with no apparent trigger (idiopathic causation).

What is known is that the synovial sheath that covers the portion of the tendon in the tunnel gets inflamed and undergoes degenerative changes. It triggers a chronic, localized inflammatory response. Pain comes from tiny nerve endings in the synovial sheath that are irritated by rubbing against the ligament holding it to the distal radius, and perhaps also by exposure to the products of inflammation.

The condition is known to be self limiting, running its course for a few months and then resolving as the body regenerates the synovial sheath. However, during its acute stage it is quite unpleasant, despite the fact that only about an inch of tendon is involved.

TREATMENT:

Wrist immobilization (wrist brace with thumb splint) to limit movement of the adductor pollicus longus is recommended for 1-3 weeks. Wear most of the day and night; remove every hour or so to do ice therapy.

Ice massage is helpful in temporarily reducing the pain by numbing the area and constricting blood vessels, which tends to suppress production of inflammatory chemicals. A wrist ice wrap can also be effective. Apply ice for 10-20 minutes directly onto the painful area.

Topical ointments may be helpful in reducing the severity of the pain. Narayan oil and products containing capsaicin (don’t use together) are worth trying. Rub into inflamed tendon gently.

Chinese herbal patches may be helpful in temporarily relieving the pain as well.

Cortisone injection into the tunnel can be effective in neutralizing the pain; however it still may take a few weeks to months for the pain to go entirely away.

Carpal Tunnel Syndrome

by Pain Doc | Sep 6, 2010 | Hand and Wrist Pain

Image via Wikipedia

Carpal tunnel syndrome is a condition where one of the major nerves of the arm gets compressed in the wrist. It can lead to pain, numbness, and tingling in the hands. Advanced symptoms are muscle weakness in the hands, muscle atrophy (shrinking), especially of the thumb pad; and loss of motor coordination in fine dexterity skills, like buttoning a blouse.

The three main nerves that are responsible for controlling the arm are the ulnar, median, and radial nerves. The median nerve, like its name implies, travels down the middle of the arm. It passes through the carpal tunnel which is just above the crease in the wrist before splitting into branches that go to the thumb, index, middle, and inner half of the ring finger.

The carpal tunnel is a small diameter hole formed by the wrist bones and the transverse carpal ligament. It contains the tendons that flex the fingers (flexor tendons), and the median nerve. Pressure as light as a penny can adversely affect nerve tissue, so any pressure increase in the carpal tunnel will over time injure the median nerve.

The most common cause of increased pressure in the carpal tunnel is thickening of the flexor tendons due to long term repetitive use of the fingers such as in typing. Over time the tendons press the median nerve against the rigid transverse carpal ligament. The nerve loses oxygen and it starts to malfunction. Left alone, the damage will be permanent as nerves have a limited ability to regenerate.

Other possible causes are prior injury to the wrist that narrows the carpal tunnel and arthritic or other pathological changes in the wrist bones that cause them to occlude the tunnel.

Pregnancy and thyroid conditions may mimic symptoms of carpal tunnel syndrome.

TREATMENT:

Image via Wikipedia

If the symptoms are advanced (pain, numbness, tingling especially at NIGHT and loss of hand coordination and muscle atrophy) see your doctor. The doctor should refer you to a hand specialist who may order a nerve conduction test to diagnose carpal tunnel syndrome. If your test is positive, you may be referred for physical therapy, which will involve mostly stretching and hand exercises. If that doesn’t work, you may be offered a cortisone injection and exercise prescription, a wrist brace and orders to avoid prolonged hand usage. The last option is carpal tunnel release surgery, where the transverse carpal ligament is surgically cut to relieve pressure in the tunnel.

If your condition is not advanced, do the following:

If your job or hobby requires lots of finger and hand activity, there is a good chance that this is the cause of your symptoms. Check your work station set up and ensure the following:

a. Keyboard should be low enough so that your fingers are at the level of the keyboard when:

your upper arms and shoulders are relaxed; your upper arms (above the elbow) are to the side of your body almost touching;
your elbows are bent 90-100 degrees
your wrists are straight or even bent slightly downward

The most important part is having your shoulders relaxed. To see if you are doing it right, using your right hand press the top of your left upper shoulder, from the neck down to the shoulder joint. It should be relatively soft. If it is not, you are unconsciously contracting the neck and upper trapezius muscles and lifting the arm.

If you find you can’t accomplish the above, due to your desk being too high, you need to get an adjustable keyboard tray and install it under your desk. Place the keyboard on this tray and lower and angle the tray so that you can meet these requirements (see video below on how to do this).

b. The top 1/3 of your monitor screen should be at eye level. Use phone books or a monitor lift to get it to this position. Place the monitor close enough that you don’t have to bend your neck forward to see text on your screen, or adjust your screen settings to magnify the text.

c. The mouse and frequently used equipment should be close so that you don’t have to reach forward for them. Your keyboard tray should have an attached mouse pad; use it.

d. Remember to keep your head in a position where your ears are directly over your shoulders.

e. Every few minutes, relax your hands and wrists for 20-30 seconds.

f. Every hour do the wrist, neck and shoulder exercises in the video.

g. When symptoms are gone, you can do wrist strengthening exercises.

Exercise for Thoracic Outlet Syndrome

by Pain Doc | Sep 5, 2010 | Hand and Wrist Pain

The thoracic outlet is an “opening” at the base of the neck, on both sides, where the nerves and artery that service the arm on that side exit through as they descend into the arm. It is formed by the anterior and medial scalene muscles, the first rib, and the clavicle (collar bone).

If the thoracic outlet narrows in any way, due to one or more of these structures, neurovascular compression is possible (compression of the nerves and artery). This can result in shoulder pain, neck pain, weakness in the affected arm and hand, numbness and tingling in the arm down to the hands, especially the last three fingers; and in some cases swelling of the arm. Carrying something like a heavy bag on the affected shoulder makes the symptoms worse.

In thoracic outlet syndrome there is usually a history of prior injury/trauma to the shoulder girdle, such as a car accident or sports injury. People with long necks and long arms are said to be more predisposed to this condition as the weight of the arm and length of the neck tend to put more stress in the thoracic outlet area.

Left alone without resolution, it is possible to develop permanent nerve damage resulting in chronic pain, weakness in the arm and hand, and reduced sensation in the inner arm area.

What to Do if You Suspect You Have Thoracic Outlet Syndrome

If you suspect you have thoracic outlet syndrome, see your doctor or an experienced chiropractor. There are some simple orthopedic tests that can be done to see if you likely have TOS. An MRI study can help visualize the thoracic outlet and identify if there is swelling; and needle electromyograph (EMG) can determine if the arm muscles are getting the proper amount of nerve flow.

If the diagnosis is confirmed, physical therapy exercises are usually prescribed to help open the thoracic outlet space. In some cases, imaging studies show a fibrous band responsible for compressing the neurovascular structure; in these cases surgery may be an option. This involves the scalene muscles — three, short muscles that connect the lower neck vertebrae to the ribcage.

In the meantime, try doing this exercise. It is designed to create more space between the collar bone and the ribcage. If this is where your compression is occurring, it may help.

How to Tell if Your Pain is from Arthritis

by Pain Doc | Aug 28, 2010 | Arthritis, Bone Pain, Hand and Wrist Pain

Image via Wikipedia

If you have deep, achy pain in a joint that doesn’t go away with time it’s likely some form of arthritis. Lower back pain can be arthritic in nature (as opposed to muscle) if it behaves similarly– deep, achy, doesn’t seem to ever go away entirely; and you have a history of repetitive, physical impact to your body such as construction workers/ laborers, martial art practitioners and gymnasts. However, with rheumatoid arthritis (explained below) no history of trauma is necessary.

Most people associate arthritis with the elderly. But did you know it can affect younger people as well?

The word arthritis translates to “joint inflammation.” There are several forms of arthritis, the two most common types being rheumatoid arthritis and osteoarthritis.

Image via Wikipedia

Rheumatoid arthritis (RA) is an auto-immune disorder, where the body’s white blood cells attack the synovium of synovial joints. Synovium is the inner lining of a synovial joint— encased (capsular) joints like in the spine, hips, knees and shoulders. The synovium produces synovial fluid, which lubricates the inner surfaces of the joint as it moves.

People suffering from rheumatoid arthritis will have bouts of severe joint swelling, redness, heat and pain. RA is typically bilateral; meaning, for the extremities it strikes both sides, not just one. It is an awful condition that can can severely impact mobility. Those with rheumatoid arthritis in the knuckles of the hand will have difficulty gripping things and doing fine dexterity movements such as writing and buttoning a shirt. Areas commonly affected by rheumatoid arthritis are the hands, spine, and feet.

Currently, drugs are the only medical treatment for RA including non-steroidal anti-inflammatories– NSAIDS (aspirin, Motrin, Tylenol, Ibuprofen), corticosteroids and immunosuppressives.

Palliative care to manage pain levels include acupuncture, yoga, and chiropractic. Cannabis (medical marijuana) is a popular choice for many sufferers.

Osteoarthritis (OA) is described as joint pain and inflammation from wear and tear of the cartilage. It is usually found in people who have suffered repeated joint trauma, like football and basketball players. Marathon runners can develop it in the knees and hips as well. OA is found in the weight bearing joints of the feet, ankle, knees, hips, lower spine and neck.

When repeated trauma impacts a weight bearing joint, over time it creates tiny fissures in the cartilage, which thins the cartilage and exposes the bone underneath. From there, the bone forms bone spurs called osteophytes. Radiologists describe these changes (disc degeneration plus osteophytes) as spondylosis of the joint.

Both types of joints can be painful, with RA being more acutely painful. The symptoms are pain, joint stiffness and reduced range of motion.

MAKING BONE BROTH SOUP FOR ARTHRITIS PAIN:

In both cases, eating a low-inflammation diet will be helpful: reduce sugar intake including high fructose corn syrup; limit carbohydrates to 150 grams per day; emphasize protein and fat, especially fish with high Omega 3 content; nut oils (walnut, almond, Brazil nuts), virgin olive oil, and raw plants (green leafy salads, lightly steamed vegetables). Raw milk and butter from grass fed cows, and coconut oil are also good for an anti-inflammatory diet.

Eating bone broth soup every day will give your body the constituents for rebuilding cartilage: Visit your local butcher and ask for the large beef and pork joints. They can saw these in little pieces in the back and give them to you in a bag; they price them pretty cheap; too!

You’d be amazed as to how cow/ pig knee and hip joints look very much like a human’s. If you want to understand the anatomy of these joints, this is a great way to do it. You will see and feel the smoothness of the cartilage on the femur head. You’ll see the anterior and posterior cruciate ligaments (ACLs and PCLs). You will see the patella, fat pad; and collateral ligaments, condyles and meniscus. Make sure to eat all of these parts in addition to drinking the broth to get all the proteins needed to rebuild tendons, ligaments and cartilage.

MAKING THE BROTH:

Add a couple of pieces of joints into a tall pot; fill half-way with water; add salt. For extra bone-building strength add some eggshells (from cracked RAW eggs– You want the inner shell membrane to be intact; with boiled eggs the nutrient-rich membrane sticks to the egg). Bring to a strong boil; reduce heat to low and cook for 60 minutes. Steep out the eggshells, and drink the soup. Eat any pieces of tendon stuck to the bones, and eat the bone marrow as well. You can add spinach to the soup the last minute of boiling for more variety. (chicken and turkey carcasses and whole fish bones work well, too).

The calcium and cartilage nutrients you get from this bone broth can help your joints feel better.

HOME THERAPY FOR ARTHRITIS

Arthritis pain comes from inflammation and stimulation of pain receptors in damaged cartilage by the inflammation and also by physical abrasion.

Pulsed electromagnetic field therapy (Pulsed EMF or PEMF) can help by energizing the affected cells. The electromagnetic field produced by PEMF machines are similar to the naturally-occurring fields produced by the biological activity of your cells; adding an external source helps those cells function better. The few cells that exist in the cartilage and ligaments and tendons have more energy to synthesize matrix and collagen which goes towards joint rebuilding. Use in conjunction with red light therapy for maximum effect. Red light at around 660 nm wavelength initiates photobiomodulation, which also gives cells more energy to function, much like photosynthesis in plants.

For temporary relief, heat works best with chronic pain and stiffness. An infrared heat lamp is a good choice, as it is easy to set up and penetrates all the way down to the affected tissue, unlike a hot pack which only heats the skin. Heating is not advised for rheumatoid arthritis when it is in a flare-up, hot and acute phase.

As far as medical care, joint replacement is a more drastic option but can effectively reduce pain while preserving some joint functionality. There are also experimental procedures that involve culturing cartilage cells in a lab and injecting them into the joint space, hoping that they will bond to existing cartilage and thicken, but results are mixed at this point.

If you don’t have arthritis, do things that will help prevent you for getting it. Build up your joint strength with the diet mentioned above, and avoid repetitious trauma to the weight bearing joints (activities that involve jumping and landing on a hard surface). Strengthen surrounding ligaments of your knee and hip joints with exercises like weightless squats, knee bends, and simple uphill hiking.

Your joints are the most neglected part of your body; we often take them for granted. But when one is injured or develops arthritis, you will realize very quickly how important they are to your happiness and well-being. Don’t wait until it is too late; strengthening and nurturing your joints should be a definite part of your fitness routine.

Wrist Pain and Treatment

by Pain Doc | Aug 26, 2010 | Hand and Wrist Pain

Wrist pain from overuse affects over 50% of people whose job requires frequent typing on a computer keyboard. However, any job or activity that requires repetitious finger movement is capable of causing this type of wrist pain.

wrist tendon anatomy

The leading culprit is tedonitis, or tendinitis — inflammation of the wrist tendons; more precisely the flexor digitorum tendons which pass through the wrist. As you move your fingers alternating between flexion and extension, which is essentially what typing is, the wrist tendons rub against one another. The tendons are protected by a slippery sheath to allow smooth gliding during movement, but if this sheath loses its protective qualities, it can cause the tendons to inflame and swell. Certain drug side effects and illnesses can cause this; check with your doctor.

The problem with tendonitis is that, by nature it affects tendons of muscles that are needed for work or play; for example the wrist for typing, the elbow for golf and tennis, and the achilles tendon for running. The individual therefore continues in the offending activity until she can no longer tolerate the pain, and by that time a lot of microtrauma has occurred. The microtrauma (tiny tears and fissures in the tendon and sheath) releases inflammatory products and attracts scar tissue formation, which makes them stick together even more. The tendons undergo trophic changes (changes on the cellular level) and don’t function as well as before leading to chronic pain.

Prevention is the key for all cumulative trauma/ repetitive strain injuries– these painful conditions are totally preventable and don’t need to happen in the first place. You don’t want to ignore prevention because tendonitis takes a long time to resolve once it is entrenched. In some cases, tendonitis can lead to carpal tunnel syndrome, where the median nerve in the wrist gets squeezed and injured leading to numbness and weakness of the hand.

For wrist tendonitis from typing, make sure your workstation is ergonomically set up:

Use an adjustable keyboard tray to lower and angle down your keyboard at a level where you don’t need to contract your shoulder muscles to raise your arms above the keyboard.
Keep your upper arms in the same plane as your torso, and close to your sides (don’t type chicken winged).
Keep your elbows angled at about 95-100 degrees, wrists straight in line with the forearm or slightly bent downwards
Use a good chair with lumbar support and if necessary a foot stool to rest your feet on
Head up, ears directly over shoulders, eyes in line with center top 3rd of computer monitor; shoulders relaxed.

Take 30 second to a minute mini-breaks if you are going to be typing more than an hour straight.

Stretch wrists periodically in flexion and extension; hold for 10 seconds; do wrist circles ten times in both directions.

Do shoulder circles ten times in both directions.

Do chest and neck stretches every other hour during the day.

Stand up and do wall angel exercises (50) at least twice during the day to counteract the tendency for neck and shoulder flexion during sitting.

TREATMENT:

1. Do ice massage every two hours during the day if your pain is acute (feels hot, swollen and in some cases, reddish skin). Here’s a YouTube video of how to do it.

2. Apply Red Light Therapy to your wrist. The Red Light torch is great for this. Press it gently but firmly into your wrist and depress the button. Do three times/ day, 10 minutes each. Research shows that red light therapy reduces inflammation, almost as good as a non-steroidal anti-inflammatory medications.

3. To further accelerate healing, apply Pulsed EMF to the painful areas.

SUPPORTING EFFORTS

Eat an anti-inflammation diet for 2-3 weeks: go heavy on fish oils; reduce grain intake; eat plenty of alkaline foods (green leafy plants).

Don’t do stretches when your tendons still hurt; introduce light flexion and extension stretches when the pain drops by at least 75%.

Do your best to reduce the activity that precipitated the tendonitis for 2-3 weeks.

When you have cured yourself of the pain, implement the preventive strategies mentioned above so it never happens again.

Next Entries »

Stenosing Tenosynovitis

Carpal Tunnel Syndrome

Exercise for Thoracic Outlet Syndrome

What to Do if You Suspect You Have Thoracic Outlet Syndrome

How to Tell if Your Pain is from Arthritis

Wrist Pain and Treatment

The Ultimate Home Air Purifier

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