Osteoarthritis of the hands is caused by long-term motion in the joints. A joint is any location where two bones meet, and move back and forth adjacent to each other. The joints are covered by cartilage, and are housed inside a joint capsule, where synovial fluid lubricates the joints for smooth movements. As our bodies mature, the cartilage becomes thinner, wearing out the joints, which leads to arthritis slowly developing. In a normal joint, cartilage does not contain nerve endings so movement is not painful. However, as cartilage wears away, and the bone, which is rich with nerve endings, is exposed, movements become painful. This is where the term “bone on bone” arthritis comes from. This can lead to inflammation of the joints, and clients generally report symptoms of pain and stiffness in the morning, that gradually worsens throughout the day. Additionally, previous injuries to the joint such as a fracture or dislocation can cause arthritis to develop. Diagnosing osteoarthritis involves communicating with your doctor, that the joints are painful, x-rays may then be taken to confirm the diagnosis and determine severity. Although osteoarthritis is not reversible, because all moving parts will eventually wear out, therapy is integral to helping clients continue to perform activities of daily living or (ADL’s). Performing non-painful movements under the guidance of a hand therapist, will allow for lubrication of the joints, which will help reduce symptoms, because motion is lotion for the joints.
Basilar Joint Arthritis, or arthritis that occurs at the base of the thumb, is common considering 40% of hand motion occurs at this joint. A small wrist bone called the trapezium, and the first bone in the thumb called a metacarpal form the base of the thumb. Symptoms of basilar joint arthritis, or arthritis of the first CMC joint includes weakness and pain, difficulty gripping & pinching, and difficulty with motions that involve turning, such as opening a jar, using a key, or turning a doorknob. Weather changes can also cause the thumb joint to become painful. Symptom development can begin as early as age 40, and women are more commonly affected than men. Treatment options involve receiving an anti-inflammatory medicine, or injection, resting the thumb, with use of splint either prefabricated or customized by a hand therapist, and therapy to address the symptoms. If conservative management is not successful, surgical options may be performed such as reconstruction of the basilar joint, to replace the worn out bone.
Carpal tunnel syndrome is the most common type of nerve compression that occurs in the upper extremity. The median nerve passes through a tunnel in the wrist that is made up of wrist bones and a tough ligament that forms the roof of the carpal tunnel. In this tunnel, the median nerve and nine flexor tendons pass from the forearm into the hand. When the pressure in this tunnel builds up from swelling, it puts pressure on the nerve. The pressure from the swelling causes the median nerve to be disrupted, and clients will often complain of numbness, tingling, swelling, and pain in the hand and fingers that worsens at night. These symptoms can cause a decrease in strength and ability to perform fine motor activities. In severe cases, clients will report complete loss of sensation in the thumb, index, middle finger, and half of the ring finger.
About 50% of all carpal tunnel cases occur between 40 to 60 years of age, with women, more often diagnosed, than men. A common misconception is that it is caused by frequent computer use, only. However, many conditions can cause this pressure build up including hypothyroidism, gout, rheumatoid arthritis, and diabetes. Pregnancy can also cause an increase in fluid in the carpal tunnel. Treatment starts with explaining symptoms to your doctor, and may require Electrodiagnostic studies, or nerve conduction study (NCS) and electromyogram (EMG). These tests will help determine the severity of the nerve compression. Conservative treatment options are often indicated primarily, and may include splinting, use of anti-inflammatory medicines, or receiving an anti-inflammatory injection into the carpal tunnel, as well as therapy to address the symptoms of carpal tunnel. In severe cases, non-surgical treatments may not be as successful to address the symptoms, and surgical management may be necessary. Hand therapists are trained to manage both conservative and non-conservative approaches.
Cubital Tunnel Syndrome, is the second most common type of nerve compression in the upper extremity, where the ulnar nerve becomes trapped or pinched. The ulnar nerve travels from the upper arm behind the medial or inner part of the elbow through the cubital tunnel, and is held tightly against the bone by a ligament. It is often bumped, causing a twinge of discomfort, and is referred to as the “funny bone.” Cubital tunnel syndrome is caused by activities that require excessive prolonged bending of the elbow, which then cause this nerve to become irritated and inflamed. For example, resting your elbow on a table for a prolonged period of time, can place direct pressure on the ulnar nerve. Clients will report a dull ache in the inside part of the forearm, as well weakness in the hands, because this nerve is responsible for controlling some of the muscles in the forearm, wrist, and hands. Additionally, the ulnar nerve controls sensation to the ring and pinky fingers, and may cause numbness and tingling to occur. Treatment involves a thorough examination by a doctor, and may require an Electrodiagnostic studies, or nerve conduction study (NCS) and electromyogram (EMG). These tests will help determine the severity of the nerve compression. An elbow pad may be provided for protection of the nerve, to be worn throughout the day, and at night. Education of positions to avoid, as well as a customized therapy program to create space, slack, and stretch of the nerve is also essential to address cubital tunnel syndrome. If conservative treatment options are unsuccessful, your physician may recommend surgery where the ulnar nerve is relocated to the front of the elbow.
Tendons are cord like structures that hold muscles to the bones. Tendons can become inflamed and swollen, which causes friction, and ultimately causes the tendon to not glide smoothly. Two common types of tendonitis injuries are listed below:
De Quervain’s pronounced (de kar vans’) Tenosynovitis (ten o sin o vi’ tis) a type of tendinitis or inflammation of the tendons located in the thumb, specifically the first dorsal compartment. This is caused by performing new, repetitive activities with the wrist and hand such as gardening, writing, weightlifting with poor body mechanics, and knitting. The first dorsal compartment involves the abductor pollicis longus and extensor pollicis brevis, the muscles that help control abduction, moving the thumb away from the hand, and extension of the thumb. New mothers are also predisposed to this type of tendonitis, due to hormonal fluctuations, and awkward hand positioning when caring for a child. Symptoms include pain on the thumb side of the wrist, as well as swelling and tenderness. In some cases, a catching or snapping may occur, when the thumb is being moved. Having the client make a fist, with the fingers clasped over the thumb, and bending the wrist in the direction of the little finger confirms this diagnosis, because this maneuver will be quite painful. De Quervain’s is conservatively managed, with the use of a splint to rest the inflamed tendons, modalities, to alleviate symptoms of pain and inflammation, stretching exercises, and gradual strengthening. Education on proper body mechanics is also an essential part of treatment, and will be discussed by your therapist on a case-by-case basis. Anti-inflammatory medications may also be used to address symptoms, as well as Cortisone injections. Surgical management is only needed occasionally, and involves releasing the ligament where the tendons move, which will reduce the pressure, and alleviate the pain.
Trigger Finger or Trigger thumb (Stenosing tenosynovitis) is a condition that causes the tendons in your hand to click when your fingers or thumb are bent. The tendons are long ropelike structures that connect the muscle to the bones of the fingers, and thumb. The finger is comprised of a series of rings that create a tunnel or tendon sheath, for the tendons to glide, similar to the guides on a fishing rod, where the line or tendon passes through. As a muscle contracts or tightens, it pulls the tendons through this tunnel. If the tendon is not inflamed it fits perfectly through the tendon sheath. However, when a tendon becomes inflamed, it can create swelling or a knot to form, causing the tendon to become locked or trapped. When the tendon is trapped a popping or catching occurs as the swollen tendon passes through. This “triggering” worsens with the severity of the inflammation of the tendon. The direct cause of trigger finger is not always clear, but may be due to medical conditions such as rheumatoid arthritis, gout, and diabetes. Trigger finger or thumb, may also be caused by a direct trauma. Symptoms initially begin with pain in the palm or base of thumb, followed by triggering or locking when bending the finger or thumb, and in extreme cases the finger may completely lock up requiring surgical intervention. Treatment involves eliminating the locking or catching, and to allow for full pain-free movement, and may include the use of Cortisone injections, or anti-inflammatory medication. Hand therapy can address both conservative & post-operative management of this diagnosis. Conservatively, clients will be educated on positions to avoid, use of modalities to reduce symptoms, splinting, and activity modifications. Post-operative management involves scar management, use of modalities, and therapeutic exercises to ensure proper glide of the flexor tendons implicated with trigger finger or thumb.
Dupuytren’s disease (du-pa-trenz) is an abnormal thickening of tissue under the skin of the palm, called fascia. The disease begins with firm lump development in the palm that progresses into cord formation that develops beneath the skin, and stretches from the palm into the fingers. These cords can cause the fingers to contract and be drawn into the palm. The deeper structures of the hand such as the tendons, are not directly involved. The disease will also cause thickening to occur on the top of the finger knuckles and pads. Clients will report inability to lay palm flat on a table or any even surface. In severe cases, the fingers may be contracted into the palm, that normal hand use is not possible. For example, clients report difficulty washing hands, shaking hands, placing a hand in the pocket, and wearing gloves. The ring and little finger are most commonly involved, but any of the fingers can be affected.
Although there is no direct cause of Dupuytren’s, the typical client is a man from Northern European descent, over the age of 40. More men, then women develop Dupuytren’s, and the disease generally appears after an injury to the hand. Women generally develop the disease later in life, during their 60’s, and progression of symptoms is less severe. Treatment options depend upon the severity of the disease, as there is no permanent cure. One form of treatment is an injection of cortisone, a strong anti-inflammatory medicine, given in the early stages. However, with more severe cases surgical intervention may be indicated, and your doctor will determine the most appropriate surgical approach. Splinting and hand therapy are often required to maximize and maintain finger extension and function.
Ganglion cysts are the most common soft tissue tumors of the hand and wrist. The onset of these cysts may be sudden or slow and they can resolve spontaneously. These cysts are not cancerous and do not spread. If the mass is on the palm side of the hand it is called a retinacular cyst, and when they appear on the top joint of the nail, they are called mucous cysts, and are common with arthritic conditions. Symptoms involve pain with ganglion cyst formation, and occur when the fluid pushes out of a joint or tendon. Cyst formation may also occur after an injury to a tendon or tendon sheath. Soft tissue begins to push out of the tendon sheath, and as the tear heals, it traps soft tissue outside the joint. As the soft tissue releases the fluid the cyst expands. Women have more ganglions then men, and the cysts appear most often in the second through fourth decades of life, but they can develop at any age, and pediatric cases are not rare. A ganglion cyst that forms on the back of the hand, along the carpal or wrist bones, specifically between the scaphoid and lunate, are the most common type. Ganglion cysts on the palm side of the hand along the scaphoid, are the second most common type. Aspiration, or removal of the fluid is commonly performed to address the cyst. Surgery is recommended when a ganglion cyst is symptomatic or causes nerve compression or pain. Therapy is indicated in cases where motion was limited, and activities of daily living have been compromised.
Distal Radius Fracture: Fractures of the distal radius, are quite commonly seen, as placing your hand out during a fall, or falling on your outstretched hand, or a (FOOSH) injury, is a protective response. This results in a fracture or “break” of the radius, a bone located in your forearm, along the thumb and wrist. Fractures of the distal radius are managed either conservatively or post operatively. Conservatively, the bone is healed via use of a cast to immobilize the healing bone. The goal of therapy, after the cast is removed is to restore motion, strength, and function to promote independence with activities of daily living (ADL’s). Surgical management involves reducing or shortening the bone, and then fixating the bone with the use of a plate and screws. Clients are often referred to therapy 4-6 weeks post-surgery, where they are instructed in active range of motion exercises, strengthening activities, and scar management. Functional activities, unique to each individual are incorporated into your care, during your hand therapy treatment.
Carpal bone fractures: Fractures of the bones that compromise the wrist are quite common, and are most often seen with the scaphoid. This bone fracture or “break” can either be managed conservatively or with surgical intervention, depending upon the location of the fracture. This bone is important with the motion of the wrist, and requires skilled competent care to ensure future arthritic or avascular, (decreased blood supply) changes do not occur. Your physician will assess the severity and location of the fracture which will help determine the type of therapeutic intervention required. Although the scaphoid is mostly commonly fractured, other carpal or wrist bones may also break. For example, the triquetrum, is the second most commonly fractured bone, followed by the hamate, which can fracture during racquetball sports, or golf.
Triangular fibrocartilage complex or (TFCC) injuries are quite common, and occur from direct trauma or overloading the wrist towards the pinky. The TFCC, is equivocal to the meniscus located in your knee, and acts as a shock absorber for the wrist. It is composed of cartilage and ligaments that help stabilize the wrist. Injuries to the TFCC, can cause decreased grip strength, and decreased ability to perform activities of daily living. Your doctor will assess the severity of your TFCC injury, with various tests, and choose either conservative or surgical intervention to manage your injury. Hand therapy is an important aspect of treatment of these types of injuries. Treatment involves educating clients on positions and activities to avoid that would exacerbate symptoms which could include pain with rotation of the forearm, and with sustained gripping. Additionally, prefabricated or customized splinting will also help rest this structure as it heals. Interventions for post-surgical management include, active range of motion, scar management, and strengthening when an appropriate time of healing has taken place.
Injuries to the tendons of the hand are quite common, and can occur through a direct trauma, or over time due to wear and tear. The tendons connect the muscles to the bones, and provides the hand the ability to function by performing grasp and release. The flexor tendons located on the palm of the hand, help bend the wrist and fingers to grasp, and the extensor tendons on the back of the hand, help extend the wrist and fingers to release objects.
Extensor Tendon injuries are quite common in mature adults with arthritic conditions that can cause attritional ruptures of the extensor tendons, or wear and tear. Tendons of the hand are an integral part to the function of the hand, and when a tendon is injured, it can no longer perform the motion it is designed to perform. After surgical intervention, management varies depending upon the location of the lacerated tendon, but may involve the use of customized splints, worn while your tendons heal. The hand therapists at All-Care are trained in the creation of these customized splints, and can educate you on the healing timelines, in accordance with the care of your doctor. Clients will be instructed on proper protection of the healing tendon or tendons, wound management, range of motion, and strengthening activities, when appropriate.
Flexor tendon injuries, most often occur from a trauma to the palm of the hand, from a sharp object such as a knife, or sharp piece of metal. These injuries are serious and require the immediate attention of a skilled hand doctor, and therapist to manage your care. Depending upon the location, of injury, different structures including nerves, tendons, and arteries may be involved. Interventions include customized orthotics used for the protection of the healing tendon, education on healing timelines, wound management, appropriate therapeutic exercises to promote healing and gliding of the tendons, and strengthening activities when the tendon repair is healed.
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