Clinical Pattern Recognition - Wrist/Hand Pain

From anatomy to discovering the patient!

• Carpal tunnel syndrome is the most common upper extremity compressive neuropathy

  o 1 to 5% of general population

• There were 11,332 cases of DeQuervain’s tenosynovitis in the population at risk of 12,117,749 person-years

• Women had a significantly higher rate of DeQuervain’s tenosynovitis at 2.8 cases per 1000 person-years, compared to men at 0.6 per 1000 person-years

• Triangular fibrocartilage complex (TFCC) was torn in 46 of 118 patients with distal radial

  fracture

  o 35% of intra-articular fractures

  o 53% of extra-articular fractures

• In 59 hands with carpal tunnel syndrome, 34% also had ulnar tunnel (Guyon’s canal) neuropathy

See more prevalence information in the Clinical Pattern Recognition: Orthopaedics app here

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Clinical Pattern Recognition

Click on the pain pattern to learn about the patients and develop your clinical patterns!

1. Carpal Tunnel Syndrome- Hand Sensory Deficits (1-minute video)

2. DeQuervain’s Syndrome-Thumb Pain with Muscle Power Deficits (1-minute video)

3. Sprain of Carpal Ligaments–Wrist and Hand Pain with Movement Coordination Impairments (1-minute video)

4. Sprain of Ulnar Collateral Ligament of the Thumb- Thumb Pain with Movement Coordination Impairments (1-minute video)

5. Sprain or Tear of Triangular Fibrocartilage of the Distal Radius and Ulna- Wrist and Hand Pain with Movement Coordination Impairments (1-minute video)

6. Thumb Osteoarthritis- Thumb Pain with Mobility Deficits (1-minute video)

7. Ulnar Tunnel Syndrome or Entrapment Around Pisohamate Ligament- Hand Sensory Deficits (1-minute video)

8.  Wrist Osteoarthritis- Wrist Pain with Mobility Deficits (1-minute video)

Thumb Osteoarthritis

Thumb Pain with Mobility Deficits

• Do you or a family member have pain in your thumb? Do they complain of stiffness in the morning? Osteoarthritis of the thumb is commonly caused by injury, overuse injuries, or from a history of immobilization.  Look below for some things to consider!

  For more clinical findings click here!

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Anatomy

Image via Complete Anatomy by 3D4 Medical

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Special Tests

• A good clinical test you can use to check the integrity of the 1stCMC joint is the grind test. A positive test indicates osteoarthritis of the thumb. (Click image to watch 1-2 minute video) 

Treatment

 This technique can be used for both pain modulation and to help increase flexion range of motion in the thumb! (Click image to watch 1-2 minute video) 

Therapeutic Exercise

• This exercise can be used to help mobilize the thumb at home and help decrease pain.  (Click image to watch 1-2 minute video) 

Carpal Tunnel

Wrist Pain with Radiating Pain

• Do you or a family member have numbness and tingling in your hand? Does it get worse when you are typing at work or while you are driving? If that is true, there is a chance that they are suffering from carpal tunnel.  Carpal tunnel is caused from increased pressure put on the median nerve as it runs through the carpal tunnel. If a patient presents with carpal tunnel like symptoms it is important to look further up the chain and make sure that there are not proximal entrapment sites causing your patients problems. Look below for some things to consider!

  For more clinical findings click here!

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Anatomy

Image via Complete Anatomy by 3D4 Medical

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Special Tests

• Patients with carpal tunnel often report a lessening of symptoms when they flick their wrist back and forth. They commonly will complain of symptoms when sleeping at night, have numbness and tingling in their first two fingers, and have difficulty picking up small objects. (Click image to watch 1-2 minute video) 

Treatment

This technique can be to decrease entrapment of the median nerve in the carpal tunnel. Make sure to follow this treatment with neural flossing!  (Click image to watch 1-2 minute video) 

Therapeutic Exercise

• Nerve sliders can be used to decrease neural tension. Make sure to progress your patient to neural tensioners when appropriate. This exercise can be used to decrease sensitivity and improve mobility of the median nerve. (Click image to watch 1-2 minute video) 

DeQuervain's Syndrome

Thumb Pain with Muscle Power Deficits

• Patients with DeQuervain’s Syndrome often report burning pain around the dorso-radial aspect of the wrist and thumb often exacerbated by grasping and/or general wrist movements. Be on the lookout for a history of repetitive gripping, lifting or use of hand tools with the effected extremity! For more clinical findings click here!

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Anatomy

Image via Complete Anatomy by 3D4 Medical

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Movement Fault

• Many upper quarter syndromes, including DeQuervain’s Tenosynovitis, result from repeated faulty movements during work and/or hobbies. In order to better serve patients, it is imperative to understand the movements they perform regularly and address any problematic patterns. (Click image to watch 1-2 minute video)

Key Findings

Finkelstein’s test is an excellent provocation exam to help the clinician determine if DeQuervain’s is indeed present! (Click image to watch 1-2 minute video)

Treatment

• If the patient suffers from acute symptomology, soft tissue mobilization for pain modulation and gentle range of motion exercises should be considered for early intervention. (Click image to watch 1-2 minute video)

Therapeutic Exercise

•  In the case of sub-acute or chronic symptomology, research continues to supports the use of eccentric loading of pathological tendons. It should be noted that the mechanisms behind the benefits of eccentric tendon loading are still being debated.

• As always, address the patient as a whole. Pathology in one area could be a result of compensation for other areas of the kinetic chain!

Sprain of Carpal Ligaments

Wrist and Hand Pain with Movement Coordination Impairments

• If your patient presents to clinic after falling on an outstretched arm or has a history of repetitive/forceful use of the wrist, they may have incurred a sprain of the carpal ligaments! For more clinical findings click here!

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Anatomy

Image via Complete Anatomy by 3D4 Medical

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Key Finding

• Although other mechanisms such as repetitive forceful use of the wrist can potentially cause carpal ligament sprains, a history of falling on an outstretched hand significantly increases the likelihood of carpal ligament pathology! (Click image to watch 1-2 minute video)

Special Test

The scapholunate ligament is one of the more common injured carpal ligaments. With moderate sensitivity and specificity, the Watson test can help the clinician determine potential involvement! (Click image to watch 1-2 minute video)

Treatment

• If the patient suffers from acute symptomology then techniques such as wrist isometrics for muscle activation and pain gating may prove beneficial; however, if subacute mobility deficits arise then wrist mobilizations with movement (MWM) can help restore the lost motions! (Click image to watch 1-2 minute video)

Therapeutic Exercise

• Various ways exist to help strengthen the musculature, which cross the wrist joint. Here is an example of wrist flexion and extension strengthening using a flexbar! This technique not only allows for strengthening, but can also help with range of motion! (Click image to watch 1-2 minute video)