Common Problems


 

Carpal Tunnel Syndrome

 

Ganglion Cyst

 

Plantar Fascitis

 

Cubital Tunnel Syndrome

 

Impingement Syndrome

 

Rheumatoid Arthritis

 

DeQuervain's Tendonitis

 

Lateral Epicondylitis

 

Thoracic Outlet Syndrome

 

Dupuytren's Disease Osteoarthritis

 

Trigger Finger

 

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome occurs when the median nerve becomes compressed as it runs from the wrist to the hand through a narrow bony passageway known as the carpal tunnel. The carpal tunnel is formed in the wrist by the eight carpal bones, which make up the floor and sides of the tunnel. The transverse carpal ligament stretches across the roof of the tunnel. There are nine flexor tendons which flex the fingers and thumb. The median nerve also runs through the tunnel delivering thousands of nerve fibers which supply sensation to the thumb, index, and middle fingers, and half of the ring finger. When the wrist or fingers bend or straighten, the median nerve comes in contact with the ligament. Carpal tunnel syndrome is caused by pinching of the median nerve due to increased pressure in the carpal tunnel. Blood flow to the nerve can become restricted when the median nerve is pushed up against the ligament. Symptoms include aching, pain, numbness or tingling in the fingers, muscle weakness, and sharp pains which may extend up the arm into the elbow, shoulder or neck. Lack of feeling in the affected hand may result in clumsiness and cause the person to drop objects. Symptoms often occur at night and may cause the individual to be awakened from sleep.

Carpal tunnel syndrome can be caused by numerous conditions, including wrist injury, arthritis, fluid retention during pregnancy and menopause, diabetes, hypothyroidism, and repetitive actions which involve repeated grasping and flexing of the fingers or wrist or prolonged use of power tools.

Conservative treatment involves rest of the hand and arm and avoidance of repetitive activities. A splint may be worn during the day until symptoms resolve, which may take 4-6 weeks. A cortisone injection may be given to decrease swelling and reduce pain. When non-operative management fails, surgery is recommended. An incision is made on the palm of the hand and the transverse carpal ligament is cut to relieve pressure on the median nerve. Blood flow returns to the median nerve, and symptoms are usually relieved after surgery.  There may be continued soreness at the site of incision for 4-6 weeks, and discomfort may be expected for several months. Normal grip strength may not return for several months. Regeneration of nerve fibers will occur over the course of six months to a year. Therapy may be prescribed to regain strength and increase motion of the fingers and hand

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Cubital Tunnel Syndrome

The ulnar nerve passes through a tunnel between the inside of the elbow and the tip of the elbow. The tunnel is covered with tissue to prevent the nerve from displacing with motion of the elbow. Cubital tunnel syndrome occurs when there is compression or injury of the ulnar nerve in the cubital tunnel. Almost everyone has experienced striking their “funny bone”, which easily demonstrates how the ulnar nerve can be directly injured. Chronic pressure to this area may produce swelling and inflammation within the cubital tunnel, which irritates the ulnar nerve. Over time, this may lead to the formation of scar tissue. The tissue covering the cubital tunnel may lose its ability to stabilize the ulnar nerve during elbow motion. The nerve then becomes exposed to repetitive trauma as it slides in and out of normal position.

Symptoms of cubital tunnel syndrome include intermittent numbness or tingling in the ring and little fingers of the affected arm. This may occur with prolonged flexion of the elbow or resting against the elbow. There may be an aching discomfort along the inner forearm or elbow. There may be a loss of sensation in the ring and little fingers if nerve damage persists. As it progresses, there is loss of pinch and grip strength.

In the early stages, symptoms may be alleviated by avoiding activities requiring prolonged or repetitive elbow motion. A long arm splint may be used to prevent elbow flexion at night. An elbow pad may be work during the day to protect the cubital tunnel from direct pressure. An oral anti-inflammatory medication may be helpful to alleviate symptoms.

When the symptoms fail to improve with non-operative management, surgery may be necessary to relieve the compression of the ulnar nerve.  Elevation and finger motion are important to prevent swelling. Additional elbow immobilization may be required up to 3 weeks following surgery. Therapy exercises are initiated and strengthening begins 4-8 weeks after surgery. Recovery from cubital tunnel surgery requires 2-3 months before resuming unrestricted use of the affected arm. Maximum benefits of surgery may not be seen for months, and in severe cases, complete recovery may not be possible. Early diagnosis and treatment are essential to prevent progression of this condition.

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DeQuervain's Tendonitis

DeQuervain’s tendonitis is a painful inflammation along the thumb side of the wrist. Tendons which pass over the back of the wrist help the muscles which extend or straighten the fingers and thumb, as well as lift the hand at the wrist joint. The tendons run through compartments under a thick layer of fibers, known as the extensor retinaculum or dorsal compartment ligament. The tendons for the APL (abductor pollicis longus) and EPB (extensor pollicis brevis) muscles run through the first dorsal compartment, which lies above the bony area at the base of the thumb. They are necessary for movement of the wrist, extension of the thumb away from the hand and formation of a strong grasp.

When inflammation occurs, the tendons may become swollen and constricted within the lubricated sheath which lines the dorsal compartment. This may be due to repetitive trauma or overuse of the wrist and hand. It is more common among women than men, particularly in mothers taking care of newborn infants. It occurs more frequently in individuals between the ages of 30 and 50, and those who perform activities with repetitive motion of the wrist and gripping with the thumb.

Patients usually present with swelling over the thumb side of the wrist. Motion is painful and worsens with use of the hand and thumb. Grasping and pinching are difficult. There also may be triggering of the thumb. A Finkelstein test is administered to make a definitive diagnosis of this disease. The patient flexes the thumb into the palm while making a fist. The wrist is then bent downwards. This is a very painful maneuver to a patient with DeQuervain’s tendonitis.

Initial treatment is by immobilization with a thumb spica splint and/or anti-inflammatory medication. Injection of steroid and lidacaine into the inflamed area may also help to decrease the inflammation and reduce the symptoms. More than one injection may be necessary for relief. If the symptoms fail to respond to treatment, surgical release of the compartment is usually necessary and performed on an out-patient basis. An exercise program for the thumb and wrist is important. Most patients can expect resolution of symptoms within 2 to 4 weeks.

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Dupuytren’s Disease

Dupuytren’s disease is the thickening of the fascia, or tissue between the skin and the tendons in the palm of the hand. A cord may form which extends from the palm into the fingers. It can cause the fingers to bend into the palm so that they cannot be fully straightened. Once this contracture occurs, it may progress to a severe deformity of one or several fingers.

The cause of Dupuytren’s contracture is not known. It develops more commonly in men than women after the age of 40. It is usually hereditary and occurs in people of European descent. It may occur slowly, with the first symptom being a small lump or pit in the palm. It progresses when the palm cannot be placed flat on an even surface. This process is not malignant and involvement of both hands is common. It is usually not painful. It is sometimes associated with inflammation and thickening of the tissue on the sole of the foot.

Surgery is recommended to regain maximum hand function if there is a deformity which interferes with everyday activities. There is no cure for this disease. After surgery, thickening of the palm and development of the fibrous cord may return in the same place or new place within the hand. The procedure to remove the retracted fascia from underneath the palm and fingers is usually performed on an outpatient basis under a regional anesthetic. A zigzag incision is made in the palm which extends into the fingers. Many stitches may be required for closure of the wound. Skin grafts may be necessary to cover the open areas. A drain may be inserted to remove drainage from the hand. A splint may be used following surgery to keep the fingers straight. Our hand therapists will design a specific exercise program. Hand therapy will be necessary to monitor progress and improve joint mobility and finger motion.

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Ganglion Cyst

A ganglion cyst is a benign mass that develops in the hand. It is not associated with malignancy. It is a balloon-like sac filled with a jelly-like material. It can arise near almost any joint capsule in the wrist and hand. Ganglions may form near a weak place in the joint capsule, following trauma or degeneration of the tissue which lubricates the joint. The cyst forms an extension of the joint, allowing fluid to flow into the sac through a one-way valve. The ganglion becomes increasingly large and may limit motion or generate discomfort from compression of soft tissues. As they continue to grow, the patient is usually bothered by the unsightly appearance.

Asymptomatic ganglions are usually observed for a period of time before treatment is recommended. Cysts may change in size and disappear spontaneously. Aspiration of the ganglion may treat the condition and confirm diagnosis of the lesion. This involves numbing of the area with a local anesthesia, insertion of a needle to withdraw the fluid from the sac, and a dressing or splint may be applied. The ganglion may recur. Surgical Excision offers a more reliable method of treating the ganglion. This is performed on an out-patient basis under a local or general anesthetic. An incision is made directly over the area of swelling and the ganglion is removed. It may be necessary to excise a portion of the joint capsule from where the ganglion originated. A dressing is applied and hand therapy is initiated early to prevent stiffness and maintain wrist motion. Recovery ranges from two weeks for a small ganglion of the finger, to eight weeks for those involving the wrist.

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Impingement Syndrome 

The rotator cuff is comprised of 4 muscles that move the shoulder joint. They originate from the shoulder blade and evolve into tendons as they course to the outer part of the shoulder. These four tendons surround the front, back, and top of the shoulder joint. There is a lubricating tissue, which lies on the surface of the tendons to help them glide smoothly between the bone at the tip of the shoulder and the bone of the upper arm. The muscles contract to pull the tendons and move the shoulder during every day activities.

The rotator cuff may become injured by trauma, such as falling on an outstretched arm, or by repetitive overhead activities. This leads to swelling and inflammation of the tendons and surrounding tissue, which is referred to as impingement syndrome.

Pain is often the first sign that a problem exists. It frequently worsens at night, often interrupting sleep. There may be some weakness in the arm associated with severe pain. Diagnosis is made by physical exam and X-rays of the shoulder. An MRI may be recommended to rule out a rotator cuff tear.

Treatment includes rest from the offending activity and anti-inflammatory medication. An exercise program may be prescribed. Injection of cortisone into the space above the rotator cuff tendon may be helpful to reduce inflammation and pain. If conservative management fails, and the patient is unable to complete his or her work, perform daily activities, and has difficulty sleeping, surgery may be recommended.

An arthroscope may be inserted into the shoulder joint and will allow for visualization of the bone surface, ligaments and space beneath the rotator cuff. It will confirm that the rotator cuff is intact. The arthroscope can then be moved into the space above the rotator cuff. Using a small shaver, this procedure will allow for the inflamed tissue and any bone spurs to be removed, thus allowing the rotator cuff to move smoothly without impinging on the undersurface of the bone. This is performed on an outpatient basis and usually takes approximately an hour for completion.

A dressing is applied to the shoulder area and the arm is place in a sling for support during the first 24 hours following surgery. The dressing is removed after 48 hours. There may be some bruising and swelling, as well as a few stitches over the small incisions. Follow-up examination is usually done within 7-10 days. An exercise program developed by our therapy department will be initiated to regain motion and strength. Physical activity and heavy lifting may be delayed for several weeks. Return to pre-injury activities generally occurs in 8-12 weeks.

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Lateral epicondylitis

Lateral epicondylitis, also referred to as “tennis elbow” is a degenerative or traumatic tear of the tendons at their attachment to the bone. It is caused by repeated strain on the muscles of the forearm that extend the wrist and fingers. Repeated twisting or extension of the wrist during activities may strain these muscles and irritate their attachment at the bone on the outside of the elbow. This leads to pain, swelling, and a decreased ability to carry a heavy load with the arm extended. Nonoperative treatment includes rest from the offending activity, anti-inflammatory medications, physical therapy, and steroid injection. Operative treatment is reserved for failure of a thorough trial of nonoperative methods. An incision is made on the outside of the elbow. Degenerative tissue is removed. Blood supply may be improved by release the tendon at its attachment to the bone. Following surgery, the wrist and elbow may be immobilized by use of a splint for approximately 7 days. Passive motion is encouraged, but resisted wrist and finger extension are avoided. Strengthening exercises can be started at 4-6 weeks. Return to normal activities is encouraged by the third to fourth month. This technique results in an 85% rate of return to full activities without pain.

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Osteoarthritis

The most common form of arthritis is osteoarthritis, otherwise known as degenerative joint disease. Cartilage is present in the joints to cover the ends of articulating bones. In a normal joint, there is smooth, painless movement. However, osteoarthritis occurs when the cartilage layer wears out. Bone makes contact against bone, which destroys the joint.  Arthritis at the base of the thumb is noticeable during activities that involve pinch (opening jars and turning door knobs). Heavy use of the thumb may produce aching discomfort. Pinch strength diminishes as arthritis progresses, swelling may develop, and motion of the thumb becomes painful. Limited activities and rest is recommended as the first line of treatment, followed by use of anti-inflammatory medication, protective splint, and cortisone injection. When this fails, surgery may be performed to decrease pain and preserve motion in the thumb Post-operative care usually involves a wrist and thumb splint or cast for approximately 2-4 weeks of immobilization. Therapy is recommended four to six weeks following surgery.  Unrestricted movement of the thumb may be permitted 12 weeks after surgery. However, maximum benefits of surgery may not be achieved for up to one year.

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Plantar Fascitis

Within the foot lies a band-like ligament known as the plantar fascia. It makes the foot arch, and can be the source of great heel pain when it is stretched or torn. A bony heel spur may develop at the site where the fascia attaches to the heel bone. The nerve that travels under the heel bone may also become compressed.

The most common symptom of plantar fascitis is sharp pain in the bottom of the heel when placing weight on the foot, particularly during the first step in the morning.  Some patients may have pain throughout the day when walking or standing, while some patients report lessening of pain after walking.

The plantar fascia may become injured during excessive activity, improper shoes, flat feet, poor gait, or additional weight on the foot.

Stretching is recommended to alleviate pain and prevent future injury. Cushioning in the heel of the shoe may provide support for the arch and ease pressure off of the heel.  Pads may be inserted into the shoe to cushion the force of the heel as it hits the ground. Anti-inflammatory medication may be given to decrease inflammation and pain. A night splint may be used to prevent tightening of the plantar fascia during sleep and prevent injury in the morning. Improvement can often be seen within two to six months of treatment and activity modification. A walking cast, which will allow the tissues to heal in the proper position, may be recommended for patients who are affected with severe disease and have failed initial conservative therapy.

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Rheumatoid Arthritis

Rheumatoid arthritis is an inflammatory condition within the lining of the joints. Its symptoms usually include pain, swelling, and stiffness of the joints. It is distinguished from other forms of arthritis, like osteoarthritis, since it is caused by an inflammatory reaction. Blood flow increases in the inflamed area, causing heat and redness.  Fluid may accumulate and joints or tendons may become damaged.

The precise cause of rheumatoid arthritis is not known. It is believed to be a disease of the body’s immune system which causes a reaction to one’s own cells and tissues in the joints leading to inflammation. It may be genetic or have inherited susceptibility.

Rheumatoid arthritis is diagnosed based on the characteristic symptoms of the patient along with laboratory tests and X-rays. The wrists and many of the joints of the hands may be affected. It may also involve other joints, including the elbow, shoulders, neck, hips, knees, ankles, and feet. A blood test which identifies the substance called the “rheumatoid factor” may help in the diagnosis. Another blood test known as “ESR” – erythrocyte sedimentation rate – may be performed to assess the activity of this disease. X-ray’s may show patterns of joint damage or bone erosion.

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Thoracic Outlet Syndrome

Thoracic outlet syndrome is a condition involving the shoulder and upper arm. Symptoms usually include numbness and tingling of the fingers, often most severe in the third, fourth and fifth fingers and inner forearm. Pain starts at the base of the neck and radiates into the arm and/or hand.  Use of the arm aggravates pain and patients often complain of a "fatigued arm". Grip strength is also weakened.

It is caused by compression of the nerves or blood vessels in the brachial plexus. Activities such as carrying a heavy suitcase, frequent overhead lifting, and sleeping with arms above the head can increase the risk of this syndrome.

Diagnosis may be made during a thorough physical examination of the arm, shoulder and neck. A nerve conduction study and EMG may be used to confirm nerve abnormalities. An X-ray and/or MRI may be necessary to rule out other causes or symptoms.

Treatment includes physical therapy to relieve muscle tension and improve posture. Rest, modification of daily activities, anti-inflammatory medication, and/or steroid injections may be prescribed. If non-surgical treatment fails to relieve pain, surgery may be recommended.

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Trigger Finger

Trigger finger is a common disorder of the hand, which causes snapping and clicking in the fingers or thumb. This usually occurs when one bends or straightens the fingers or thumb. Sometimes, this may result in a digit locking either in a fully bent or straightened position. Prior to the actual development of “triggering”, there may be discomfort near the crease in the middle of the palm of the hand. Pain may also be felt directly beneath the affected finger or thumb.

Tendons that bend the fingers glide through a tunnel that holds them attached to the finger bones. This allows one to bend the fingers inward when making a fist or extend them to straighten the hand. The tunnel is lined with a thin membrane called synovium. This lining helps reduce friction as the tendons glide through it. Inflammation of the tendon leads to formation of lumps that catch as they pass through the narrow tunnel. The synovium may also become thickened, which reduces the amount of space for the tendons to pass.  Then the finger or thumb bends, the enlarged section of the tendon is pulled through a constricted space, which is accompanied by a painful snap. The finger or thumb may become locked in a bent position.

This condition may be the result of repeated grasping or prolonged use of equipment or tools that press on the area at the base of the finger or thumb. The tendons may become irritated, resulting in inflammation. Other conditions, such as gout, rheumatoid arthritis or diabetes may be associated with trigger finger.

Treatment consists of conservative and surgical methods. Unless the finger or thumb is in a locked, unmovable position, initial treatment usually involves modification of activities, possible restricted movement with a splint, oral anti-inflammatory medication, and/or injection of cortisone around the tendon to reduce swelling and alleviate symptoms.

In cases when this treatment fails, surgery to release the trigger finger is recommended. This involves enlarging the narrow section of the tunnel, which allows the inflamed tendons to freely glide back and forth resulting in normal motion. Surgery is performed on an outpatient basis under a local anesthetic. A light dressing is applied to the wound for protection while still allowing motion of the finger or thumb. Sutures are usually removed 10-14 days following surgery, and activities involving use of the affected hand may be restricted for 4-6 weeks.

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