Know Your Body
DEQUERVAINS TENOSYNOVITIS
INCIDENCE
It is second most common entrapment tendinitis of the hand and wrist with prevalence being 8-17%.
It is 10 times more frequent to be found in women heath symptoms as compared to men. The condition is most common between 30-50 years of age.
ABOUT THE CONDITION
- De Quervain tenosynovitis is an entrapment tendinitis of the tendons contained within the first dorsal compartment at the wrist.
- The tendons of the abductor pollicis longus and the extensor pollicis brevis are tightly secured against the radial styloid by the overlying extensor retinaculum. Any thickening of the tendons from acute or repetitive trauma restrains gliding of the tendons through the sheath.
- Movements at the thumb, especially when combined with radial or ulnar deviation of the wrist, cause pain and perpetuate the inflammation and swelling, tender to touch.
- Causes may include chronic overuse injury, direct trauma leading to scar tissue formation, or inflammatory arthritis.
TREATMENT
- Thumb spica brace (if needed) reduces pain by immobilizing the thumb and the wrist joint, thereby preventing thumb metacarpo-phalangeal joint flexion and wrist ulnar deviation.
- Icing to reduce swelling and tenderness
- Ultrasound therapy
- Soft tissue releases for the forearm muscles to relax them and enhance drainage of fluid from the muscle tissue.
- Along with increasing control of the wrist muscles, eccentric exercises will also assist soft tissue mobilization and promote healing.
- Daily activity modifications are required on a long term basis to allow for neutral wrist positioning.
- Sometimes corticosteroid injection is delivered into the first dorsal compartment if the pain is severe.
- Surgical release of first dorsal compartment needs to be performed if the pain doesn’t subside with conservative management.
- Postoperative physiotherapy is started 2 weeks post-surgery which includes improving range of motion, scar and edema management.
- Strengthening and return to functional activity is gradually started after 4 weeks of surgery.
References-
DEQUERVAINS TENOSYNOVITIS
INCIDENCE
Commonly associated with sports which involve weight bearing through wrist (gymnastics) or involving repetitive radial and ulnar deviation of the wrist (javelin throwers, discus throwers).
Attritional tears or degenerative pathology involving the TFCC are common, with a reported incidence of tears being greater than 50% of those over the age of 60 years.
It is estimated that TFCC injury occurs in up to 80% of displaced distal radius fractures.
ABOUT THE CONDITION
- Triangular fibrocartilage complex suspends distal radius and ulnar carpus from distal ulna. It is the major ligamentous stabilizer of the distal radioulnar joint (DRUJ) and the ulnar carpus.
- Causative factors for TFCC injuries are
- Ulnar deviation with load compression on TFCC (fall on an outstretched hand)
- Forced ulnar deviation (swinging a racket or bat)
- Commonly associated with positive ulnar variance (this is when the joint surface of ulna at the wrist joint is more longer than the joint surface of radius) which occurs mostly post-surgery or post fracture.
- Patients mostly presents with:
- ulnar-side wrist pain
- frequently accompanied by clicking
- weakness in grip and instability
- X-rays may reveal any avulsion fractures associated with injury and MRI is highly recommended with high sensitivity and specificity for identification of tear.
TREATMENT
- Initial treatment consists of rest and icing.
- Conservative treatment for 6 months is advisable if there is no instability.
- Dry needling the TFCC helps to reduce pain.
- Gradually proceeding to muscle activation and strengthening followed by stability and proprioceptive exercises in order to regain functional activities.
- If congenital ulnar variance is present, conservative management is started after 18years of age (i.e. post complete bone maturation) which includes improving stability in the wrist joint.
- Strengthening the shoulder girdle will help to off load the load on the wrist
- If conservative management fails, surgery is considered.
- Depending on the cause of injury the type of surgery will vary which includes arthroscopic repair, arthroscopic debridement, ulnar shortening, and the Wafer procedure.
- Corticosteroid injections are also preferred in some cases.
- Length of physiotherapy varies from 4 to 16 weeks depending on surgeon’s preference.
- Activity modifications are required on a long term basis.
References-
CARPAL TUNNEL SYNDROME
INCIDENCE
- The estimated prevalence of CTS is 4-5% of the population.
- CTS usually affect people between 40 and 60 years.
ABOUT THE CONDITION
- Carpal tunnel syndrome (CTS) is a condition in the wrist. It is caused by compression, traction, pinching, squeezing or irritation of the median nerve, while it runs through the transverse carpal ligament.
- The median nerve runs from the forearm to the palm side of the hand. It controls sensations to the palm side of the thumb and fingers, except for the little finger. It also allows the fingers and thumb to move.
- The CT is very rigid and narrow, so a little swelling of the tendons causes a lot of compression on the median nerve.
- The carpal tunnel syndrome generally starts with tingling or numbness in the thumb, the index finger, the middle finger and the lateral half of the ring finger. This sensation often appears while holding an object like a phone or steering wheel.
- Symptoms develop gradually, as the disorder progresses, the feeling of tingling or numbness may become constant and patients may complain of burning pain. The final symptoms are weakness and atrophy of the muscles at the base of the thumb.
- Probable risk factors for CTS include age, gender, diabetes , hypothyroidism , obesity , family history of CTS , menopause and concurrent pathologies such as rheumatoid arthritis. Also tobacco consumption and smoking can be risk factors.
- Diagnostic procedure like EMG/NCV studies can determine if there is any muscle damage and can rule out other conditions.
TREATMENT
- Splint and activity modifications
- Soft tissue release or dry needling of the muscles along the course of the nerve to relieve the compression on the nerve is done.
- Neck joint mobilization to reduce neck stiffness which will help to free the nerve root.
- Median nerve gliding exercises are required to mobilize the nerve.
- Rigid taping for the wrist for relief in acute stage.
- Strengthening of scapular and wrist muscles to reduce the load on the muscles entrapping the nerve.
References-
DEQUERVAINS TENOSYNOVITIS
INCIDENCE
It is second most common entrapment tendinitis of the hand and wrist with prevalence being 8-17%.
It is 10 times more frequent to be found in women heath symptoms as compared to men. The condition is most common between 30-50 years of age.
ABOUT THE CONDITION
- De Quervain tenosynovitis is an entrapment tendinitis of the tendons contained within the first dorsal compartment at the wrist.
- The tendons of the abductor pollicis longus and the extensor pollicis brevis are tightly secured against the radial styloid by the overlying extensor retinaculum. Any thickening of the tendons from acute or repetitive trauma restrains gliding of the tendons through the sheath.
- Movements at the thumb, especially when combined with radial or ulnar deviation of the wrist, cause pain and perpetuate the inflammation and swelling, tender to touch.
- Causes may include chronic overuse injury, direct trauma leading to scar tissue formation, or inflammatory arthritis.
TREATMENT
- Thumb spica brace (if needed) reduces pain by immobilizing the thumb and the wrist joint, thereby preventing thumb metacarpo-phalangeal joint flexion and wrist ulnar deviation.
- Icing to reduce swelling and tenderness
- Ultrasound therapy
- Soft tissue releases for the forearm muscles to relax them and enhance drainage of fluid from the muscle tissue.
- Along with increasing control of the wrist muscles, eccentric exercises will also assist soft tissue mobilization and promote healing.
- Daily activity modifications are required on a long term basis to allow for neutral wrist positioning.
- Sometimes corticosteroid injection is delivered into the first dorsal compartment if the pain is severe.
- Surgical release of first dorsal compartment needs to be performed if the pain doesn’t subside with conservative management.
- Postoperative physiotherapy is started 2 weeks post-surgery which includes improving range of motion, scar and edema management.
- Strengthening and return to functional activity is gradually started after 4 weeks of surgery.
References-
GOLFERS ELBOW
INCIDENCE
Golfers elbow accounts for 0.4% of the population. It usually occurs between the age group of 40- 60, and is much less common than tennis elbow. Women and men are equally affected.
ABOUT THE CONDITION
Risk factors in athletes includes
Training errors which includes
Improper technique, equipment,
Functional risk factors includes lack of strength, endurance, or flexibility.
Occupation-related risk factors includes heavy physical work, excessive repetition, smoking, the presence of comorbidities, and high psychosocial work demands.
Aching pain on the inner side (medial) of the elbow
Sometimes radiating pain from the epicondyle down into the forearm and wrist
Often insidious in nature
Pain increases with forearm motion, gripping, or throwing.
In athletes, this includes overhead throwing, forearm tennis stroke, or golf swing.
Pain resolves with rest or discontinuation of activity.
Elbow stiffness, weakness, numbness, or tingling most common in an ulnar nerve distribution.
More chronic presentations may report weakness with grip strength.
TREATMENT
- This is mostly managed non-surgically.
- Initially cessation of aggravating activities or decreasing their volume, frequency, or intensity is advised.
- Icing to reduce inflammation and pain in and around the joint during acute stage and post activity.
- Tightness in the extensor muscles causes an overload on the flexors while moving the wrist. So release of the extensor muscles using dry needling or myofascial release helps to reduce pain while movement.
- Isometric exercises provide analgesic effect for around 40 minutes post exercises. Later concentric and eccentric exercises can be added.
- If conservative management of 6 months fails, steroid injections are given.
To prevent recurrence, strengthening of shoulder girdle muscles and correcting the movement patterns can be added.
PROLAPSED INTER-VERTEBRAL DISC(PIVD)
INCIDENCE
1% to 3% with the highest prevalence among people aged 30 to 50 years, with a male to female ratio of 2:1.In individuals aged 25 to 55 years, about 95% of herniated discs occur at the lower lumbar spine (L4/5 and L5/S1 level); disc herniation above this level is more common in people aged over 55 years.
ABOUT THE CONDITION
PIVD is a condition in which disc between the two vertebrae bulges/protrudes out leading to compression of spinal cord or nerve.
The human spine is made up of alternating vertebrae and intervertebral discs extending from the neck to the tail bone. The intervertebral discs are the ‘shock absorbers’ of the body and are composed of an outer strong fibrous membrane and an inner ‘jelly-like’ nucleus giving both strength and elasticity. A disc prolapse occurs when there is weakening in the outer membrane which leads to a protrusion of the inner nucleus. This protrusion usually heads towards the spinal canal thus compressing them giving rise to the symptoms.
Disc herniation can occur in any disc of the spine, but the two most common site are lumbar disc herniation and cervical disc herniation
As we grow older, our intervertebral discs begin to lose water content. However, several other factors may encourage or exacerbate prolapsed discs in both the young and the elderly, such as:
Repeated improper movements that place stress upon the spine, often due to sports, improper lifting and even sitting or sustained postures for prolonged period of time. Sudden injuries or traumas that might occur during a high-impact sport, fall or car accident Sedentary lifestyle Symptoms include mild to severe back pain which can be caused by muscle spasm and may radiate to leg due to nerve irritation. In case of cervical disc herniation in can radiate to the hand. There may be pins like sensations, tingling, numbness, burning , pully like sensation and weakness in the affected area. In severe cases there may be bladder and bowel incontinence and weakness/paralysis of the muscle supplied by that particular nerve root.
Physical assessment along with an MRI scan can confirm the diagnosis.
The human spine is made up of alternating vertebrae and intervertebral discs extending from the neck to the tail bone. The intervertebral discs are the ‘shock absorbers’ of the body and are composed of an outer strong fibrous membrane and an inner ‘jelly-like’ nucleus giving both strength and elasticity. A disc prolapse occurs when there is weakening in the outer membrane which leads to a protrusion of the inner nucleus. This protrusion usually heads towards the spinal canal thus compressing them giving rise to the symptoms.
Disc herniation can occur in any disc of the spine, but the two most common site are lumbar disc herniation and cervical disc herniation
As we grow older, our intervertebral discs begin to lose water content. However, several other factors may encourage or exacerbate prolapsed discs in both the young and the elderly, such as:
Repeated improper movements that place stress upon the spine, often due to sports, improper lifting and even sitting or sustained postures for prolonged period of time. Sudden injuries or traumas that might occur during a high-impact sport, fall or car accident Sedentary lifestyle Symptoms include mild to severe back pain which can be caused by muscle spasm and may radiate to leg due to nerve irritation. In case of cervical disc herniation in can radiate to the hand. There may be pins like sensations, tingling, numbness, burning , pully like sensation and weakness in the affected area. In severe cases there may be bladder and bowel incontinence and weakness/paralysis of the muscle supplied by that particular nerve root.
Physical assessment along with an MRI scan can confirm the diagnosis.
TREATMENT
Medical treatment would include muscle relaxants, anti-inflammatory , analgesics(pain-killers), tricyclics for nerve pain.
Physiotherapy management would include :
In acute state complete rest with medications for 3-5 days.
Bracing with lumbar corset or rigid tape to support weak or tight muscles which are in spasm.
Dry needling of the tight paraspinals or surrounding muscles.
Joint mobilisation to improve thoracolumbar junction there by relieving the overload off the lumbar spine.
Lumbar core muscles activation which includes transverses abdominis , pelvic floor muscles and lower abdominal in case of lumbar PIVD.
In case of cervical PIVD activation of cervical core and relaxation of superficial muscles like sternocleido mastoid and sceleni.
Improve breathing pattern without using neck muscles.
Neural mobilisation to improve nerve mobility.
Gradual return to activity.
OA: OSTEOARTHRITIS
Osteoarthritis is the most common form of arthritis, affecting millions of people worldwide. It occurs when the protective cartilage on the ends of your bones wears down over time. Although osteoarthritis can damage any joint in your body, the disorder most commonly affects joints in your hands, knees, hips and spine. Risk factors for developing OA include age, female gender, obesity, anatomical factors, muscle weakness, and joint injury (occupation/sports activities).
Classically, OA presents with joint pain and loss of function; however, the disease is clinically very variable and can present merely as an asymptomatic incidental finding to a devastating and permanently disabling disorder. The presentation and progression of OA vary greatly from person to person. The triad of symptoms of OA is joint pain, stiffness, and locomotor restriction.
Patients can also present with:
Muscle weakness and balance issues pain hampers activity and resolves with rest Swelling Joint deformity and instability (patients complain that joint is “giving way” or “buckling,” a sign of muscle weakness).
Classically, OA presents with joint pain and loss of function; however, the disease is clinically very variable and can present merely as an asymptomatic incidental finding to a devastating and permanently disabling disorder. The presentation and progression of OA vary greatly from person to person. The triad of symptoms of OA is joint pain, stiffness, and locomotor restriction.
Patients can also present with:
Muscle weakness and balance issues pain hampers activity and resolves with rest Swelling Joint deformity and instability (patients complain that joint is “giving way” or “buckling,” a sign of muscle weakness).
TREATMENT
- Symptoms can usually be effectively managed, although the underlying process cannot be reversed. Staying active, maintaining a healthy weight and other osteoarthritis treatment slows progression of the disease and help improve pain and joint function
- Icing for 20 mins atleast 3-4 times a day, in order to numb the pain and reduce swelling and inflammation around the knee
- Kinesiotaping for support of patella and activation of the muscles around it
- Dry Needling/ Myofascial release to relax the tight Vastus lateralis, internal rotators of hip and knee; as well as to activate the glutes and VMO
- Strengthening exercises of weak and stretching of tight muscles around the knee (Vastus medialis obliquus, Vastus lateralis, hamstring), hip (Iliopsoas, TFL, Gluteus medius and maximus, piriformis) and core (Transverse abdominis)
Prognosis:
CERVICAL AND LUMBAR SPONDYLOSIS
The term spondylosis is used to define a generalized natural ageing process. Cervical and lumbar spondylosis results from the process of degeneration of the intervertebral discs and facet joints of the cervical and lumbar spine. Biomechanically, the disc and the facets are the connecting structures between the vertebrae for the transmission of external forces. They also facilitate cervical spine mobility.
On radiological finding, 90% of men older than 50 years and 90% of women older than 60 years have evidence of degenerative changes in spine. 70% Of individuals may show bad changes on X- ray but are asymptomatic. Sex ratio reports have been variable but are essentially equal.
Symptoms:
Cervical spondylosis:
Cervical radiculopathy – Pain most often occurs in the cervical region, the upper limb, shoulder, and/or interscapular region, numbness, heaviness, weakness in upper limb, reduced grip strength
Lumbar spondylosis:
Neurologic claudication, which includes: lower back pain, leg pain, numbness, heaviness, weakness when standing and walking
Treatment:
- In the acute phase, taping can be done to offload the overused structures
- Spinal mobilization to improve mobility of the spinal segments, thus improving overall mobility
- Dry needling and stretching of paraspinals to relax the tight muscles around neck and back
- After a detailed postural examination, the patient will be taught basic posture correction exercises program to correct the postural deviations caused by muscle weakness or tightness
- Strengthening exercises for the scapula retractors, sub-occipitals, core, transverse abdominis and gluteal muscles, as these muscles provide support and stability to the spine
- In case of any neural symptoms, neural mobilization helps in improving nerve mobility and pliability
- In severe cases, surgery needs to be done after which post-surgery rehabilitation is necessary