Stretching

Longitudinal Stretching with Osteoarticular Decoaptations

By Warren Hammer, MS, DC, DABCO

Imagine being able to create a fascial stretch that localizes tension to a particular spinal level. Frenchman Guy Voyer,MD,DO, has created and used such stretches since 1977 with great success. 
For patients to perform these stretches, it is necessary for them to develop an awareness of the specific positions. The patient must "engage in a posture that aims at a specific vertebral level in reference at all times to both a fixed and mobile reference, which, when placed under a self-induced tension, results in a precise osteoarticular decoaptation."

According to Dr. Voyer, the local effects of this stretch are zygopophyseal separation, imbibition of the disc, increased venous return, normalization of muscle tone (by extreme eccentric contraction), proprioceptive facilitation of the paraspinal muscles, and improved kinetic sense. General effects from this procedure include normalization of myofascial tensions, decreased psychomotor barriers, and an increased well-being. Putting the myofascial chains around a primary lesion (the local spinal decoaptation) into tension will result in an increase in postural normalization. Patients report that after this type of stretch, not only do their back pains decrease, but other symptoms also improve.

The author demonstrates the T10-T11 stretch.

The accompanying photo shows the position for a specific stretch for the T10-T11 disc level.
These stretches are not easy to perform. Several visits are required to make sure the patient is in the correct posture. For some spinal segments, the patient cannot create the total stretch at first, but over time it may be accomplished. Inability to perform the stretch is sometimes valuable in finding where other fascial/structural problems may be located.

The right hip is flexed straight back as far as it can go. The right foot is resting on the heel in dorsiflexion and eversion. The left lower extremity is stretched out at 45 degrees with the foot dorsiflexed and inverted. The shoulders and spine are pressing against the wall. The right arm is fully extended vertically with the wrist dorsiflexed, and the arm and hand externally rotated. The chin is retracted and the head is extended vertically. All stretching and extending is done to the maximum and held for a minute. In this position, if everything is correct, the patient will feel the tension specifically at the T10-T11 level. Good luck.

wrist

Lunate and Perilunate Dislocations

By Deborah Pate, DC, DACBR

There are three smooth arcs which can be identified on the dorsovolar view of the normal wrist. Figure 1 demonstrates the three arcs that should be evaluated when assessing the wrist for dislocations. The common dislocations in the wrist are lunate, perilunate, transscaphoid perilunate, and scapholunate dislocations -- the most common being the lunate dislocation. The PA and lateral view of the wrist will demonstrate most suspected lunate and perilunate dislocations. On the lateral view, the normal alignment of the longitudinal axis of the lunate, the capitate, and the third metacarpal over the distal radius can be demonstrated; any break in the imaginary line is pathognomonic of subluxation or dislocation of the lunate. Figure 2 demonstrates the normal alignment of the wrist.

Figure 1

Figure 2

A lunate dislocation on the lateral view is present when the axis of the lunate is angled away from the distal radial surface, while the capitate remains in its normal alignment with the radius. On the PA view, disruption of the arc II is present with lunate dislocations.

Figure 3A

Figure 3B

Perilunate dislocations can be recognized on the lateral view of the wrist by the dorsal or volar angulation of the longitudinal axis of the capitate, away from its normal central alignment with the lunate and distal radial surface. The lunate in this case remains in articulation with the radius, although there may be some degree of tilt of the lunate.

Figure 4A

Figure 4B

Transscaphoid perilunate dislocations are associated with a fracture of the scaphoid. This type of injury will be demonstrated on the PA view of the wrist; the arc II will be disrupted.

Figure 5

Lastly, the scapholunate dislocation results in injury to the intercarpal ligament that leads to rotary subluxation of the scaphoid. There are two signs that will indicate this type of injury: 1) the Terry-Thomas sign (or maybe David-Letterman for the present) which is widening of the space between the scaphoid and the lunate, which normally measures only 1 mm. 2) the signet-ring sign, which is a cortical ring shadow that is normally not seen on the scaphoid, which is due to rotation of the scaphoid.

Figure 6

Figure 7

It is extremely important that strict positioning of the wrist be followed, otherwise false positives could become a problem. When obtaining the PA view of the wrist make certain that the wrist is flat against the cassette; making a fist with the hand is a common way to prevent elevation of the wrist. The lateral view should be taken with the wrist in a neutral position in order to evaluate the alignment of the lunate with the rest of the wrist.

References and Diagrams:

Adam Greenspan, Orthopedic Radiology, Gower Medical Publishing 1988.

Pronator Syndrome: A Cause of Carpal Tunnel Syndrome

By Warren Hammer, MS, DC, DABCO

According to Leahy¹ the most common condition caused by entrapment at the pronator teres is the carpal tunnel syndrome and "the most common site of peripheral nerve entrapment is the pronator teres."

The median nerve can be constricted by a fibrous band within the pronator teres, by hypertrophy of the pronator teres, or can be compressed as it passes deep to both heads of this muscle.² Leahy¹ finds that the pronator teres is much more frequently involved than the actual carpal tunnel as a causative factor; that it is always necessary to evaluate and treat multiple areas of adhesion of the particular nerve which often exist before the actual symptoms appear.

Other common areas affecting the median nerve may be at the subscapularis, ligament of Struthers (originating from a spur located on the anteromedial surface of the humerus about 5cm above the medial epicondyle and attaching to the medial epicondyle), or distally past the pronator teres down the forearm.

In a Mayo Clinic series,³ seven of 35 patients were operated on for carpal tunnel who later were found to have a pronator teres syndrome. In this series 50 percent of the patients with definite pronator teres syndrome had a positive Phalen's test. It was thought that compression of the median nerve at the pronator teres caused the nerve to be more susceptible to compression at the level of the carpal tunnel. A positive Tinel's sign associated with firmness and tenderness over the pronator teres, compared to the opposite side and associated with carpal tunnel symptoms, points to involvement at the pronator teres level.

Of course an actual pronator syndrome can exist without creating any carpal tunnel symptoms. The median nerve after crossing the elbow must pass beneath the lacertus fibrosus which is a thick fascial band extending from the biceps tendon to the forearm fascia. A thickened lacertus fibrosus could compress the median nerve by indenting the flexor muscle mass² and visibly depress the contour of the forearm. Besides the pronator teres as described above, the median nerve may be compressed by a tight fibrous arch of the flexor digitorum superficialis.²

The most frequent symptom of pronator symptom may be a mild to moderate aching pain in the proximal forearm described as "tiredness" or "aching,"² especially with repetitive movements. Pain may radiate to the elbow and shoulder. Dawson et al.,² states that carpal tunnel syndrome can be differentiated by its frequency of night symptoms and exacerbation by wrist movements which pronator syndrome would not express. Apparently he does not recognize the frequency of the pronator teres as a cause of the carpal tunnel syndrome. In my practice I have found the pronator syndrome to be causative of carpal tunnel syndrome in at least 50 percent of the cases which were effectively treated by Leahy's method of "active release" as described in articles by Leahy and Mock.^4,5 In severe cases of pronator syndrome there may be weakness in the intrinsic muscles of the hand and muscles of the forearm, but usually the weakness is not severe compared to compression at the level of the anterior interosseous nerve.

To determine the level of compression of the median nerve about the elbow, Spinner⁶ has developed several tests which, although often negative, are significant if found positive.

Pain at the level of the lacertus fibrosus is surmised by resisting pronation of a patient's arm which is fully supinated and flexed at the elbow. This test contracts the biceps and tightens the lacertus fibrosus.

Compression at the level of the pronator teres is determined by instructing the patient with the elbow extended to place the forearm in full pronation with the wrist in flexion. The patient resists against the examiner attempting to supinate and extend the wrist. Pain in the proximal forearm indicates possible pronator teres involvement.

Evaluation of compression of the flexor digitorum superficialis is determined by having the patient flex the proximal interphalangeal joint of the middle finger against resistance. If this test creates forearm pain there may be compression of the median nerve at the level of the superficialis arch.

References 

1. Leahy M. Improved treatments for carpal tunnel and related syndromes. Chirop Sports Med 1995;9:6-9.
   
   
2. Dawson DM, Hallett M, Millender LH. Entrapment Neuropathies, 2nd. ed. Boston, MA: Little, Brown & Co. 1990.
   
   
3. Hartz CR, Linscheid RL, Gramse RR, Daube JR. The pronator teres syndrome: Compressive neuropathy of the median nerve. J. Bone Joint Surg., 1981;63A:885.
   
   
4. Leahy PM, Mock LE. Myofascial release technique and mechanical compromise of peripheral nerves of the upper extremity. Chirop. Sports Med. 1992;6:139-150.
   
   
5. Leahy PM, Mock LW. Synoviochondrometaplasia of the shoulder: a case report. Chirop. Sports Med. 1992;6:5-8.
   
   
6. Spinner M. Injuries to the Major Branches of Peripheral Nerves of the Forearm. Philadelphia: Saunders, 1972.

Warren Hammer, MS, DC, DABCO
Norwalk, Connecticut

Wrist Injuries, Part II

By Thomas Souza, DC, DACBSP

Imaging

Radiographic decision-making for the wrist is dictated by the degree of trauma with acute injury (suspicion of fracture or ligament rupture) or suspicion of arthritide involvement with a chronic pain history.

Following are some common examples: 

• A combination of anatomical snuff-box tenderness in a patient with a history of a fall on an outstretched hand would suggest scaphoid injury. A scaphoid series includes a posteroanterior (PA) view, a true lateral, a 45 degree pronation view (PA view), and an ulnar deviation PA view.¹ Another view that may be helpful is the Stecher view.² This is a PA shot with an angle of 20 degrees to the vertical angled from distal to proximal. When no fracture is evident but suspicion of fracture is high, additional angled views may help catch the fracture line. Initial radiographs are often unrevealing, even when a fracture is present. When the suspicion of a fracture is high, yet radiographs are negative, immobilization for 2-3 weeks in a thumb spica cast is recommended, followed by a second radiographic evaluation. Most fractures become apparent at this time. If an immediate determination is necessary (e.g., a professional athlete), a bone scan should be performed at three days post-injury. A negative bone scan rules out fracture.³ CT scans may also be beneficial in equivocal presentations.
• If a patient has joint-line tenderness, coupled with a history of a fall on a dorsiflexed hand and a positive Watson's test, ballottement, or midcarpal stability test, scapholunate dislocation or subluxation, lunotriquetral, or midcarpal instability respectively are likely. The lateral view will show a disrelationship between the radius, lunate, capitate, and third metacarpal. Two patterns may be evident: the dorsal intercalated segmental instability (DISI) pattern, or the volar intercalated segmental instability (VISI) pattern (sometimes called PISI). These instability patterns are based on the position of the lunate in relationship to the radius. Several angles can be measured, however the most common is the scapholunate angle that normally ranges between 30-60 degrees; greater than 70 degrees indicates scapholunate dissociation. If not evident statically, stability or stress views should be added. These include the clenched fist (anterior to posterior) view or a traction view, lateral views in flexion and extension, and AP views in radial and ulnar deviation.⁴
• A combination of trauma to the pisiform with local tenderness coupled with any sensory abnormalities into the fourth and fifth fingers would be suggestive of a hook of hamate fracture. The PA view may demonstrate subtle signs, such as absence of the hook or cortical ring, or sclerosis in the area of the hook.⁵ A carpal tunnel view and/or a 45 degree supinated oblique view is suggested.⁶ When these views are unrevealing, yet the suspicion of fracture is high, referral for a CT is warranted.⁷

It is crucial to include the distal radiulnar joint on wrist radiographs. The view should extend 5-7 cm proximally in an effort to determine: 

• any subtle breaks in cortical margins;
• disruption of the epiphysis in the child or adolescent; or
• callus formation subsequent to an undiagnosed fracture, especially when a younger patient reports a history of a fall 2-3 weeks previous (e.g., torus fracture of distal radius).

Management

Fractures and instability are the two major considerations when there is a history of trauma. Management is dependent on radiographic evidence or lack thereof. If a fracture is evident, refer for orthopedic consult (some chiropractors are experienced with casting for scaphoid fracture). If the suspicion of fracture is high, yet the radiographic evaluation is negative, a bone scan might be appropriate in higher level athletes. If there is insufficient evidence of fracture on initial radiographs, yet fracture is still being considered, a period of 2-3 weeks of immobilization followed by repeat films is prudent. Often the fracture is not evident until 14-21 days post-injury.

Instability is a difficult matter. There is some disagreement as to the appropriateness of immobilization as an initial management approach. With scapholunate dissociation, it is generally agreed that the damage is significant enough and the potential disability great enough that surgery is the first course of action. With other forms of instability, such as lunotriquetral dissociation or midcarpal instability, a period of six weeks splint immobilization is considered a reasonable initial approach.

If the patient is left with pain or obvious disability, a surgical consult is necessary. The chiropractor must be aware that permanent disability may result from an assumption that an athlete's wrist pain is simply a sprain and will resolve with time. It is beyond the scope of this small article to detail surgical options, but these approaches are generally divided into two categories: (1) arthrodesis/intercarpal fusion, and (2) ligament reconstruction. Ligament reconstruction, although appearing as the most logical approach, has had limited success. Arthrodesis is more successful, but may result in a significantly limited range-of-motion that can profoundly affect performance in some sports. It may, however, be the only option in patients with chronic pain failing conservative management.

It is important to consider the possible restrictions to play if the athlete is fitted with a splint or a cast. Some sports do not allow participation of athletes wearing these devices. The primary concern is injury to other players by the protective device. Rigid devices made of fiberglass, plastics, or thermoplastics are banned from most high school, college, and professional sports. The GE RTV-11 is a playing cast made of silicone and is accepted by the NCAA, NAIA, and the National Federation of State High School Associations (NPSHSA).⁸ Thermoplastic splints are allowed in some sports if a silicone rubber overwrap is used. The padding must be no less than one- half inch thick and be constructed of high-density, closed-cell polyurethane or similar material.

Soft tissue injuries are usually due to overuse or misuse and require an evaluation of the inciting activity. Sometimes it is possible to modify the activity and prevent future occurrence. In the acute phase of management, it is important to decrease the inflammatory reaction and prevent exacerbation by imposing a period of rest, coupled with ice and a possible course of myofascial release to the related muscles. Many athletes will be noncompliant with rest recommendations requiring a period of imposed immobilization. Using a soft-splint that is bivalved, the athlete is able to take off the device for small periods of time. If the patient is still noncompliant, a hard cast with a thumb spica may be required.

Repetitive dorsiflexion impact injuries such as handstands or vaulting may be addressed with a dorsal block. This involves taping or strapping a felt or similar soft obstruction on the extensor side of the wrist. This will prevent forced hyperextension, yet provide a soft end feel. This approach is often used in gymnastics during acute exacerbations.

The wrist is a difficult complex of joints to stabilize muscularly. The individual joint restraint provided by the various intercarpal ligaments is not easy to duplicate given the inherent design of the muscle tendon architecture around the wrist. Wrist tendons mainly insert onto metacarpals and can only indirectly provide support due to the physical overlap across the wrist joints.

In considering a generalized wrist strengthening program, it is important to consider that the wrist flexors are inherently stronger then the wrist extensors. This is primarily a protective design strategy; most survival activities and functional activities require flexion of the wrist. One such survival reflex is grabbing onto a support to prevent falling. There are few functional activities that require active extension of the wrist. Due to this natural imbalance, it is not unusual to overstrain the weaker extensor muscles. One strategy for prevention is to focus on extensor exercises. Like all exercises, overuse is possible and the athlete must be reminded that the wrist extensors require high frequency low repetition exercises.

Prevention is needed when falls on an out-stretched hand are likely, such as with skateboarding and roller blading. Wrist guards are a requisite.

References 

1. Leonard RN. Fractures and dislocations of the carpus. In: Brown BG, Jupiter JB, Levine AM et al., eds. Skeletal Trauma. Philadelphia, PA: WB Saunder, 1992.
2. Stechers WR. Roentgenography of the carpal navicular bone. AJR. 1937;37: 704-705.
3. Jorgenson TM, Anderson J, Thammesen P et al. Scanning and radiology of the carpal scaphoid bone. Acta Orthop Scand. 1979; 50: 663-665.
4. Dobyns JH, Linscheid RL, Chao EYS, et al. Traumatic instability of the wrist. American Academy of Orthopaedic Surgeon Instructional Course Lectures 1975; 24: 182.
5. Norman A, Nelson J, Gren S. Fracture of the hook of the hamte. Radiographic signs.Radiology. 1985; 154: 49-53.
6. Nisenfield FG, Neviasser RJ. Fracture of the hook of the hamate. A diagnosis easily missed.J Trauma. 1974; 14: 612-616.
7. Polivy KD, Millender LH, Newberg T, et al. Fractures of the hook of the hamate: a failure of clinical diagnosis. J Hand Surg (Am). 1985; 10: 101-104.
8. Sailer SM, Lewis SB. Rehabilitation and splinting of common supper extremity injuries in athletes. Clin Sports Med. 1995; 14: 411-446.

Thomas Souza, DC, DACBSP
San Jose, California 

The Forgotten Rotator-Cuff Muscle

Evaluating and treating teres minor injuries.

By Ben Benjamin, PhD

The teres minor is the weakest of the four rotator-cuff muscles. It is the brother of the infraspinatus because they are generally responsible for the same thing: lateral rotation. The teres minor gets a lot of use when you turn the steering wheel of your car or reach high up on a shelf to get something. The teres minor works more at slightly different angles from the infraspinatus and assists in adducting the arm.

Try this: Put your hand on top of your head with your thumb facing down toward the floor, put your other hand on the ulna side of your wrist for resistance and then push up with the bottom hand. You are now engaging a number of muscles, but more of the teres minor than with any other motion.

The teres minor originates at the dorsal surface of the axillary border of the scapula. Its fibers run obliquely upward and laterally; the upper fibers end at the teres minor tendon, which is inserted into the inferior facet of the greater tubercle of the humerus. The tendon of the teres minor passes across the glenohumeral joint and joins with the posterior part of the joint capsule.

The infraspinatus and teres minor attach to the head of the humerus and form the posterior part of the rotator cuff. They help hold the humeral head into the glenoid cavity of the scapula. They work along with the posterior deltoid muscle to laterally rotate the humerus, as well as perform adduction and assist in extension of the arm behind you. Sometimes the teres minor is actually fused with the infraspinatus.

Evaluating for Teres Minor Involvement: Two Key Tests

1. The patient's arm is overhead, the elbow bent at about 15 degrees, hand facing anteriorly above the forehead. Gently grasp the patient's wrist on the ulna side. They push up as you apply an equal and opposite force down. Remember, with resisted tests no movement through space should occur. It often takes very little pressure to induce the pain when a teres minor injury is present, so start out with very little pressure.

2. In this next test, we combine lateral rotation with adduction (with the hand at the elbow). Since the teres minor is both lateral rotator and an adductor of the shoulder, this test performs both at the same time. The patient bends the elbow at 90 degrees and brings it a few inches away from the body. Place one hand on the patient's distal dorsal forearm just proximal to the wrist, and place the other hand on the medial elbow. Ask the patient to push laterally at their wrist as the try to bring their elbow toward their ribs into adduction.

When the teres minor is injured, one or both of these tests are painful. The overhead push test is most likely to be painful.

Differentiating a teres minor from an infraspinatus injury is a tricky piece of assessment. The first thing to notice is weakness as well as pain. When the body is injured, it's very difficult, if not impossible, to maintain strength, especially for a little muscle like the teres minor.

People who suffer this injury are usually very athletically active. In most cases, the infraspinatus is the one that gets injured when lateral rotation is involved. In order to engage the teres minor, you need to do something either very strenuous or something that pulls you to the medial aspect of your hand.

One way to get this injury is by doing a handstand, because you have to balance yourself using all parts of the shoulder in subtle ways. In order to balance yourself side to side, you have to use the teres minor, and if you lose your balance slightly, you'll grip with this part of the rotator-cuff complex.

Treating Teres Minor Injuries

When treating the teres minor, the injury usually occurs either in the tenoperiosteal junction or in the tendon body itself. Let's take a moment to review the tenoperiosteal junction. This is where the tendon attaches to the bone.

The teres minor attachment is just lateral to the infraspinatus tendon. And if you have ever done cadaver work you know that it's enmeshed in a common fascia. Sometimes the teres minor is even conjoined with the infraspinatus tendon.

What this means is you're going to work on the most lateral part of the tendon attachment to the greater tubercle of the humerus; or slightly distal to the lateral aspect of the tendon body itself. When this tendon attachment or tendon is injured, it's extremely tender to the touch.

I remember one client who said to me, "Wouldn't that hurt anybody?" To which I replied, "No, as a matter of fact, it wouldn't." Then I asked him to turn over on his other side and did the same palpation to his healthy teres minor tendon. He was amazed that it didn't hurt at all. This is often a good way to educate your patients that both the pain on the assessment tests and on the palpation together form the evidence as to what is injured.

For the treatment, first ask the patient to lie on their side, injured side up, with a pillow under their head to protect their neck. Then have them extend the arm upward at about 70 degrees. This puts the teres minor on the stretch, and makes it easier to access and treat the tendon or its attachment.

Using your thumb, find the greater tubercle at the posterior aspect of the shoulder; now move to the most lateral portion of the tubercle and palpate the tendon, both as it attaches to the bone and further distally at the tendon body. When you palpate it, if it's injured it will be quite uncomfortable to the touch.

The treatment involves a friction therapy at a 90 degree angle to the injured tendon, done in one direction only for a period of 5 minutes. Take a break and then repeat for another 5 minutes. Remember to keep the discomfort to a minimum just so it is slightly annoying, but never really painful.

You have to be able to do this treatment for a period of time in order for it to succeed, so be sure to monitor the patient's discomfort as you work. The patient may be sore for up to 48 hours. Don't forget to tell them that so they understand if they are sore for a few days. They may not be sore at all – and that's OK, too.

Exercises to Assist in the Rehabilitation / Healing Process

Since the teres minor and infraspinatus muscles perform some of the same actions, the first strengthening exercise is the same for both. As soon as the patient can perform the motion described in exercise #1 below using 1 pound of weight without pain or discomfort, they can begin doing the exercise daily. This usually occurs after several treatments. Show the patient the exercise and then check to see they are doing it correctly on their next visit.

Exercise #1: Patient lies on their side with the injured side up, and allows the injured arm to hang down in front of them. They grasp a 1-3-pound weight, keeping the elbow and upper arm close to their body, and lifts their hand, rotating the arm toward the ceiling until it is at a 180 degree angle to the body.

Patient should perform three sets of 10 of this exercise, resting momentarily between each set. If there is pain during exercise, patient should stop. There should be a sense of fatigue near the end of the third set.

After the patient has been conscientiously doing exercise #1 for a week or two, add exercise #2 as follows:

Exercise # 2: This second teres minor exercise, which combines lateral rotation with adduction, requires a soft 5-6-inch ball or a rolled-up bath towel in addition to a light free weight.

Patient should lie down on their "good" side with a pillow under the head, and place the ball or rolled-up towel in the axilla. They grasp a weight and bend the elbow of the injured shoulder at 90 degrees. The weight should be just in front of the navel. Next, patient should slowly laterally rotate the shoulder, bringing the hand into the air, while simultaneously squeezing the ball or towel toward the ribs.

The patient continues performing the exercises until they can perform three sets of 10 with 6-10 pounds without any fatigue. The maximum weight will depend on the size and strength of the person. In order to establish a benchmark, see how much weight the person can handle with their good shoulder.

Wrist Injuries: Part I

By Thomas Souza, DC, DACBSP

Working with students in the college clinic or at sporting events or with doctors at seminars, it has been my observation that most chiropractors (and probably medical doctors) are least familiar and comfortable with wrist complaints compared to almost any other joint. 
If the patient does not have an obvious carpal tunnel or a subluxated lunate, the doctor is often left with no sense of direction. I would like to think that this was less due to an inadequate education (being an educator) and more due to the obvious. What you don't see often (or get tested on) tends to be a low priority. Ironically, the wrist is often an occupational victim for the busy side-posturing chiropractor. This is when many doctors search for a logical approach to wrist complaints. For the sports chiropractor, wrist complaints are far more common than for the general practitioner. The wrist, therefore, should be comfortable territory easily navigated without the luxury of a quick escape to the reference shelf (while the patient believes your absence is an indication of your popularity). Following is a short overview to help direct the examiner through a logical approach to patients with wrist complaints (peripheral nerve entrapments will be discussed in another article).

Although the wrist is not considered a weightbearing joint, it is transformed into one when athletes protect themselves from a fall with an outstretched arm/hand. The wrist is subjected to the compressive or shearing effects of a high-force contact injury. Repetitive weightbearing injury is a natural consequence of many gymnastic maneuvers: handstands, transition support through various flips, and propulsion with vaulting. So common is wrist pain with gymnasts, that many consider it part of the price you pay to the sport, just like finger calluses with bar events. In either a single-event acute injury or repetitive weightbearing injury, radiographs must be taken to detect fracture or a reactionary process in bone, such as avascular necrosis or osteophyte formation. Hidden, yet prevalent, is ligamentous injury. It is often assumed that when radiographs are negative that the patient has a simple sprain and needs a minimal period of taping or bracing. It is possible though that more severe ligamentous damage has occurred. This can only be detected by a careful physical examination for stability, coupled with specialized radiographs and markings.

Many other injuries are the result of repetitive overstrain. Although there are a number of tendons that may become involved, localization is usually possible through a selected tension approach as described below. Additionally, a sport-specific predisposition occurs due to the demands of a given activity. For example, DeQuervain tenosynovitis involving the abductor policis longus (APL) and the extensor policis brevis (EPB) is more common in golf and bicycle riding, where a tight grip coupled with repetitive wrist movement result in an inflammatory process. Extensor carpi ulnaris (ECU) tendinitis is the second most common tenosynovitis (following DeQuervain's), found most commonly in wrist-intensive sports (rowing, racquet sports, golf, and baseball). Intersection syndrome involving the radial wrist extensors as they cross under the APL and EPB is more common with rowers and canoeists ("oarsman's wrist") and weightlifters performing repetitive, high-resistance, wrist or arm curls.¹

History

When there is a report of a single traumatic event, combining the mechanism of injury with pain location narrows down the possibilities. The two most common general mechanisms are a fall onto the wrist or direct contact with a sports apparatus such as a bat or club. 

• fall on an outstretched hand (dorsiflexed wrist) -- Axial loading usually occurs to the ulnar, palmar side of the wrist creating compressive and shearing forces. Common injuries include scaphoid and distal radius fractures, scapholunate and lunotriquetral ligament damage leading to varying degrees of instability, and triangular fibrocartilage injury at the ulnar side of the wrist.


• fall on a flexed hand -- This may result in a compression injury to the flexor (palmar) wrist with avulsion or stretch injury to the dorsal wrist. Similar structures are involved as in dorsiflexion injuries with slightly different fracture patterns, additionally, dorsal capsule avulsion may occur.


• misjudged bat or club swing -- If the centrifugal force of the bat exceeds the grip of a baseball batter, the hypothenar region may be directly hit, causing a hook of the hamate fracture. A similar mechanism in golfing involves hitting the ground instead of the ball.

When there is no single event recalled, it is important to determine first if a constant compression force is applied during a sports activity. 

• bicycling -- Compression of the ulnar nerve in the tunnel of Guyon may cause distal pain and numbness over the fifth finger and ulnar half of the fourth finger (sometimes the hypothenar area is also involved).


• gymnastics -- Handstands, walkovers, vaulting, and other forms of springing off of dorsiflexed wrists add substantial pressure to the dorsal wrist causing a number of dorsal impaction reactions such as a localized hypertrophic synovitis or bony hypertrophy of the ulna or scaphoid. Another condition more common in gymnasts is triangular fibrocartilage complex (TFCC) perforations.


• martial arts -- It is believed that the compression from punching may be the cause of a higher incidence of Keinbock's disease (avascular necrosis of the lunate) in young men.²

Next determine if there are any demands for repetitive wrist movements, such as those that occur in rowing, throwing, and racquet sports. Some examples include: 

• DeQuervain's tenosynovitis -- This is more common in sports that require a forceful grip and/or repetitive use of the thumb while in ulnar deviation, including golf (left thumb of right-handed golfer), fly fishing, racquet sports, javelin and discus throwing).


• intersection syndrome -- This is found with anyone who must use a repetitive wrist movement; most common with rowers, canoeists, weightlifters (heavy wrist or forearm curls), and tennis players.


• Extensor carpi ulnaris tendinitis -- This is found in racquet sports, baseball, golf, and rowing.


• Flexor carpi ulnaris tendinitis -- This is found commonly in golf and racquet sports.

Examination

Observe the involved wrist and compare it to the uninvolved one to determine any obvious deformity suggestive of fracture. Palpation of the wrist may reveal small nodular swellings especially on the dorsal surface. These often represent ganglions and are more common in gymnasts. Unless fracture is obvious or likely, proceed to instability testing. Keep in mind that many wrists pop and click. The hard positive for these instability tests is painful popping or clunking. 

• Watson's test for scapholunate stability -- The examiner presses the scaphoid from anterior (volar) to posterior (dorsal) with the wrist first in ulnar deviation. Moving it passively into radial direction, a painful clunk or pop may be produced indicating that the proximal pole of the scaphoid subluxated over the posterior rim of the radius.


• Lunotriquetral ballottement test -- The examiner stabilizes the lunate between a thumb and index finger and does the same with the triquetrum. A shearing between the bones is accomplished by moving the bones in opposite directions (i.e., lunate forced posterior while triquetrum is forced anterior). A painful clunk or pop is indicative of lunotriquetral joint instability.


• Midcarpal instability -- By either having the patient actively or examiner passively pronate and ulnar deviate the wrist, a painful pop is felt on the ulnar aspect of the wrist. This indicates midcarpal instability.

If these tests are negative, it is important to realize that instability is not ruled out. A radiographic evaluation described in next month's column should also be included. It is also important to realize that many of these tests are also testing for accessory motion between carpal bones. The difference is that accessory motion testing (motion palpation) evaluates restriction of movement, as opposed to the excessive movement found with instability testing.

Palpation, range of motion and strength testing can be combined to produce a comprehensive evaluation of tendon involvement. Knowing the insertion point of each tendon and the movement accomplished by the tendon, a strategy using palpation, stretch, and contraction may localize the involved tendon. Below is a summary of several possibilities: 

• Extensor carpi radialis -- Tenderness may be found at the base of the second and third metacarpals (dorsal surface); pain may be increased with stretching into wrist flexion and ulnar deviation, or contraction from this stretch position into radial deviation and wrist extension.


• Extensor carpi ulnaris -- Tenderness may be found at the base of the fifth metacarpal (dorsal surface); pain may be increased with stretching into wrist flexion and radial deviation, or contraction from this stretch position into ulnar deviation and wrist extension.


• Flexor carpi radialis -- Tenderness may be found at the base of the second metacarpal (palmar surface); pain may be increased with stretching into ulnar deviation and wrist extension, or contraction from this stretch position into radial deviation and wrist flexion.


• Flexor carpi ulnaris -- Tenderness may be found at the pisiform; pain may be increased with stretching into radial deviation and wrist extension, or contraction from this stretch position into ulnar deviation and wrist flexion.


• DeQuervain's (APL & EPB) -- The patient is asked to clench the hand over the thumb. The examiner then passively ulnar deviates the wrist taking care not to press on the metacarpophalangeal joint of the thumb. Although this maneuver is uncomfortable it is usually not painful; compare it to the opposite, uninvolved side.

Next month, we will discuss imaging and management options.

References

1. Plancher KD, Peterson RK, Steichen JB. Compressive neuropathies and tendinopathies in the athletic elbow and wrist. Clin Sports Med 15; 331-371: 1996.
2. Howse C. Wrist injuries in sports. Sports Med 17; 163-175: 1994.

Thomas Souza, DC, DACBSP
San Jose, California

Treating CTS and Wrist Tendinitis of Myofasial Origin

By Guy Hains, DC

Carpal tunnel syndrome (CTS) is the most common and most clinically significant of all nerve entrapment syndromes,¹ present in 2.7 percent of the adult population.² Numbness and paresthesia along the distribution of the median nerve in the hand, i.e., the thumb, index, major and half the ring finger, are common symptoms related to CTS.³

Symptoms and concurrent discomfort often peak at night and may wake the patient several times. To ease pain and discomfort, he/she often will shake the affected hand(s) and flex the fingers vigorously.³

Conservative allopathic treatment usually includes wrist support, change in activity and anti-inflammatory medication. If symptoms are not relieved by conservative approach within a six-month period, cortisone injection may be used. Wrist surgery, which involves cutting the transverse ligament of the wrist, is considered where symptoms remain pronounced and sensitive functions decline.^4-5

The three main reasons why patients require surgery for CTS are night pain (36 percent), hand numbness (21 percent) and relief of daytime pain (13 percent).6 Almost a third of the patients who have undergone CTS surgery experience persistent or recurrent symptoms aftersurgery and report that the initial improvement associated with CTS surgery is lost within less than two years.⁶ On the other hand, when CTS is not treated surgically, 22 percent of patients continue to have symptoms as long as eight years later.⁷

Ischemic Compression for CTS

The rationale for using ischemic compression therapy along the median nerve in the treatment of CTS is as follows: In patients suffering from CTS, the median nerve is twice (2.1 times) its normal size when it enters the carpal tunnel.⁸ The present author hypothesizes that part of the cause of the related edema is noxious myofascial sites along the median nerve. Along its course, part of the median nerve enters the axilla of the shoulder, runs immediately adjacent to the biceps, and descends within the hollow of the elbow under the pronator teres muscle and the bicipital aponeurosis.

In a randomized clinical trial by the present author,⁹ there were trigger points (TrPs) and hypertonicity along the biceps of every participant. TrPs in the hollow of the elbow were also present in all cases. TrPs in the axilla of the shoulder were present in around 50 percent of participants.

The following hypothesis explains why the symptoms of STC are worse during the night: In skeletal muscles, the blood flow is extremely variable and is tied to activity level. At rest, only 25 percent of the capillaries are open. With exercise, blood flow can increase up to 10 times, at which point almost all capillaries open up to admit more blood.¹⁰

In our trial, the affected biceps (principally) was in partial contraction because of the TrPs. It is well-known that TrPs in a muscle cause a partial contraction.¹¹

This contraction state results in higher consumption of oxygen and glucose. However, during the night, with blood flow being much less, the supply of oxygen and glucose diminishes andlactic acid accumulates, accentuating the contraction state. Shaking the hand vigorously increases the blood flow and eliminates the lactic acid. Consequently, the biceps relaxes partially, the median nerve is less irritated, and the numbness and pain diminish.

Treatment Protocol / Discussion

Our trial aimed to determine the efficacy of 15 treatments by ischemic compression, involving one thumb on the other on the TrPs localized along the biceps, at the hollow of the elbow and at the axilla of the shoulder. Our study population included 55 patients suffering from daily CTS for at least three months.

After 15 treatments, diminution of symptoms was greater in the experimental group (37 patients) than in the control group (18 patients): 42 percent versus 26 percent amelioration. In a questionnaire establishing the patient's perceived amelioration of symptoms using a scale from 0-100 percent, results demonstrated 67 percent amelioration for the experimental group compared to only 50 percent for the control group. Of interest, 89 percent of the experimental group felt evident amelioration within six treatments. Six months later, the amelioration was still significant.

All patients in this study presented with multiple trigger points and taut bands along the biceps and at the biceps aponeurosis (in the hollow of the elbow), at the pronator teres muscle and at the axilla of the shoulder. All patients were examined for TrPs in these four areas while in a supine position with the arm spread along the body – except in the case of the axilla of the shoulder, for which the patient's hand was positioned under their head. In this scenario, treatment should be done over the clothes (question of hygiene).

Most of the time, when the TrP of the axilla is treated, one thumb on the other for 8 seconds, the patient feels a neurologic irradiation directly to the fingers. The treatment along the biceps consists of two- or three-second pressure on every 2 centimeters from the upper part of the biceps to the elbow. The pressure is painful, but bearable, and should be repeated at each visit until the hypertension is completely gone. At the elbow, the TrP(s) should be treated for 8 seconds.

Numbness at the tips of the fingers will usually respond to the same treatment.

In cases of ulnar neuropathy, in which the numbness is felt at the little finger and half the ring finger, the trigger points are normally at the lower part of the triceps. A good way to treat that area is with the patient kneeling perpendicular to the table, forehead on the asymptomatic arm, with the symptomatic arm stretched along the table and the hand turned in such a way as to put the triceps in evidence.

In chronic cases, 10 to 15 treatments may be necessary to get rid of these problems. Some patients work too much all the time; this has to be discussed with the patient so doctor-patient can brainstorm effective ways to reduce recurrence of symptoms.

In up to 10 percent of older patients, some TrPs are at the inside of the wrist, which could contribute to CTS. The cause may be a trauma; if the CTS has been present for years, there could also be arthritic irritation.

Examination of the wrist consists of forced flexion of that wrist with the doctor's two thumbs (side by side) on the inside of the articulation while using his/her other fingers to force the flexion. If a hypersensitivity is present, the test is positive.

Treatment is like the examination, except the forced flexion is kept at the patient's tolerance for 8 seconds. This mobilization is repeated at each visit until there is no more irritation.

In my experience, this approach to treating CTS is very efficacious and in about 50 percent of the cases, the patient feels amelioration the night following the first treatment.

Wrist Tendinitis: Examination and Treatment With Ischemic Compression

Many of my patients also present with wrist tendinitis. Ischemic compression combined with mobilization is effective in just about every case. Our examination is done with the patient supine, the two thumbs of the practitioner applied on the inside of the wrist. The fingers of the two hands force flexion of the symptomatic wrist while at the same time pressing vertically with the thumbs. If that produces pain, then the examination is positive.

As with CTS, treatment is exactly like the examination, except that it lasts 8 seconds, and the pressure and the flexion are maintained without moving, to the maximum of the patient's pain tolerance. The treatment has to be careful and delicate, and we have to be very attentive to the patient's reaction. It has to be painful, but bearable, and repeated at each visit until there is no irritation.

The examination and treatment of wrist extension is the same as for the flexion, except that it is done with the hand in pronation. To examine the rotation of the wrist, the contact with the thumb is on the pisiform bone. While forcing the rotation, maintain the pressure for 8 seconds.

These three examinations are carried out in all cases of wrist tendinitis, and treatment administered accordingly. Just about every patient has some pain when we examine the wrist, but the symptoms are present only above a certain level of irritation. Some TrPs could be above the aforementioned sites, at the distal extremity of the radius and cubitus.

These sites should be examined attentively if irritation of the previous sites has been eliminated, but the patient still has some pain in his/her wrist. Often the patient will pinpoint the remaining TrPs. That area has to be examined with a strong thumbtip pressure, one thumb on the other. All hyperirritable TrPs should be treated with 8 seconds of pressure.

These TrPs may be present anywhere on the carpal bones, as well as at the carpophalangeal or interphalangeal articulations. We treat these articulations with the patient's hand flat on the table, keeping pressure vertical and bearable. Normally, five to 10 visits may be necessary in order to get rid of these irritations.

References

1. Nordstrom DL, Vierkant RA, DeStefano F, et al. Risk factors for carpal tunnel syndrome in a general population. Occup Environ Med, 1997;54:734-740.
2. Atroshi I, Gummersson C, Johnson R. Prevalence of carpal tunnel syndrome in the general population. JAMA, 1999;282:153-158.
3. Phalen GS. The carpal tunnel syndrome. Clinical evaluation of 598 hands. Clin Orthop Relat Res, 1972;83:29-40.
4. Practice parameter for carpal tunnel syndrome (summary statement). Report of the Quality Standard Subcommittee of the American Academy of Neurology. Neurology,1993;43:2406-9.
5. Keller RB, Largay AM, Soule DN et al. Maine carpal tunnel study: small area variations. J Hand Surg (Am), 1998;23:692-6.
6. Bessette L, Keller RB, Liang MH et al. Patients' preferences and their relationship with satisfaction following carpal tunnel release. J Hand Surg (Am), 1997;22:623-620.
7. DeStefano F, Nordstrom DL, Vierkant RA. Long-term symptom outcomes of carpal tunnel syndrome and its treatment. J Hand Surg (Am), 1997;22:200-10.
8. Mesgarzadeh M, Schneck CD, Bonakdarpour A. Carpal tunnel: MR imaging. Part 1. Normal anatomy. Radiology, 1989;171:743-8.
9. Hains G, Descarreaux M, Hains F. A randomized controlled ( intervention ) trial of ischemic compression therapy for chronic tunnel syndrome. J Can Chiropr Assoc, 2010;54(3).
10. Marieb EN. Essentials of Human Anatomy and Physiology, 2nd Edition. Benjamin / Cummings Publishing, 1992.
11. Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyography Kinesiol, 2004;14:95-107.

Conservative Treatment of Repetitive-Stress Injuries: Exercise Is the Key

By Adam Silk, DC

Chiropractic has now reached its 115^th year. During that time, many things have changed, of course, but the mission to get sick people well without drugs has been the course that remains unchanged.

Gone are the days when chiropractors were sent to jail for practicing medicine without a license and scope of practice was limited to cricks in the neck or back pain. The modern-day chiropractor is a primary health care provider, a portal of entry to the health care system, with a plethora of techniques and modalities at their disposal. Today's chiropractor uses a whole-body approach and effectively helps patients with a myriad of health conditions ranging from headaches and nutritional issues to arthritis, musculoskeletal problems and even systemic health issues.

Repetitive-Stress Injuries: A Significant Health Problem

Advancements in technology have brought about an increase in repetitive stress injuriessuch as carpal tunnel syndrome (CTS), lateral and medial epicondylitis of the elbow, and general complaints involving the thumb and hand. Chiropractors have very successfully risen to the challenge of treating these common problems without the use of drugs or surgery; and with the growing lack of confidence patients have taking medications, overuse of anti inflammatory drugs to control painful symptoms, and long recovery times involved with surgery and rehabilitation, patients are increasingly open to other treatments.

Chiropractors are not immune to these health issues, either; the constant pounding our hands and wrists take, along with the repetitive nature of our work, can create CTS-like symptoms at times. Treating these overuse injuries of the hand, wrist and elbow in our patients and ourselves without drugs or surgery should always be the first option.

Resistance and Flexibility Exercises

Directed exercise is the missing link; all conventional exercises force flexion of the hands to grip the weight or machine. In chiropractic college we were told to use rubber bands and do finger extension exercises. Three to five minutes of appropriate exercise helps to strengthen the muscles associated with extension of the fingers and help protect the associated structures of the hand by increasing their ability to handle repetitive stress regularly placed on them. Although it not always possible to correct through exercise alone, this is an effective strategy to help avoid surgery and reliance on OTC medications.

Millions of people suffer each year with tennis elbow and carpal tunnel symptoms. Computer / data entry personnel, dentists and hygienists, auto technicians, machinists, assembly workers, massage therapists, musicians, tennis players, golfers, and yes, chiropractors are all at risk. The common risk factor is the necessity to repetitively grip, squeeze and apply force to closing of the hands in order to accomplish their daily tasks. This repetitive action (hand/finger flexion) required by people in all of the above activities (along with numerous others) perpetuates an imbalance in the relationship between the finger flexor muscles that close the hand and the finger extensor muscles that open the hand. The tendons that affect movement of the hand are long, passing over several joints. The muscle bellies located far away further complicate the relationship.

It is necessary and actually very healthy when there are naturally occurring muscle imbalances among the opposing muscle groups; however as with most things, too much of any one thing can be a problem. In the case of the wrists and elbows, the extrinsic location of the opposing muscles of the hands and wrist are naturally very imbalanced in favor of hand flexion. This imbalance forces the hand to close and squeeze; this hand and wrist flexion puts a near-constant strain on the extensor muscles. Directed resistance exercise and flexibility exercises for the palms help stimulate blood flow and increase the distribution of blood to the distal portion of the tendons involved in movement of the hand, fingers and wrist.

The Chiropractic Opportunity

This is probably not the chief complaint or primary issue that brings patients to your office. However, consider that 60 percent of people over age 55 suffer from some type of hand stiffness, wrist or elbow pain. The problem begins with some muscle cramping or feeling of fatigue in the extensor region, many times going ignored. The more these repetitive activities continue, the risk of injury increases, as the finger extensor muscles rarely - if ever - receive any opportunity for conditioning. (If you think about it, this is one of the few areas of the body faced with this problem.)

You can equate this with the effect gravity has on the spine over time. The constant pushing of gravity, if left unattended, contributes to postural issues over time. The solution, as you know, is as simple as preventative measures such as stretching the front and back of the legs and the pectoral region, inversion traction of the spine, chiropractic spinal adjustments and strengthening the muscles of the upper and lower extremities and back.

When dealing with hand and wrist pain, we must take into consideration that the flexor muscles that close the hands are the workhorses of the upper extremity. This constantly overstimulated muscle group creates an unhealthy dynamic and a major imbalance in the hand. The decreased flexibility in the finger flexors and the reducing power in the finger extensors create instability in the structures of the wrist and elbows. As repetitive forces are applied to these structures, pain and limitations can develop.

As chiropractors, we are well-suited to handle these cases with our innate understanding of balance and openness to comprehensive treatment programs that do not place potentially dangerous pain-relieving medication at the forefront of the treatment program. The real answer is to increase blood flow; this helps to bring increased nutrition to the damaged tissues and optimize the healing process. It can take less than 10 minutes a day.

Certainly there will be patients who will require surgical intervention and anti-inflammatory medication; but in many of these cases it may be as simple as tailoring a strategy that includes rest from the activity causing the problem, applying ice to reduce inflammation, and rebalancing the relationship between the finger flexors and finger extensors, specifically addressing the muscles involved with extension of the digits. Corrective chiropractic care plans including exercise techniques applied to all involved areas of the body while increasing flexibility in the muscles that close the hands will allow the patient to handle greater levels of repetitive motion in the wrist and elbows.

There are a multitude of devices on the market that aid in strengthening the finger flexor muscles; in many cases, the exercises are not particularly unique, as everything we do in life - holding a phone, eating with utensils, carrying packages, driving a car, riding a bike, holding a tennis racket or golf club - provides similar muscle stimulation to make our grip strong.

With about five minutes a day of directed exercises, my hands and wrists and fingers feel almost perfect. The exercises are the perfect balance and work great for me and my patients. I recommend finger extension exercises to anyone with elbow, wrist or hand pain and stiffness. Give it a try; all you have to lose is the pain. Your patients will thank you.