WHAT IS HAND-FOCUSED THERAPY?
Hands are highly specific and challenging regions to effectively assess, diagnose and treat. Proper assessment and diagnosis of hand injuries requires a very strong knowledge base in anatomy. Many hand injuries are extremely limiting and prevent day-to-day function and involvement in sports and recreation. In many cases, a hand injury will impact the function of the entire upper extremity. A thorough assessment and a detailed diagnosis is the first step in resolving these complex and often frustrating injuries.
COMMON HAND INJURIES:
- Trigger Digit
- Osteoarthritis of the finger joints
- Pulley Injuries
- Flexor Tendon Injuries
- Carpal Tunnel Syndrome
- TFCC Tears
Trigger digit (aka trigger finger) is a condition in which the flexor tendon is enlarged within the tendon sheath (casing around the tendon), resulting in the tendon ‘catching’ on structures such as the A1 pulley. The finger will feel like it gets stuck and will often require passive assistance to straighten from a bent position. Treatment of trigger digit depends on the duration and severity of the condition. In the early stages, reduction of inflammation of the tendon within the sheath is sufficient to restore normal mechanics. This is achieved by a combination of splinting, mobility exercises, topical or injected corticosteroids, and IMS needling to affected muscles. In later stages, a corticosteroid injection is usually recommended to begin with, followed by mobility exercises and strengthening of hand intrinsics to prevent progression of the condition.
OSTEOARTHRITIS OF THE 1ST CMC JOINT (OA OF THE THUMB)
OA of the thumb is a particularly painful and disabling condition, beginning as pain and reduced mobility in the base of the thumb and eventually progressing to a significant loss of mobility and permanent deformity of the joint. It is particularly common in musicians, gardeners, and any occupation involving gripping (i.e. nurses, manual laborers). As with OA in any joint, the treatment and prognosis depends on the stage of the condition. In the early stages, the focus of treatment is on reducing the compression across the joint to halt the progression of the joint surface degeneration. This is achieved through a combination of manual therapy to the affected joint as well as to surrounding joints that may be impacting/overloading the thumb. Soft tissue release such as IMS needling is also often indicated to reduce the muscular compression across the joint. A careful functional assessment of the entire upper extremity will determine if there are strength or muscle length deficits that have contributed to or resulted from the degeneration of the CMC joint. This will direct a patient-specific home exercise program. In more advanced cases, splinting, corticosteroid or PRP injections may be indicated.
Acute and chronic pulley injuries comprise the most common hand injury sustained by rock climbers. At the time of an acute injury, a pop may be felt in the palmar side of the finger followed by pain and swelling. Chronic pulley injuries are often felt as tenderness to direct pressure over the palmar side of the finger. The A2 pulley of the ring finger is the most commonly injured pulley. The acuity of the injury will dictate the treatment plan, with acute injuries requiring some degree of immobilization and chronic injuries requiring more aggressive treatment such as shockwave therapy and loading exercises to facilitate remodeling of the collagen. Training faults that may have contributed to the injury also need to be identified. In the case of rock climbers, this can be an imbalance of strength in the FDP/FDS tendons resulting in hyperextension of the DIP (tip of the finger) when loading a full-crimp position. Other considerations are the length and strength of the intrinsic hand muscles as well as shoulder strength and hand positioning when loading the finger.
FLEXOR TENDON INJURIES
Injuries to the flexor tendons are quite common in a wide variety of sports and occupations. The injury can range from tendonitis or tenosynovitis to a partial or full tear of one or both of the flexor tendons. The injury needs to have a thorough and detailed examination of all elements of the hand and flexor tendons in order to direct the treatment plan. Some cases require splinting while others are more responsive to tendon mobilization and intrinsic hand strengthening.
CARPAL TUNNEL SYNDROME
Carpal Tunnel Syndrome is a compression injury to the median nerve as it passes through the carpal tunnel at the wrist. It presents as numbness, tingling, or pain in the thumb, palm, and index, middle, and half of the ring finger. It can also present as weakness in grip strength. It is common in sedentary occupations involving excess computer work as well as manual labour occupations involving repetitive motions at the wrist. In many cases, it can be complicated by additional nerve compression in proximal regions such as the neck, shoulder, and elbow. Although uncomplicated carpal tunnel syndrome is treated with local rehabilitation to the wrist (ie splinting, joint mobilizations, corticosteroid injections, or surgery), failure to identify and address additional areas of nerve compression will result in a poor outcome. A complete upper quadrant exam is indicated to determine all areas of nerve compression which will direct the treatment plan for each individual case.
OSTEOARTHRITIS OF THE FINGER JOINTS (PIP AND DIP JOINTS)
OA to the fingers presents as stiffness and pain in the small joints of the hand, particularly in the morning. As the condition progresses, small bumps can appear at the joints (Herberden’s and Bouchard’s nodes). The primary focus of treatment for any stage of OA in these regions is to reduce the amount of joint compression occurring. This can be achieved by releasing the tension in the extrinsic muscles crossing the joints (extrinsic flexors and extensors in the forearm), as well as strengthening and retraining the intrinsic small muscles of the hand. Simple grip strengthening will usually aggravate the condition, therefore careful assessment and prescription of isolated and individualized exercises is extremely important. Additional treatment options include manual therapy to the affected joints, soft tissue mobilization of the forearm and hand, and IMS needing to hypertonic muscles. Shockwave therapy may also be indicated in treatment of this region.
The TFCC (Triangular Fibrocartilagenous Complex) is comprised of cartilage, ligaments, and tendon tissue on the outer side of the wrist (side closest to the little finger). This structure is often injured with a compression/rotation mechanism such as falling off a mountain bike or overloading the wrist during weight-bearing exercises such as push ups and hand-stands. This is also an extremely common and debilitating injury for rock climbers and occurs when the hand is loaded in particularly vulnerable positions (such as on open-hand holds – i.e. slopers). Diagnosis is primarily achieved by clinical assessment, as diagnostic imaging is often difficult to access and can be insensitive to this type of injury. Treatment planning depends on the severity of the injury as well as the location of any suspected tears or lesions of the TFCC. Most cases require some type of splinting or bracing in the early stages, followed by manual therapy and exercises to normalize the mobility of adjacent joints such as the elbow (proximal radioulnar joint) and wrist/hand (radiocarpal joints). Strengthening exercises are often only indicated in the later stages of healing, as the TFCC is highly susceptible to aggravation from overload. If conservative therapy is unsuccessful, a surgical consult may be indicated.