Differential Diagnosis For Wrist and Thumb Pain · PDF fileDifferential Diagnosis For Wrist and Thumb Pain ... • Shoulder, elbow, forearm ... – Biomechanics 29 Cooper 2007

Differential Diagnosis For Wrist and Thumb Pain

Amy Bohn, OTR/L

Hand and Upper Extremity Program

Children’s Healthcare of Atlanta


Wrist and Thumb Injuries

• Presentation of Wrist pain:

– Scaphoid fractures

• Therapy:

– Non‐surgical

– Surgical

– Triangular Fibrocartilage Complex (TFCC) Injuries

• Therapy:

– Non‐surgical

– Surgical

– Thumb MP joint pain

• Therapy

– Non‐surgical

– Surgical management

– Steps for successful Return to Sport

Children’s Healthcare of Atlanta 3

Wrist Pain:Scaphoid Injuries


Where is Scaphoid?

• Second largest carpal bone

• “Kidney Bean”

• Sits in Proximal row

– Spans over mid‐carpal joint

• Blood supply enters at dorsal distal pole

– If fracture disrupts the proximal pole, a non‐union may occur

4Cooper 2007

http://orthoinfo.aaos.org/topic.cfm?topic=A00012


How does it occur?

• Mechanism of injury

– Fall on outstretched hand (FOOSH)

– Wrist usually extended with radial deviation

– Compression of the waist of scaphoid against radial styloid

• Typically patient presentation

– Young Male

– Often complaining of wrist pain for a while

– “Sprain”

– Forearm based thumb spica

5

https://sites.google.com/site/activecarephysiotherapyclinic/scaphoid-injury

https://www.amazon.com/Breg-Wrist-Cock-Up-Splint-Medium/dp/B00IDRVKL0


Evaluation…..

• Primary responsibility with patient presenting with wrist pain symptoms:

– Good clinical reasoning to monitor progress or lack of progress

– Good biomechanical evaluation of tissues

• Discuss:…

– Good history injury

– Mechanism of injury

– Course of treatment thus far

• Early on in treatment:

– Splints??

– Therapy??

– Exercise??

6

Cooper 2007


Evaluation….

• Physical Exam

– Tenderness and pain over scaphoid

• Aggravated by palpation at “snuff box”

– Restricted Range of Motion

• Wrist extension‐ Primary

• Ulnar deviation

• Radial deviation

– Functional measurements:

• Thumb

– Radial abduction

– Palmar abduction

– Opposition

• Grip strength

– reduced by more than 50%

– Edema• Consider volumetric measurement

– Complete on both sides

7Prosser et al 1996

http://teachmeanatomy.info/upper-limb/areas/anatomical-snuffbox/


Evaluation…..

• After few session is there improvement with…..

– Pain

– Range motion

– Edema

• Communicate with MD!!!!

8


Scaphoid Fracture:Conservative Management


Conservative management

• Treated with cast immobilization

– Long thumb spica

• 6 weeks

– Short thumb spica• Fractured heal

• 6 weeks

– May be longer depending on location and healing

10

Canton 2001


While in cast….

• Edema control of digits

– Compressive wraps

– Edema massage

• AROM digits

• What they need to succeed?

• 504

• Private school

• Assist in talking to coaches and peers

11


While in cast….

• How do we get buy in?

– Educate on:• Proximal Stability for distal function

• Effects of substitution and compensatory motion

– Have them doing:• Postural stretch/strengthening

• Shoulder stretching/strengthening

• Posterior Strengthening

• Elbow strengthening

• Core strengthening

• Endurance

12


After cast is removed….

• Primary Goals of Therapy:

– Elimination of wrist pain

– Restore maximum ROM and strength within pain limits!!!!

– AVOID aggressive therapy

• Splints…

– Forearm based thumb spica

• Motion

– PROM (6‐8 x/day)• Elbow , forearm, wrist and thumb

– AROM – (6‐8x/day)• Wrist

• Thumb

– Light functional tasks

13Canton 2001


After cast removed…

• Good pain free motion:

– Strengthening• Begin Slowly

– Edema

– Pain

– Discomfort

• When strengthening is improving…

– Begin with weight bearing

14

Cannon 2001


Weight Bearing

• KEYS

– Avoid torsion loading to wrist

– Look for substitution in other joints due to lack of strength

• Shoulder, elbow, forearm

– If no pain with initial weight bearing, proceed to return to sport activities

15


Scaphoid Fracture:Surgical Management


Post-Operative Management

• Casted• 10‐14 days

• Therapy

– Sutures removed

– Splints• Short arm thumb spicafabricated with IP free

– Active and PROM

• Fingers

• IP joint of thumb

– Scar management

– Edema control

17Canton 2001


Post-operative Management

• Primary Goal:

– No wrist pain

– Restore maximum ROM within pain limits!!!!

– AVOID aggressive therapy

• What they need to succeed?

• 504

• Private school


• How do we get buy in?

• Postural stretch/strengthening





• Endurance

18


Progression…

• Weeks 2‐4

– Flexible wrist splint• Controlled active wrist flexion and extension

• Advantage:

– Helps to decrease bone osteopenia

– Helps to maintain articular cartilage health

– Promotes bone mineralization of fracture site

• Continue with:

– Scar management

– Edema control

– Strengthening to:• Scapula/Shoulder area

• Elbows

• Forearms

• Endurance training

19

Wright et al, 2002


Progression….

• Weeks 4‐16

– Progression depends on:• Fracture showing clinical and radiographic healing

• MD will determine

• When you have clearance that fracture is healed:

– Active range of motion to wrist

20

Canton 2001


Progression….

• One week after active motion:

– Active assistive motion

– Gentle Passive motion

• Complication:

– Having trouble regaining Motion

• Solution:

– Try using heat modalities

– Switch to a static progressive or dynamic splint

21

Cannon 2001


Progression….

• 3‐4 weeks after active motion began

– Progressive strengthening to entire upper extremity

• Continue with:

– Scar management

– Edema control

– Strengthening to:• Scapula/Shoulder area

• Elbows

• Forearms

• Endurance training

22

Cooper 2007


After cast removed…



23

• KEYS

– Avoid Torsion load to wrist

– Look for substitution in other joints due to lack of strength:


– If no pain with initial weight bearing –progress with return to sport activities


TIPS…

• Complication

– Over dorsal radial wrist, complaint of following:

• Pain

• Numbness

• Tingling

• Burning

– Aggravated by:

• Wrist flexion and ulnar deviation and thumb flexion

• Common Answer:

– Compression of dorsal radial sensory nerve

• Treatment:

– Radial nerve gliding exercises

• 5 times per day

24

Cooper 2007


Wrist Pain:TFCC Injury


Where is TFCC?

• “Hammock‐like” Structure

• Composed of:

– Cartilage and Ligaments

• Acts as:

– Suspension of the ulnar carpus

– Distributor of force between the ulnar head and triquetrum

– Primary stabilizer for distal radioulnar joint

26Cooper 2007

https://en.wikipedia.org/wiki/Triangular_fibrocartilage#/media/File:Anatomy_TFCC.jpg


How does it occur?

• When there is a high demand for the wrist to become weight bearing structure:

– Increase in ulnar‐sided force transmission

– Ulnar positive variance

– Change in forearm motion and force distribution, which can lead to tear

• Most common ligamentous injury to gymnast wrist

• Location of injury:– Central:

• Poor blood supply=poor healing

– Peripheral:

• Good Blood supply=good healing

27

(Dobyns and Gabel)

(Cooper 2007)

http://petesportstuff.com/gymnastics-injury-prevention


Evaluation…..

• Primary responsibility with patient presenting with wrist pain symptoms:

– Good clinical reasoning to monitor progress or lack of progress

– Good biomechanical evaluation of tissues

• Discuss:…

– Good history injury

– Mechanism of injury

– Course of treatment thus far

• Early on in treatment:

– Splints??

– Therapy??

– Exercise??

– What else hurts??

28

Cooper 2007


Evaluation….

• Physical Exam

– Complaint of ulnar sided wrist pain

– Palpable tenderness over ulnar wrist joint

• With movement of:– Ulnar deviation and

pronation/supination = popping or clicking

– Forearm rotation or axial loading = pain

• Functional measurements:– Decreased strength with gripping

– Pain with any activity that loads wrist

– Types activities

– Biomechanics

29

Cooper 2007

http://i35.tinypic.com/25zi688.jpg


Evaluation….

• What else is there to look for?

– Where does pain occur?• Daily activities and/or gym

• Have they changed how they are doing things?

• Are there overuse issues?

• Why is it occurring:– Is there postural issues?

– Is there good proximal control/strength?

– Is there substitution patterns?

• Evaluation:– Postural

– Motion/strength test:• Observe if there is

hyperextensions

• Substitution at:

– Elbow/forearm/wrist

• Look at weight bearing in multiple positions

30


Patient X

31


Patient X:

32


Evaluation…..

• After few session is there improvement with…..

– Pain

– Range motion

– Weight bearing

• Communicate with MD!!!!

33


TFCC:Conservative Management


Conservative approach…

• Typically: 0‐6 weeks– Splint

– Rest of forearm and hand

– Do they need something else to address secondary injury

• Keys:– Educate on:

• Proximal Stability for distal function







• Endurance

Canton 2001



• Typically: 6‐8 wks.

– Splinting• Progress to wrist immobilization

– ROM• Active and Active Assistive exercise to wrist and forearm

• Modalities

– Ultrasound/Moist heat

– Cryotherapy at end of sessions

Canton 2001



• Typically 8‐12 weeks:– Splinting:

• Wean from splint

• Consider taping or supportive brace with weight bearing

– ROM• Active and Passive exercise to

wrist and forearm

– Closer to 10 Weeks:• Strengthening

– If asymptomatic progress to hand and wrist strengthening

– Low weight light repetitions



• After improvement in strength…


38

• KEYS

– Avoid Torsion load to wrist

– Look for substitution in other joints due to lack of strength:


– If no pain with initial weight bearing –progress with return to sport activities


Conservative Management

• Typically……– If pain persist with

strengthening or there is no improvement in pain/symptoms after 2‐4 weeks:

• Refer back to MD for evaluation for surgical interventions

– Keep in mind that for long standing injuries conservative management is not typically effective

• > than 6 months

• TIPS:– Refer sooner:

• If plateau with:– Pain

– Range of motion

– Strengthening

– Returning symptoms

39


Tips….

• If pain persist with strengthening

– Refer back to MD to consider surgical interventions

• If minimal to no improvement in pain/symptoms 2‐4 weeks

– Refer back to MD to consider surgical interventions

• Keep in mind….

– If it is long standing injury (>6 months)

• Conservative management typically not effective

40

Nagle 2001


TFCC:Surgical Management


Post-operative Managment:Phase I

• Central repair– 0‐3 weeks

• Peripheral repair: – 0‐4/6wks

• Patient is in:– Bulky post‐operative

dressing/splint

• Interventions:– Edema control

• Ice

• Elevation

– Control pain

– Protect Repair

– No weight bearing activities

– Minimized de‐conditioning– Postural stretch

– Shoulder stretching

– Posterior Strengthening

– Core strengthening

Canton 2001

http://doctorlib.info/surgery/plastic/plastic.files/image861.jpg


Post-operative Management:Phase II


• Peripheral repair– 4/6 to 7 weeks

• Patient has: – Bulky post‐operative dressing

removed

– Long forearm based ulnar gutter

• No forearm rotation

• Allows elbow, finger and thumb motion

• Continued Interventions:• Control edema

• Control pain

• Protect repair

• Continue with no weight bearing

• Continue with minimizing de‐conditioning

• New Interventions:• Begin Scar management

• Begin ROM– Central: AROM and AAROM

wrist and forearm

– Peripheral: AROM and PROM elbow and wrist.

» Emphasize EDC excursion

Canton 2001


Post-operative Management:Phase III

• Central repair– 5‐6weeks

• Peripheral repair– 7‐8 weeks

• Continued Intervention:• Control edema

• Control pain

• Protect repair

• Continue with no weight bearing


• Continue Scar management

• New Interventions:

– Central:• PROM wrist and forearm

• Light wrist strengthening

• Light ADL’s

• Wean from long splint; consider ulnar wrist gutter splint

– Peripheral• AROM to forearm

• Weighted stretches to elbow

• Wrist mobility and weighted stretches

• Light ADL’s

Canton 2001


Post-operative Management:Phase IV

• Central repair– 6 weeks

• Peripheral repair– 8‐10weeks

• Continued Intervention:• Control edema • Protect repair• Continue with no weight bearing


• Continue Scar management

• New Interventions:– Central:

• Initiate strengthening ifpatient is pain free with ROM

• If patient is asymptomatic= discharge splint

– Peripheral• PROM exercises to forearm• Dynamic splinting

– if needed to increase ROM

• Light strengthening • Splint:

– Long arm splint changed to wrist immobilization splint

Canton 2001


Post-operative Management:Phase V


• Peripheral repair– 10‐12 weeks

• Continued Intervention:• Continued scar management

• Continue with ROM and strengthening


• New Interventions:– Central and Peripheral:

• Begin progressive weight bearing

• Wean from all splints

• If no pain with initial weight bearing – progress to return to sport activities

Canton 2001


Tips…..

• As athlete is returning to higher level activity:

– Bracing

– Taping

47

Ulnar Squeeze strap

Tiger Paws

Ulnar gutter splint Skids


Thumb MP Pain


Overview of Thumb MP

• Primarily:– Hinge Joint

– Arc of motion:

• Flexion and extension

• Secondary Arc of motion– Pronation/Supination

– Abduction/Adduction

• Stability– Thenar muscles

– Adductor pollicis

– Flexor pollicis brevis

– Abductor pollicis brevis

• Range of Motion• Flexion varies:

– 6 to 86 degrees

• Lateral motion:

– 0‐20 degrees with MP in extension

49

http://eorthopod.com/hand-anatomy

Cooper 2007


Thumb MP Joint Injuries

• Injury can happen to the UCL or RCL

– UCL injuries occur 10x’s more than RCL

• Cause UCL:

– “Skier’s thumb” or “Gamekeepers thumb”

– Outstretched hand with thumb in abduction

– Forced radial deviation of thumb

50

http://www.houstonmethodist.org/orthopedics/where-does-it-hurt/hand/ulnar-collateral-ligament-injuries/

Cooper 2007


Thumb MP Joint Injuries

• Symptoms:

– Along collateral ligaments

• Pain

• Tenderness

• Swelling

– Any gentle passive stress

• Tender

• Painful

51

http://www.healthhype.com/thumb-joint-pain-causes.html

Cooper 2007


Conservative Treatment of Thumb MP Injury



• Goal therapy

– Stable and pain free functional joint

• Week 0‐4

– Edema control

– Short opponens splint

• Fitted palmar abduction

• NO MP motion

• As edema decreases may need to adjust

53

Cooper 2007



• What they need to succeed?• 504

• Private school


– Educate on:• Proximal Stability for distal function







• Endurance

54


Progression

• Week 4‐6

– Re‐evaluate!!!!

– If pain is significantly decreased:

• AROM to thumb

• Not uncommon to have to wait until 6 weeks

• Week 6

– Relatively asymptomatic:• Unrestricted AROM thumb

• Lateral pinch only

• Splint continued between exercise for comfort and protection

55

Campbell et al 2002


Progression….

• Week 8

– Splint is D/C as long as:• Non‐tender along collateral borders

– Begin Tip pinch

– Begin Thumb tip loading exercise begun

• Tips:• Persistent discomfort may benefit:

– Heat

– Deep heat in conjunction with active exercise

56

Canton 2001


Progression….

• When good pain free motion with light resistance is achieved:

– Begin Strengthening:• Begin Slowly

– Edema

– Pain

– Discomfort



– When tolerate weight bearing – return to sport activities

57

Cooper 2007


Surgical Treatment of Thumb MP Injury


RCL/UCL Repair Thumb MP Joint

• 10‐14 Days– Edema control

– Scar massage

– Long thumb spica with IP joint free

• Week 4– Pin removed

– Continue:• Edema control

• Scar management

– AROM • CMC and MP

• Week 6– Active Assist ROM 6‐8 times per day

• Flexion/extension/palmar abduction/adduction and circumduction

– Lateral pinch activities

59

(Cannon 2001)


RCL/UCL Repair Thumb MP Joint

• Week 7:

– PROM

– Dynamic flexion splint

• Week 8

– Long thumb spica splint D/C

• except for heavy lifting

– Begin Tip pinch and tip pinch loading exercises

60Cannon 2001


Progression….

• When you have:

– Good, pain free motion with light resistance is achieved:

• Begin Strengthening:

– Go Slow

– Monitor

» Edema

» Pain

» Discomfort

• At 10 weeks:

– Return to normal activity with exception of:

• Avoid sustained power pinch until 14‐16 weeks

– Weight bearing…

• Watch biomechanics!

61

Cooper 2007


TIPS…..

• If Incision is over EPL:

– Scarring may become issue prevent good excursion of EPL

• Solution

– Consider IP splint in extension at night and between exercises

62


Tips….

• FPL is easier than FPB to fire:

– So with stiffness of MP ‐ may be hard to isolate active flexion at MP…..

• Solution

– Fabricate a volar IP extension gutter splint then do MP flexion exercises

63

Return to Sport Activities

64


At this point, patient has progressed to:• Stable

• Full range of motion

• Pain free with:

– At rest

– With all motion

– Light strengthening

– Light weight bearing activities

– Began strengthening for proximal stability

65


Return to Sports:

• GOAL:

– Return to full Sport Activity

– Give them tools to remain injury free

• No repeat of same injury

• How do we do?

– Assess all biomechanics

• Postural Stretching

• Shoulder Stretching and Strengthening

• Proximal Stability


• Core Strength

• Elbow Position

• Wrist Position66


Postural Stretching

• Towel Stretching and Retraining Scapular Positioning

– Supine Towel Roll Stretch

– Side lying Towel Roll Stretch and Elongation stretch

– Trunk rotation


Shoulder Strengthening

• Proximal Stability– Shoulder collapse allows for wrist

hyperextension forces

• Posterior Strengthening– Prevent injury/re‐injury

Air Splints Exercises

Terrible 3’s

Theraband Exercises

http://www.pponline.co.uk/encyc/increase-your-dynamic-hitting-power-with-periodized-resistance-training-and-shoulder-exercises-39309


Shoulder Stability

• Shoulder Collapse • Stable Shoulder

69


Core Strengthening

70


Stability in Elbows

• Watch for hyperextension since this cause over‐rotation of wrist

71


Wrist Positioning

72


At the End, We have this….

73


References

Brach P, Goitz R: An update on the management of carpal fractures, J Hand Ther 16:152‐160, 2003

Campbell PJ, Wilson RL: Management of joint injuries and intraarticular fractures. In Mackin EJ, Callahan AD, Skirven TM et al, editors: Rehabilitation of the hand and upper extremity, ed 5, St. Louis, 2002 Mosby.

Canton, Nancy M., ed. Diagnosis and Treatment Manual for Physicians and Therapist. 4th ed. The Hand Rehabilitation Center of Indiana. Indianapolis, IN. 2001: 163‐165.

Cooper, Cynthia: Common Finger Sprains and Deformities. In Cooper, C, Editor Fundamentals of Hand Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity, Philadelphia, 2007 Mosby.

Dobyns JH and Gabel GT: Gymnast’s wrist, Hand Clin 6:493‐505, 1990.

McGough C, Surwasky M: Effect of exercise on volumetric and sensory status of the asymptomatic hand, J Hand Ther 4:177‐182, 1991.

Moscony, Anne: Common Wrist and Hand Fractures. In Cooper, C, Editor Fundamentals of Hand Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity, Philadelphia, 2007 Mosby.

Nagle DJ. Triangular fibrocartilage complex tears in the athlete. Clin Sports Med. 2001:20(1): 155‐66

Prosser R, Herbert T: The management of carpal fractures and dislocations, J Hand Ther 9:139‐147, 1996.

Wright T, Michlovitz S: Management of of carpal instability. In Mackin EJ, Callahan AD, Skirven TM et al, editors: Rehabiliation of the hand and upper extremity, ed 5, St. Louis, 2002, Mosby.

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Differential Diagnosis For Wrist and Thumb Pain · PDF fileDifferential Diagnosis For Wrist and Thumb Pain ... • Shoulder, elbow, forearm ... – Biomechanics 29 Cooper 2007