Wrist Injuries, Tendinopathy, RSI and Carpel Tunnel Syndrome

Our wrist is made up of 8 small bones (carpal bones).  These bones are held together by ligaments.  In addition to these ligaments, many small muscles, nerves, tendons and blood vessels pass through the wrist to supply your hand (6).

The nerves for your arm and wrist leave your spinal cord at your cervical spine (your neck). Compression of the nerves any where along their course can cause pain, tingling, numbness and burning. You can strain or sprain these ligaments or muscles from a sudden movement, improper movement, or through over use. Some common injuries include (6):

1.    Tendinopathy
2.    RSI (repetitive strain injury)
3.    Carpel Tunnel Syndrome

 

1. Tendinopathy

Tendinopathy is an over use injury that can occur with over use of any muscle. The tendon is the tissue that attaches the muscle to the bone. Tendons are usually surrounded by a sheath of tissue similar to the lining of the joints (synovium)(6). They're subject to the wear and tear of aging, direct injury and inflammatory diseases. The most common cause of tendinitis is injury or overuse during work or play (10).

You have a greater risk of developing tendinopathy if you perform excessive repetitive motions (7). For example, swimmers, tennis players and golfers are susceptible to tendinopathy in their shoulders, arms and elbows. Basketball players, runners and dancers are more prone to tendon inflammation in their legs and feet (10).

You don't have to be a professional athlete to develop tendinopathy. The incidence  increases with age as muscles and tendons lose some of their elasticity. Improper technique in any sport is one of the primary causes of overload on tissues, including tendons, which can contribute to tendinitis.

Lateral epicondylitis (tennis elbow) can cause wrist/ forearm or hand pain (7,10).  This type of tendonitis includes the muscles that extend your wrist (bends your wrist back wards).  This causes pain on the outer side of your forearm near your elbow when you rotate your forearm or grip an object.   Working at the computer with your hand bent up toward you is a common cause of this type of tendinopathy (8).  It is often confused with carpal tunnel syndrome. A less common problem is tendinopathy of the wrist flexors (muscles that bend wrist forward) (10).  The technical name for this is medial epicondylitis, also known as golfer's elbow.  Golfer's elbow causes pain on the inner side of your forearm near the elbow when you grip objects or flex at the wrist.



Treatment
The aim of  treatment is to try and relieve pain and reduce inflammation. If the pain is present for more than a couple of days seek attention from your  primary care provider.  The role of your chiropractor or osteopath is to help you  via hands-on treatment (11,12,13) and appropriate self management such as appropriate excercises (14,15).

2. Repetitive Strain Injury (RSI)

Repetitive Strain Injury (RSI), or cumulative trauma disorder (CTD) develops from continuous low level stress on any muscle or joint. It is appears to becoming more common in the wrist and arm from the increased use of computers (8).

RSI can be difficult to treat.  It often involves tendinopathy of all the wrist muscles, mild carpal tunnel syndrome, as well as problems at the wrist, shoulder and neck. If you have aches in your hands that lasts after you stop work and keeps getting worse you should consider getting it checked.  Treatment with soft tissue techniques, active release technique, excercises, neural mobilisations, and manipulations may help (4,5).
 
Signs and Symptoms:      
  • Pain, deep ache, numbness or burning of the hand, wrist, arm or shoulder.
  • Limited range of motion of fingers, wrist or shoulder. Check your other wrist to find out what is normal for you.
  • Stiffness or soreness of the muscles at the hand, elbow, or shoulder

Causes
  • Repeated use of the arm or wrist in an awkward position such as typing, using the phone, operating a machine or playing sports.
  • Postural strain ( improper position when sitting - reaching )
  • Falling and landing on an out stretched arm. This is a common cause of a wrist fracture.
  • Swelling of the wrist. This can compress the median nerve as it passes through the carpal tunnel.
  • Often there is no obvious cause.

Risk Increases With
  • Working at a desk for long periods.
  • Repeated bending the wrist or reaching out with the arm.
  • Participation in sports without proper training. Especially golf, tennis, squash, and baseball.
  • Sharp increase in athletic activity (weekend athlete)
  • Playing musical instruments. Proper training and following a program where you gradually increase the amount of time you play can prevent injury.

How to Prevent
  • Rest your arm in a comfortable position when you are using your arm and wrist (see section on posture )
  • Take frequent breaks at work, or when learning a new sport or instrument, to stretch your arms.
  • Get proper training when taking up a new sport or learning a new instrument.
  • Use proper equipment on the job or with sports.
  • Learn how to sit properly.

3. Carpel Tunnel

Carpal tunnel syndrome (CTS) is an injury caused by a pinched or irritated median nerve in the wrist. The injury causes pain and numbness in the index and middle fingers and weakness of the thumb. The carpal tunnel receives its name from the eight bones in the wrist, called carpals, which form a "tunnel" through which the nerve leading to the hand extends (9).

Signs and symptoms of CTS include(9):

  • Night time painful tingling in one or both hands, frequently causing sleep disturbance
  • Feeling of uselessness in the fingers
  • A sense that fingers are swollen even though little or no swelling is apparent
  • Daytime tingling in the hands, followed by a decreased ability to squeeze things
  • Loss of strength in the muscle at the base of the thumb, near the palm
  • Pain shooting from the hand up the arm as far as the shoulder

The carpal tunnel is filled with tendons (bundles of collagen fibers that attach muscle to bone) that control finger movement Carpal Tunnel Syndrome stems from prolonged repetitive use of this nerve.



The compression present in carpal tunnel syndrome (or 'pinched nerve') does not always occur at the wrist. A pair of nerve roots emerges from the spinal cord at each vertebral level of the spine and the median nerve is formed by several nerve roots emerging from the lower neck. From there, the median nerve travels down the arm to the wrist and hand and can become entrapped anywhere along its path.

Carpal Tunnel can originate from a number of activities, such as repetitive keyboard typing. Carpal Tunnel Syndrome develops most commonly in people aged 40-60, particularly women.

Symptoms of Carpal Tunnel Syndrome such as shooting pain, weakness and tingling may also be the result of nerve entrapment in the elbow or a previous autoimmune injury. Thorough examination can determine whether your wrist pain may be due to Carpal Tunnel Syndrome or another musculoskeletal condition (9).

There are a number of non-surgical options for the treatment of CTS, such as exercises or mobilisation, ergonomic modification (equipment or positioning), splinting, therapeutic ultrasound, oral medication, vitamins and complementary therapies (1,3,5). Exercise and mobilisation interventions include chiropractic and osteopathic manual interventions (1).

Behaviour modification may be necessary, and advice can be given by your health practitioner as to how to implement changes in your work and daily life. Paying attention to proper ergonomic principles and posture can also help overcome Carpal Tunnel Syndrome (2).

CTS in advanced stages can become quite serious, involving a loss of sensation, muscle deterioration, and permanent loss of function, in these cases surgery may be necessary.

References
1. Page MJ,  O'Connor D, Pitt V and Massy-Westropp N. Excercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database of Systematic Reviews. June 2012

2. Pierre Côté, Kristi Randhawa, et al. Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults. Cochrane Database of Systemic Reviews. Aug 2012

3. Muller M, Tsui D, Schnurr R, BiddulphDeisroth L, Hard J, MacDermid J C. Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review. Journal of Hand Therapy.2004;17(2):210228.

4. .Sutton D, Gross DP, et al. Multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Chiropractic & Manual Therapies 2016 24:8

5. Kobesova A, Dzvonik J, Kolar P, Sardina A, Andel R. Effects of shoulder girdle dynamic stabilization exercise on hand muscle strength. , Isokinetics and exercise Science. , 2015;23:21-32, 0959-3020
6. Magee DJ (2008). Orthopedic Physical Assesment Ed 5. pg 972-1012. Saunders Elsevier. ISBN-13:978-0-7216-0571-5
7. Fedorczyk JM. Tendinopathies of the elbow, wrist, and hand: histopathology and clinical considerations. J Hand Ther. 2012 Apr-Jun;25(2):191-200; quiz 201. doi: 10.1016/j.jht.2011.12.001
8. Victor CW Hoe , Donna M Urquhart , Helen L Kelsall and Malcolm R Sim (2012). Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults. Online Publication Date: August 2012. Cochrane Database
9. CushJJ, Kavanaugh A, Stein CM (2015). RheumaKnowlegy. ICD9 code:270.0. www.rheumaknowledgy.com
10. Brukner P, Karim K (2012). Clinical Sports Medicine 4th Ed. McGrath-Hill Education. ISBN:9780070998131.
11. Paungmali A, O'Leary S, Souvlis T et al (2003). Hypoalgesic ans sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Phs Ther;83(4):374-83
12. Vicenzino B,
Paungmali A, Buratwoski S et al (2001). Specific manipulative therapy for chronic lateral epicondylalgia produces uniquely characterstiv hypoalgesia. Man Ther;6 (4):205-12
13. VicenzinoB, Collins D, Wright A. The initial effects of cervical spine manipulative physiotherapy treatment on pain and dysfunction of lateral epicondylalgia. Pain;68:69-74
14. Pienimaki T, Tarvainen T, Sira P et al. (1996). Progressive strengthening and stretch excercises and ultrasound for chronic lateral epicondylalitis. Physiotherapy;82:522
15. Svernlov B, Adolfsson L (2001). Non-operative treatment regime including eccentric training for lateral humeral. Scand J Med Sci Sports;11:328-34