Patellofemoral Pain Syndrome

The management of Patellofemoral Pain Syndrome(PPS) is difficult, primarily because of the lack of consensus in the medical community regarding the cause and treatment. Most often athletes who participate in sports where jumping and squatting is prevalent (basketball & volleyball) experience this painful knee condition, especially female athletes. However, a large population of the general public experience this pain as well (more prevalent in middle aged women.) People who suffer from PPS generally complain of pain in the front of the knee during such activities as stair climbing and sitting for long periods of time with their knee flexed greater than 90 degrees. Swelling can be present in the front or anterior aspect of the knee.
There are a few trains of thought associated with Patellofemoral Pain Syndrome. The original thought process focused on the problem originating at the knee. When the medial quadriceps muscle (Vastus Medialis Oblique-VMO) is weak and lateral quadriceps muscle and lateral structures are too tight, this causes the patella to track incorrectly (laterally) which wears down thinner cartilage on the back of the patella resulting in a painful bone-to-bone contact. The treatment for this is to tape the patella in correct alignment and strengthen the VMO pulling the patella back to track correctly within the thicker cartilage. This increases shock absorption and lubrication providing painfree knee function. This methodology is still widely used and has approximately 50% success rate in treating PPS.

A newer thought process has surfaced recently whereby instead of looking at Where the pain is occurring, it looks at Why the problem is occurring. This approach focuses on the problem originating at the hip rather than the knee. Therapists and trainers for years have realized that a larger Q angle from the hip to the knee will increase lateral patellar tracking causing the knee to be more susceptible to PPS. This is a structural human “flaw” found more frequently in women when experiencing knee pain than men (women tend to have slightly wider hips than men). This newer thought process focuses more on weak hamstring muscles allowing the hip to rotate forward too much. This forces the femur to the inside, displacing the knee cap to the outside, causing chondromalacia patella (deterioration of the articular cartilage on the back of the patella). A common special test used is Clarke’s Sign.
To continue our focus on the hip, if we look at the function of the gluteus maximus muscle (hip extension and external rotation), we can also see that a weak gluteus maximus will allow internal rotation of the femur which gives the hip an adduction and knee genu valgum (knock knee) posture. These both will increase lateral tracking of the knee cap, leading to deterioration of the cartilage on the back of the patella (Chondromalacia).
The last anatomical structure possibly involved with Patellofemoral Pain Syndrome is the foot. If a patient has a pes planus foot posture (flat foot), this would also cause increased genu valgum at the knee, again equating to an increase in lateral tracking of the Patella.
Patellofemoral Pain Syndrome

In summary, evaluation of Patellofemoral Pain Syndrome must take several etiologies into consideration when attempting to identify the root of PPS pain:

  • Weak VMO (vastus medialis oblique) muscle
  • Weak Hamstrings
  • Weak Gluteus Maximus
  • Pes Planus (pronating foot posture)
  • Large Q angle from hip
  • Overly tight lateral knee structures

Now, let’s look at the treatment. Treatment for PPS should encompass all potential etiologies. First, strengthening the VMO which attaches to the medial border of the knee cap and helps to medially glide and hold the patella in correct tracking pattern. Second, the treatment program should address strengthening the hamstrings and gluteus maximus to avoid increasing the Q angle from the hip. The feet then should be properly evaluated for pes planus or pronated posture and corrected with orthotics. Taping techniques, such as patellofemoral taping, can be used to properly align the patella while strengthening, avoiding increased inflammation and pain in the knee. The use of therapeutic modalities such as ultrasound, electrical stimulation and icing will help stimulate the healing process as well as control symptoms. Last, a stretching program will be incorporated to such structures as the hip, quads, hamstring and calf muscles to reduce muscle tightness and promote balance.

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3 Common Overuse Injuries in the Elbow

There are many overuse injuries in the forearm.  A lot of the time the injuries occur due to poor ergonomics at work and play.  This newsletter will cover a few of the more common overuse injuries such as cubital tunnel syndrome, medial epicondylitis and lateral epicondylitis.

Cubital Tunnel Syndrome is an ulnar nerve entrapment injury at the “Funny Bone” that can occur from sleeping with the elbow flexed, leaning on elbows or medial forearm, and/or from repetitive elbow motion such as supination/pronation. Cubital Tunnel Syndrome can present symptoms of vague aching at the medial elbow, decreased sensation of ulnar 4th & 5th digits and/ or possible ulnar hand distribution only.  A late sign may also be weak intrinsic muscles of the hand. Passive overpressure to full elbow flexion with manual compression on the nerve should elicit symptoms as well as having a positive Tinel’s at the medial elbow. Treatment of cubital tunnel syndrome begins by resolving compression at the medial elbow (i.e. resting on elbow, sleeping with flexed elbow, or repetitive elbow flexion) by modifying the aggravating activity and/or wearing a night sleeping splint. Anodyne infrared light therapy over the ulnar nerve helps to improve the conductivity of the nerve and is greatly effective when used in conjunction with inflammation reducing modalities (such as iontophoresis) over the cubital tunnel. Nerve glides also help to reduce neural tension.

Lateral Epicondylitis (Tennis Elbow) is a non-neurological overuse injury causing pain at the lateral epicondyle. Other signs and symptoms may be an increase in pain with extended elbow grip (especially while pronated), pain with resisted wrist extension and pronation, and a possible decrease in wrist flexion. Tennis Elbow is usually caused by activities that involve excessive grasping with an outstretched arm, reverse “wrist curls” and one handed backhand in tennis. Treatment usually begins with pain and inflammation reducing modalities such as: ultrasound, light therapy, iontophoresis, and cryotherapy. Lengthening of the extensor carpi radialis (ECR) and extensor tendons by stretching and myofascial release to the muscles are effective ways of reducing the tension on the tendon and epicondyle, helping to reduce the cause of the problem. Isometric and eccentric strengthening of the ECR and extensor muscles is also a good way of lengthening the muscles while increasing
their strength. Patient education regarding avoidance of exacerbating activities and proper ergonomics is key for keeping the tendon and epicondyle from being irritated by overuse. If conservative treatment is ineffective, a possible Cortisone injection may be warranted and possibly even platelet concentrate growth factor injections.

Medial Epicondylitis (Golfer’s Elbow) is characterized by pain at the medial epicondyle and flexor muscles of the forearm. Patients generally have pain with resisted wrist flexion and may possibly present a decrease in wrist extension. Golfer’s elbow may be elicited by activities that require repetitive wrist flexion/gripping or tight gripping. Other activities that may cause or exacerbate this condition are repetitive activities with the wrist fully extended (i.e. push-ups), pronation with wrist snap into flexion during tennis, lack of follow-through with golf swing, and static supination. Treatment of medial epicondylitis is generally the same as lateral epicondylitis with the focus moving to the flexor group of muscles.

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Painful Numb Feet

An estimated 15 million people nationwide suffer from Peripheral Neuropathy. While effectiveness of treatment for this in the past has been less than ideal, we at Humboldt Hand and Foot Therapy believe we’ve found an answer.
Cause: First ,we must take notice to the fact that there are multiple causes for Peripheral Neuropathy. Not just a diabetic problem, many people with circulatory, chemotherapy, alcohol, or central nervous system problems also suffer from this disorder. Peripheral Neuropathy presents with the following symptoms: burning, electrical sharp/shooting pains, tingling and numbness that gradually progresses proximally from the toes or fingers to involve the feet and/or hands. Another common experience is that the severity of the symptoms increases at night often disrupting sleep patterns. Put simply, Peripheral Neuropathy is nerve damage caused for one reason or another by insufficient blood flow to the nerves in the feet, legs, and hands.
Treatment Options:1. Anodyne Infrared Therapy 2. Dynatron STS 3. The ReBuilder
Our Approach
We begin with an individual assessment of the difficulties patients are experiencing. We ask what the patient’s goal in treatment is and how they would like to improve. Then, with the help of their physician, we determine what is causing the pain or loss of sensation. This enables us to specialize a therapy program to help reach those personal goals, whether it be with our Anodyne, STS, ReBuilder or combined programs.
Anodyne Infrared Light Therapy (MIRE)
Photo energy increasing microcirculation, possibly through the release of nitric oxide, has been clinically documented in many published studies. This is exactly what a neuropathy patient needs improved blood flow to return the nutrients that the nerves have been starving for. Most patients say that Anodyne therapy feels warm and soothing. This clinically proven program may reduce pain, improve sensation and certainly prevent further progression of the neuropathy. Doppler imaging below shows just how substantial these increases in circulation can be in the feet of neuropathy patients. A 400% increase with Anodyne vs. 40% with a hot pack is seen below.

Sympathetic Therapy System (STS)
STS is a revolutionary new therapy for the treatment of chronic intractable pain. From Peripheral Neuropathy to Complex Regional Pain Syndrome, this treatment program has shown great promise for treating chronic pain. STS works by applying electrodes bilaterally over peripheral dermatome sites. This comfortable, unique form of stimulation is different than the typical TENS unit. By stimulating bilaterally over these peripheral nerve sites, communicating along these nerve pathways across the spine we can target the Sympathetic Nervous System. Calming or normalizing these nerves helps to shut down pain signals and dilate peripheral blood vessels, increasing blood and nutrient supply to the hands and feet. This treatment program has great results treating Peripheral Neuropathy and shows good potential in helping patients with RSD and other intractable pain disorders. In a study of 47 patients over only 28 days of treatment, 70% of patients reported a 30% decrease in symptoms; 36% of patients reported a 50% improvement in symptoms. These are significant numbers in only 1 month of treatment.
The ReBuilder
The Rebuilder is another electrical stimulation device designed to directly heal damaged nerves. When our nerves are starved of blood supply, hypoxia ensues (oxygen deprivation). This causes our nerves to shorten which increases the synaptic gap adjoining the nerves. This enlarged synaptic gap may be the cause of neuropathies random tingling and disoriented shooting nerve pains. The Rebuilder re-polarizes and re-educates the nerves to follow the correct paths. It jumps that widened gap, reconnecting the injured nerves, delivering minerals and nutrients, which revitalize those nerves. When this is accomplished it promotes new nerve growth, restores blood flow and returns feeling to the patient’s extremities, reducing pain. The Rebuilder is used at the Cancer Treatment Centers of America to treat chemotherapy induced neuropathy with a 96% success rate.
These comfortable non-invasive treatments have no negative side effects and can, combined with specific stretching, strengthening, and balancing exercises, help to reverse the symptoms of many nerve pain conditions. Best results are achieved with a 3 treatment per week protocol for 4-6 weeks. All of these treatments are FDA and Medicare approved and have home units to continue treatments at home once proven to be effective.
*Contraindications- Pregnancy, Thrombosis (blood clots), Pacemakers, actively treated cancers
Our clinically proven programs may reduce the discomfort of neuropathic pain syndromes and help patients recapture the life they once enjoyed.

Please call us with questions or to schedule an appointment (707)-441-1931

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Growing Pains

Young athletes can suffer with several different growth plate disorders associated with running and jumping in a particular sport.  Soccer and basketball players who put on either miles of running in cleats or running and jumping on hardwood floors top the list of most commonly affected by these diagnoses.  This article will summarize the three most common “growing pains” syndromes associated with young athletes.

Sever’s Disease – Calcaneal Apophysitis

Athletes 9 to 14 years old who are experiencing increased heel pain may have Sever’s disease (not truly a disease) or commonly referred to as calcaneal apophysitis. Any sudden increase in running and/or jumping can cause irritation to the growth plate in the calcaneus (heel bone).   This presents with significant heel pain, usually where the Achilles inserts into the calcaneus.  Sometimes pain can run under the bottom of the heel as well.  Athletes complain of generalized heel pain with running and jumping and often have a limp with walking.   Low grade localized swelling may be present at the heel, again where the Achilles inserts into the calcaneus.  Typical cause of Sever’s calcaneal apophysitis is the length of the muscles not keeping up with bone growth.  During growth spurts bones get longer and strong muscles and tendons lag behind in length.  Combined with running and jumping, this creates significant tugging where the muscle’s tendon inserts into the bone close to the growth plate causing bone irritation and pain.

Treatment of Sever’s disease includes rest, stretching of gastroc and soleus musculature (calf muscles), massage and icing.  A comprehensive evaluation of weightbearing foot posture is important as improper foot mechanics can lead to increased stress at the heel.   Orthotics make sure a young athlete’s foot is in the correct heel and arch and position.  With rest, stretching, icing and proper foot wear and orthotic, the athlete will totally recover and returned to their sport.  If pushed and not treated, this can continue to be painful until the athlete takes a couple of months off to rest.

Osgood-Schlatter’s Disease

One of the most common causes of knee pain in young athletes is OsgoodSchlatter’s disease – another stress to growth plate caused by tight muscles pulling at growing bones. With increased running and jumping, the insertion of the patellar tendon tugs at or near the growth plate on the top front of the shin bone – the anterior tibial plateau.  The bone gets inflamed and irritated, sometimes responding by putting down more calcium deposits which is why at times we see an enlarged hardened growth where the patellar tendon inserts into the shin bone.  Athletes complain of anterior knee pain with running, jumping, climbing and descending stairs.  Treatment consists of rest, stretching of quadriceps muscles, massage and icing.  They do make knee braces for this diagnosis which have moderate success.  The knee brace applies pressure to the patellar tendon which decreases the pull of the tendon on the bone allowing a better chance for healing. Again, this diagnosis can drag on for months if not rested and treated.

Sinding-Larsen-Johansson Syndrome

Similar to Osgood-Schlatter’s, this growing pains diagnosis affects the knee. With Sinding-LarsenJohansson syndrome the patella (kneecap) itself is painful. The kneecap is painful to touch, the athlete complains of anterior knee pain with running, jumping, stairs and squatting. Lengthening of the quadriceps muscle is imperative to decrease the tugging on the patellar tendon’s insertion into the kneecap.   This diagnosis, as with the previous two, is caused by short muscles pulling on growing bones causing irritation to the bone itself.   Treatment is the same: rest, stretch, massage, ice.  Knee braces can be of some help to decrease tugging of the tendon on the bone.

All three of these diagnoses cause irritation and inflammation to the bone.  Rest, stretching, icing, proper foot wear and a healthy diet of natural antioxidant anti-inflammatories will help return the young athlete to their sport.  Continued treatment and slow progression into a strengthening program of all adjacent musculature after symptoms are at least 80% resolved helps to prevent recurrence of these “growing pains” syndromes.

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Shoulder Replacement Procedures

Two Shoulder Replacement Procedures that we commonly treat in the clinic are: the Total Shoulder Arthroplasty (TSA) and the Reverse Total Shoulder Arthroplasty (rTSA). The primary reason for either surgery is PAIN. The common etiologies for severe shoulder pain are Osteoarthritis, Rheumatoid Arthritis, Severe Rotator Cuff Pathology, Osteonecrosis ( When blood supply to the bone is limited and the bone cells die) and Fracture of the Humeral Head. When conservative therapeutic rehabilitation measures are exhausted, shoulder replacement surgery is considered. The TSA and the rTSA are surgical procedures that can improve the quality of life for those who have severe pain with activities of daily living and sleeping. Surgical outcomes for these procedures are moderate to complete relief with restored functional range of motion. The goal of these surgeries is to replace the shoulder joint or glenohumeral joint with a prosthesis, to create a stable fulcrum of rotation.
The Shoulder is made up of three bones the Humerus, Scapula and the Clavicle. The Rotator Cuff is made up of four primary muscle; Supraspinatus, Infraspinatus,Teres Minor, and Subscapularis. The rotator cuff is the primary stabilizer for the shoulder joint. The Total Shoulder Arthroplasty (TSA):
The TSA replaces the glenohumeral joint with a prosthesis consisting of a metal ball with a stem and a polyethylene cemented component (plastic socket).
The TSA was first introduced to the medical community by Dr. Charles Neer in the early 1950’s to treat severely displaced fractures and dislocations of the proximal humeral head. There are approximately 53,000 shoulder replacements performed each year in the United States. The TSA is considered, when the patient does not have sever rotator cuff pathology.
The most common approach of access to the glenohumeral joint is through the anterior aspect of the shoulder (deltopectoral approach). In this approach it is necessary to alter the position of the subscapularis. This can be done in two ways:

  1. A Subscapularis Tenotomy- The Subscapularis tendon is cut and later repaired after the shoulder prosthetic is placed.
  2. Lesser Tuberosity Osteotomy -the location of the insertion of the subscapularis (which is the Lesser Tuberosity) is removed with the subscapularis tendon attached. Fallowing the placement of the shoulder prosthetic, the lesser tuberosity is reduced to the humerus and sutured to secure into place.

The Rehabilitation protocols differs in regard to internal rotation depending on the approach. General Guidelines are as follows for TSA rehabilitation protocol:

  • Subscapularis Tenotomy with repair: no resisted internal rotation until 4 ½ months post sur-• gery.
  • Lesser Tuberosity Osteotomy: no resisted internal rotation until 3 months post surgery and • x-ray to confirm Lesser Tuberosity healing
  • Postoperative sling • Maintain surgical motion without pushing beyond end point.
  • Strengthen surrounding musculature under the supervision of a outpatient therapist for 12-18 weeks

The Reverse Total Shoulder Arthroplasty (rTSA):
The rTSA prosthesis reverses the orientation of the shoulder joint by replacing the glenoid fossa( the concave portion of the shoulder joint) with a glenoid base plate and a glenosphere and the humeral head with a shaft and concave cup. Paul Grammont from Dijon France was successful in designing prosthesis for the rTSA that were used in Europe in 1992 and approved in the United States by FDA in 2004. Grammont’s rTSA prosthesis was designed for patients with rotator cuff deficient shoulders and failed TSA. In patients with deficient rotator cuff, the shoulder joint (or the fulcrum of motion) is unstable and the humeral head migrates anterior (forward) and superiorly (upward) to the outer rim of the glenoid fossa creating insufficiency of the deltoid muscle and significantly limited motion. Grammont’s prosthesis changes the rotation of the shoulder joint or placement of the fulcrum to be more medially (toward midline) and inferiorly (downward). As a result, the mechanical advantage of the deltoid is maximized. The deltoid compensates for the deficient rotator cuff and becomes the primary elevator for the shoulder. In patients without external rotation from a non-functioning Teres minor prior to surgery the Latissimus dorsi (a strong internal rotation muscle) is used as a tendon transfer to assist in external rotation. This allows the patient, who previously was unable to feed themselves or apply deodorant, more functional use.

General Guidelines for the Reverse Total Shoulder Arthroplasty Rehabilitation Protocol:

  • Joint Protection: rTSA has a higher risk for internal rotation dislocation.
  • Avoid such motions as extension past neutral and a combination of adduction and internal rotation for 12 • weeks (such as tucking in your shirt or performing bathroom duties/ personal hygiene.)
  • Maintain elbow in your visual spectrum• In a sling post-operatively
  • Outpatient therapy begins at 6 weeks post surgery and continues for 6-8weeks.
  • Deltoid functions is emphasized to secure stability and mobility of the shoulder joint.

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Humboldt Hand and Foot Therapy specializing in the care of the hand, upper extremity, foot and ankle. Services Offered: Evaluation• Rehabilitation• Custom splint • Custom orthotics• Personal Training• Pilates exercise classes• Balance programs• Frequently Seen Diagnoses: Tendon and nerve • lacerations Fractures• Arthritis• Cumulative Trauma• Crush Injuries• Amputation• Tendon transfers• Joint replacements• Fusions• Balance training• Conditioning• Strengthening • Rotator cuff injury• Frozen shoulder• Plantar fasciitis• Tendonitis of the ankle• Treatment May Include: Home programs• Range of Motion• Strengthening• Clinical modalities• Myofascial massage• Edema control• Scar remodeling• Kinesio Taping• Desensitization•

From Humboldt Hand and Foot Therapy, INC Treatment News November 2009 Orthotics Foot pain can impact your life and activity in a hurry. If your feet aren’t doing their job, it’s hard for you to do yours. It can also be difficult to get rid of foot pain if you are unable to get off your feet and rest. Other issues like high pressure, specific activity, diabetes and structural or biomechanical problems can make becoming pain-free even more difficult. Pain often signals an underlying problem. Common problems such as various types of tendonitis, neuromas, plantar fasciitis, heel pain, calluses, pressure wounds, bunions, flat feet, shin splints, hip/low back pain and many other issues can be resolved or improved with an orthotic. An orthotic improves improper foot motion, relieves pressure and can often be very helpful in resolving pain. An orthotic can be either functional, in that it solves a mechanical problem such as excessive pronation, or accommodative to reduce pressures, shock and shear force.
Orthotics are helpful in the following ways: Reduce unwanted pressure and distribute • forces evenly throughout the foot Help absorb shock during walking or • running Correct biomechanical imbalances• Resolve pain • Improve mechanics during gait• Improve comfort• Protect against sores and infection.

Custom Orthotics

Custom foot orthotics are fabricated for Humboldt Hand and Foot Therapy by Foot Therapy Orthotics. The orthotic lab is a full service lab with state of the art equipment. The foot can be casted or scanned and orthotics provided within two days (scanning captures a highly accurate 3-D image of the foot with +/- .5mm margin of error). Modifications or adjustments are speedy as well, often a two day turnaround. Custom foot orthotics or inserts can relieve pain by controlling how your foot moves. An orthotic reduces the speed of pronation or flattening of the foot. It also limits the swing of your heel so that your heel strikes the ground in the correct position. During midstance, the orthoses lift your arch so that the ankle and heel can obtain better alignment.

Normal Gait

When you take a step and At midstance, your heel is As your heel lifts, you regain your heel first touches the in neutral and under your your arch, your foot stiffens ground, it does so on the ankle, in a full weight-bearing to allow push-off and your outer edge and your foot position, and your arch drops. heel pressure is a bit on the flattens to absorb heel strike. inside.
When your foot does not move properly through the gait cycle, specific structures can be put under too much strain and pain or injury can result. An orthotic can help to solve this problem. The following issues can be treated with orthotics:

  • Heel or arch pain
  • Callus
  • Toeing-in or toeing-out
  • Flat feet *Morton’s neuroma
  • Pain at the ball of the foot
  • Joint pain
  • Leg length inequality
  • Deformity *Bunions
  • Knee/hip/lowback pain
  • Loss of sensation
  • Wounds that are slow to heal in the foot

Orthotic Basics Accommodative: These orthotics accommodate foot deformities, sore spots and relieve pressure. They are made from softer materials such as EVA, foam, cork and leather that cushions your foot but offers little control. Functional: Made from more sturdy materials that tend to be harder such as graphite or plastics, this type of orthotic’s job is to control unwanted foot motions. The more flexible materials will also absorb shock to reduce strain. Even hard orthotics can be topped with soft material to provide some cushion and comfort.

Over the Counter (OTC) Orthotics Our OTC orthotics are made to fit common foot types at a competitive price. They can be effectively used as a temporary solution for children who are rapidly growing or as a ‘first’ step for any age to provide relief before receiving a more corrective support with a custom-made foot orthotic. OTC orthotics generally do not last as long as the custom orthotics.

For more information or to make a referral, please call: (707) 441-1931

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Humboldt County’s Only Dedicated Hand And Foot Center

Dedicated Center for Hand and Foot Rehabilitation Did You Know? Humboldt Hand and Foot Therapy is the only dedicated hand and foot center in Humboldt County.  What is a Hand and Foot Therapy Clinic?  Humboldt Hand and Foot Therapy is a rehabilitation clinic dedicated to the specialty care of the upper extremity, foot and ankle.  We have two hand therapists on staff who have a combined total of fifty years of experience.  We treat problems or injuries of the shoulder, elbow, wrist, and hand, as well as the ankle and foot.  We work with all the local orthopedic surgeons, podiatrists, rheumatologists, chiropractors and family practitioners to provide quality specialized treatment.


De Quervain’s tenovaginitis is a common condition in one-third of all cases of tenovaginitis affecting the hand and the wrist.  The first dorsal compartment of the extensor retinaculum is comprised of the abductor pollicis longus (APL) and the extensor

pollicis brevis (EPB) tendons and is approximately 2 cm in length.  There is a great deal of anatomic variation in this area.  In fact, it is estimated that only 20% of individuals have normal anatomy.  The EPB is always thinner than the APL and may be absent in 5 to 10% of the population.  The first dorsal compartment is easily visualized by thumb extension and radial abduction.  In cases of acute symptomatology, the first dorsal compartment may appear washed out due to swelling.  Inflammation may be easily noted, and there is a spongy painful appearance with palpation. Forceful sustained or repetitive thumb adduction and simultaneous wrist ulnar deviation and flexion may contribute to the development of De Quervain’s tenovaginitis.  Pinch or grip coupled with wrist flexion and ulnar deviation is also a high risk motion.  Typically, the incidence of De Quervain’s may occur from approximately the fourth decade on but can occur in younger population performing repetitive, sustained work activities. Opening jars, wringing hands, cutting with scissors, holding surgical retractors, piano playing, and needlework are a few examples of activities that provoke De Quervain’s. Women appear most susceptible to the disease compared to men by at least a 4:1 ratio.  Women in the third trimester and those with young children are also vulnerable.  Although less common, acute injuries to the first dorsal compartment can occur.  A sudden wrenching of the wrist and thumb while trying to restrain an object or person, or a fall on an outstretched arm can lead to injury. The diagnosis is straightforward.  Active thumb extension against resistance may prove quite painful.  A Finkelstein’s test December 2008 in which the patient holds the thumb into the palm and the wrist is ulnar deviated will show a positive test when painful.  Wrist flexion and extension can be added to this maneuver with wrist flexion intensifying the pain and extension relieving it.  Additional sources of radial wrist pain must also be considered.  These include trapezial metacarpal arthritis, scaphoid fractures, arthritis of carpal joints, scapholunate instability, intersection syndrome and a radial neuritis.  These conditions can coexist with De Quervain’s.  Radiographic studies should be performed to rule out the above conditions. Once a diagnosis has been made and treatment is indicated, the first approach is to stop all provocative activity that exacerbates the symptoms.  For an active adult this is easier said than done, especially if it is the individuals dominant hand.  Utilization of a thumb spica splint to rest the APL and EPB tendons is the first step.  In the acute stages, a 14 to 21 day treatment course of NSAIDs can be helpful.  Utilization of ice can also be of benefit in managing pain and decreasing inflammation.  A steroid injection may be the next step if conservative measures are not effective.  Success rates of 50 to 90% are reported following one or two injections, with up to a 90% success rate with symptom duration of less than two months.  For those individuals apprehensive about an injection, a treatment called iontophoresis, which

is a transdermal patch with a corticosteroid solution (4% Dexamethasone) is a viable alternative and performed in the clinic. Typically, a series of 8 to 10 treatments at 2 to 3 times per week in conjunction with splinting and rest can be of benefit.  Lastly, for individuals with long term chronic pain, if conservative measures have been exhausted, an orthopedic consult should be considered for a possible 1st dorsal compartment release. Happy Holidays from Humboldt Hand and Foot Therapy

Our staff left to right: Margie Flanagan, Myrna Rousseau, Patrick Sarabia, Karen Radford, Carli Creech, and Laurel Nyborg Not pictured: Aldine Pollock and Deidra Scott

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Osteoarthritis Of The Trapezial Joint

OSTEOARTHRITIS OF THE TRAPEZIAL JOINT Trapeziometacarpal (TM) joint with osteoarthritis (OA) has a specific classification based on radiographic findings. These findings are as follows: Stage I: painful synovitis (inflammation of the synovial membrane) with effusion and hypermobility. Stage II: radiographs show classical OA changes of joint space narrowing, osteophytes or joint debris less than 2 mm in diameter. Often there is less mobility and only minimal crepitus. Stage III: advanced OA with marked crepitus but without scaphotrapezial (ST) joint disease. Stage IV: advanced OA of the TM joint with radiographic OA changes in the ST joint. OA most commonly affects the two distal joints of the fingers and thumb CMC joints. The thumb CMC joints tend to be the most symptomatic. However, osteophytes can occur at the MP joint where they can cause triggering of the flexor tendons. Osteophytes can also be found at the wrist and intercarpal joints which can limit motion and cause pain. Men and women have the same distribution of osteoarthritis, however women have more severe symptoms. One contributing factor to a painful thumb joint is generalized ligamentous laxity with consequential joint hypermobility. Recent studies document hypermobility, especially in the thumb CMC joint, which may result in a variety of overuse lesions and osteoarthritis. In the patient with moderate symptoms of osteoarthritis, asking them to point where they are having pain will often reveal them pointing to the base of the thumb. In addition, upon visual inspection of the CMC joint, a squaring (or a shoulder) can be observed at the base of the thumb. If this is noted, a further physical examination is usually not indicated secondary to prolonged pain and swelling. If no visual anomaly is noted, a grind test of the CMC joint can be performed. This test is done by palpation over the CMC joint while compressing and rotating the 1st metacarpal in the CMC joint. Distraction of the joint at the end of the grind test is also performed to demonstrate capsular tenderness. In addition, a Finkelstein’s test is also indicated for localizing the pain in the first dorsal tendon compartment and for identifying de Quervain’s tenosynovitis. The first line of treatment, once a diagnosis of trapeziometacarpal OA is confirmed, is the utilization of a custom fabricated thumb spica splint. Depending of the severity of symptoms, the splint may consist of a thumb MCP/CMC stabilization or a CMC stabilization only. However, it is important to be aware that the MCP joint is subject to greater forces when not splinted, secondary to the restriction at the CMC joint. Consequently, non stabilization of the MCP joint requires a healthy MCP joint. Many thumbs that exhibit CMC OA also have MCP issues such as hyperextension. Effective splinting for CMC arthritis may reduce the need for surgery. However, for active adults who wear a stabilization splint, nonadherence to splint usage is evident. This is secondary to the splint being too restricted, especially for writing, knitting and sports. It should also be noted that many individuals with CMC osteoarthritis have poor thumb mechanics and muscle imbalance which put this joint in a poor position and can…/hand_cmc_anat02.jpg public/patient_education/65
1775 Harrison Ave, Eureka, CA 95501 ~ Phone (707)441-1931 Fax (707)441-1940

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