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Wrist pain
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Wrist pain - October 1, 2008 10:47:48 AM
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proud
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I had a fellow today that presented with left wrist pain without a mechanism of injury. He has had the pain for 4 weeks. He has been resting it for 2 weeks.
He reported that he had started a push up -work out routine that he found on the internet that basically builds you up to doing 100 push-ups per day. But he does not recall anything involving the push-ups that brought it on.
Here are the findings:
1. Pain is not constant
2. Pain is specifically located over the doral aspect of the ulnar wrist( over the ulnar styloid with an achy feeling into the 4th and 5th metacarpels as well as up the ulna to about mid forearm
3. Pain is ALWAYs brought on with end range supination especially with my over pressure. Does not seem to matter where I direct the supination. If I de-rotate the wrist and supinate the forearm....he still gets the sharp pain. Unless he forces the supination it's not painful.
4. Resisted wrist extension, flexion, supination all reproduce the pain. Resisted elbow flexion with forearm supinated causes the pain( the elbow starts fully extended).
5. ULTT reveal nothing.
6. No tenderness on palpation.
7. Full wrist/elbow ROM
Any takers?
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RE: Wrist pain - October 1, 2008 11:53:16 AM
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bonez
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Proud is there any issues with carpal mobility (deficit or excess) near the triquetrum/lunate? Does stabilizing one carpal and shearing the adjacent reproduce pain? Or similar moves at the crtilage complex. Finally is supination discomfort improved if done with gentle distraction?
My initial thinking leans to a movement restriction of a carpal or synovial irritation in the region mentioned.
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RE: Wrist pain - October 1, 2008 12:21:28 PM
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TexasOrtho
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Ulnar sided wrist pain can be really tricky sometimes. I've heard it referred as the LBP of the hand. TFC sensitization sounds possible here. The most likely scenario is ECU tenosynovitis. Often see this with severely painful passive supination. I agree with bonez that carpal instability can play a role here as well. Any history of old trauma?
I wouldn't put too much stock in ULTT here as they aren't real specific to the ulnar nerve. I'd still consider neurodynamic movement of the distal ulnar nerve via gentle finger wrist extension with the elbow flexed 70 to about degrees and neutral pronation. I have patients perform this 100-200 times per day and see how their symptoms respond. Sometimes you will see an acute increase or decrease in symptoms and then you know you are on to something. You have to make sure they don't go to end ranges so as not to irritate the TFC and confound the findings. I also perform gentle transverse friction to the sensitized area with the forearm in slight pronation, wrist extension, and ulnar deviation.
Good case proud.
< Message edited by TexasOrtho -- October 1, 2008 12:35:47 PM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Wrist pain - October 1, 2008 12:44:18 PM
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jesspt
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I think I'd be leaning toward TFC irritation. ECU tendonitis could be a possibility, but one would certianly expect pain with palpation along the length of the tendon if this were the case.
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Jess Brown, PT
Board Certified in Orthopaedic Physical Therapy
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RE: Wrist pain - October 1, 2008 1:37:36 PM
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TexasOrtho
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quote:
ORIGINAL: jesspt
ECU tendonitis could be a possibility, but one would certianly expect pain with palpation along the length of the tendon if this were the case.
I agree for a pure tendonitis. However an ECU tenosynovitis is often exquisitely painful with passive supination. That being said I agree with you Jess. TFC should definitely be on the radar for sure.
< Message edited by TexasOrtho -- October 1, 2008 2:38:10 PM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Wrist pain - October 1, 2008 5:11:57 PM
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proud
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Very good. Thanks all,
Bonez,
No carpal bone issues s'far as I could see. I sheared the dayights out of all of them.
As for TFCC....I applied axial compression through the wrist with UD and that did not reproduce anything. As I understand things....that is the preferred way to rule in TFCC. Not necessarily rule it out.
Although tendonistis/tenosynovitis would be my first thought.....if I biased the ECU....NO PAIN Basically pure WE and WF reproduced the pain.
The one really odd finding to me was this:
1. patient supine, elbow relaxed extended and supinated( relaxed so no pain)
2. As I passively flexed the elbow and did all my elbow stuff....as I passively extended the elbow and inadvertently applied Overpressure into elbow extension....he found that painful.
3. From there if I resisted elbow flexion....it repoduced the pain on the Dorsal side from the ulnar styloid up the ulna midway to the elbow....but on the dorsal side.
This guy is legit. No googly eyes or blank stares, stupid seemeingly irrelevant questions, weird comments....you know the kind. This guy is spot on. My favorite comment from him was when I asked what the pain is on a scale of 0-10. He reported that he finds it painful when he has to lift his two year old....but it's not a 10/10 because he manages to NOT drop the child....
EDIT: One other thing. Why would passive end range supination be painful if we are talking a contractile structure like ECU?
Also....he found distal radio-ulnar joint "shearing" uncomfortable...sort of reproducing the pain. The right side was unremarkable.
< Message edited by proud -- October 1, 2008 5:41:58 PM >
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RE: Wrist pain - October 1, 2008 6:04:49 PM
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TexasOrtho
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quote:
ORIGINAL: proud
EDIT: One other thing. Why would passive end range supination be painful if we are talking a contractile structure like ECU?
The tenosynovium isn't contractile element and can be provoked with passive movements - basically a connective tissue tunnel that has a fairly good representation of free nerve endings. Passive supination can tension this structure laterally and reproduce symptoms if it is irritable.
As an analogy we see this in the proximal biceps tendon as well where resisted elbow flexion isn't painful but passive tensioning of the biceps reproduces symptoms (often fairly sharp). Some would refer to this as a biceps tendonitis while the finding may be more specific to the biceps tenosynovium.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Wrist pain - October 1, 2008 7:49:32 PM
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rwillcott
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proud,
I would say the push-up program he was following triggered these symptoms. I can recall treating a few patients with those type of symptoms that were in the military and reported pain with push-ups. The few military members that actually did push-ups!
When the wrist is in full extension and pronation (push-up) the extensor carpi ulnaris is relaxed. The head of the ulna is then free to move do to lack of stability. Sounds like this guy would have been performing his push-ups to failure. If he's shaking and fatigued and loosing his form a small jerk could then injure the ulnomenisco-triquetral complex. Triggered some inflammation that didn't become painful until later.
Or maybe sprain a portion of the collateral ligament?
Sounds like you performed a form of the TFCC grind test (passive ulanr deviation with compression). Did you check Ballottement test for instability of the luno-triquetral joint? Or the ulnomenisco-triquetral dorsal glide test? If you have Cleland's text there described on page 484 at the botom of the table. These tests don't have the greatest sensitivity/specificity but might help guide you.
What about ligament stess test of the ulnar collateral ligament?
That is odd that passive elbow extension would reproduce pain. Unless when you are applying the overpressure into elbow extension you are dorsally gliding the ulna which is reproducing his pain. Same as when you resist elbow flesion in an extended position. Could be just enough dorsal glide of the ulna to elicit his pain.
In either case I would provide him with a wrist brace to hold his wrist in neutral as his pain subsides. Have him avoid full extension or flexion for a bit.
Have you tried sending him to massage? kidding!
Really cool case. Definetly got me thinking which is nice!
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RE: Wrist pain - October 1, 2008 11:49:03 PM
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bonez
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Well lets talk about how this relates to me! It is my triquetrum that is fractured. Mechanism was FOOSH with ulnar deviation and more than full extension (metacarpals caught the step edge pisiform/ carpals did not). Best we can research is that the styloid process provides the fulcrum as it impacts the triquetrum.
My initial pain locations were identical to your patient including the path up the ulna. Passive and active elbow extension in supination were provocative initially and even in the cast end range extension while supinated are mildly painful. I suspect that ligamentous tissue in the region are involved in that motion.
Now I know that your patient did not sustain cat trauma but maybe the comment will help you source out the offending tissue. Find out if he favored ulnar deviation while in the push up postition many do as it is easier.
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RE: Wrist pain - October 1, 2008 11:57:06 PM
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steve
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Think this might be DRUJ instability despite the non traumatic cause of his injury? Pushing up from a chair is a theoretical test for this condition, I can only wonder what 100 push-ups would do...
Distal radioulnar joint (DRUJ) instability :
As the ulna is fixed, the radius is the dislocated bone, but we have kept the usual convention which describes "dislocation of the ulna". A traumatic movement in supination is responsible for anterior DRUJ instability, while posterior DRUJ instability follows a pronation injury. Dorsal ulnar dislocation is responsible for loss of supination and protrusion of the ulnar head. In case of dorsal ulna subluxation, the protrusion of the ulnar head may be clearly visible when viewed laterally, and unlike what occurs in the normal wrist, does not disappear if the injured wrist is flexed [8]. Anterior ulnar dislocation makes the dorsal skin depress and limits pronation. In anterior subluxation, the usual protrusion of the ulnar head is reduced or disappears [8]. Pain secondary to DRUJ instability is located on the ulnar side of the wrist and is intensified by pronation or supination. In such cases the examiner stabilizes the patient's forearm with one hand while with the other hand, he grasps the patient's hand as if for a vigorous handshake. When the patient resists forced passive rotation, or when there is active rotation against resistance, pain usually is elicited. If the pain is caused by compressing the ulna against the radius, it is mostly suggestive of chondromalacia [1112,15]. Patients may also complain of a snap which occurs during pronation or supination and corresponds to either dislocation of the ulnar head or to its reduction. Radioulnar instability is tested by the radioulnar ballottement test, in which the patient's elbow is flexed, and the examiner uses his thumb and index finger to stabilize the radius radially and the ulnar head ulnarly (Figure 29). Normally, there is no mobility in the anterior or posterior direction in maximum pronation or supination. Pain or mobility is very suggestive of radioulnar instability. The ballottement test must not only be done during extreme motions of pronation and supination, but also in various intermediate pronation and supination positions, because instability may only appear in some of these positions. It is sometimes possible to mobilize the ulnar head medially with two fingers [1718]. As for other tests it is useful to compare with the opposite wrist to help detect normal variation.
I would guess that there is an inflammatory component to his pain since he reports constant pain and this has sensitized many of the structures in the region, thus the multiple positive tests.
Irrespective, I agree with Rwillcott in trying to calm his pain down with a temporary brace and avoiding end ranges - often difficult to assess if the pain is quite acute. If it is DRUJ he may benefit from taping the joint for stability.
Hope that helps
Steve
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RE: Wrist pain - October 2, 2008 2:14:18 PM
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proud
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quote:
I would guess that there is an inflammatory component to his pain since he reports constant pain and this has sensitized many of the structures in the region, thus the multiple positive tests.
Actually Steve, It's NOT constant...
But I think the DRUJ is on the right track. Although I attempted to tape the joint to stabilize it and that did nothing....
I see him again tomorrow and will do some of the tests people provided here. Thanks all.
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RE: Wrist pain - October 2, 2008 3:40:54 PM
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steve
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Thats my attention deficit at play again... but to me that makes it even more likely that this is a DRUJ instability.
Steve
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RE: Wrist pain - October 6, 2008 11:59:11 PM
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ann m
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Just going back to ECU. To test it - patients elbow on table, hand in the air pronated and wrist extended, then you resist the wrist extension /ulnar deviation and they turn into supination as you maintain the resistance -a tricky manouvre. It's very painful if you have ECU tenosynovitis and/or you may be able to palpate subluxation of the tendon.
Also a word about the ECU pathology -the tendon normally moves dorsally as you supinate. The fascial housing around the tendon can rupture, which permits more of this movement, which causes synovitis with repeated forearm rotation.
Also my comment would be the TFCC is probably the most common injury on the ulnar side of the carpus, and often the patients don't recall the mechanism. Ulnocarpal abutment causing TFCC problems can be picked up by pronating and ulnar deviating the wrist, then making a strong fist. A shear test of the ulnar carpus may also help to pick up TFCC -glide the pisotriquetral complex dorsally on the ulna (sensitivity 66%, specificity 66%, +predictive value 58%, -ve predictive value 69%).
For the DRUJ, try a compression test while rotaing the forearm, as well as ballotment.
Hope this is of some help
Ann
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RE: Wrist pain - October 29, 2008 8:03:07 PM
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proud
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Update:
Looks most likley like Rod had the correct Dx. Took a bit to settle into a Tx plan and after 2 sessions...I felt ECU tenosynovitis fit the bill.
wrist spint, ice massage along ECU and this patient no longer has pain.
As the symptoms settled and became less irritable.... ECU tenosynovitis became the most clear dx.
Thanks all.
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