Earlier this month I had a patient seeking treatment for intense wrist pain, limited range of motion, and loss of function using the hand/wrist. The individual stated that the symptoms had progressively increased to the point where he was unable to workout because grabbing the weights was too much, and working at the desk typing on a computer, or writing with a pen was something he dreaded. His wrist motions were so limited that any movements in any direction caused sharp stabbing pain, especially along the thumb side of his hand and wrist.
The patient sought advice from his medical provider who diagnosed him with severe tendinitis. The patient further explained that the doctor stated there was nothing that could be done for it. Advice on keeping it wrapped it up, resting, and taking medications was the extent of care provided.
This cocktail of treatment was ineffective, and with each passing day, the symptoms the patient was experiencing was getting worse. That’s when he decided to connect and see if we could team up.
Here’s a quick summary of what was found during the initial evaluation:
Tenderness to palpation
Abduction pollicus longus belly/tendon
Extensor pollicus brevis belly/tendon
Extensor carpi radialis longus belly/tendon
Extensor retinaculum (tunnel 1/2)
Tonicity along the fascia structure of the:
Abductor pollicus longus
Extensor pollicus brevis
Extensor retinaculum
Those above mentioned structures are common players for the area of complaint, but here are other tissues worth noting:
Brachioradialis
Extensor carpi radialis brevis/longus
Pronator teres
Flexor carpi radialis
Flexor pollicus longus
Pronator quadratus
Lumbricals
Limited wrist ROM
Flexion > extension
Ulnar deviation > radial deviation
Limited elbow ROM
Extension > flexion
Pronation > supination
Orthopedic test
(+) Finkelstein’s test: recreation of chief complaint of intense sharp pain and apprehension along the radial side of the wrist
Unable to perform other tests due to limited range of motion
Just to be more thorough, I also asked other questions and looked for other clinical indicators that could help figure out if there might be something else going on besides the apparent soft tissue issues. Fevers and infections were denied, history of auto-immune diseases were negative, night sweats and unexplained weight loss was negative, neck and shoulder complaints were non-existent, traumatic injuries were denied, and popping, clicking, or instability were not present.
With those potential flags eliminated, focusing primarily on soft tissue health was the game plan. From years of experience, I’ve learned that starting away from the hot spot and strategically treating the areas around it first would work best. As the patient got used to the load of treatment to his tissues and range of motion improved, I was able to treat the insulted area directly. I used this approach efficiently and effectively, which took 2 visits lasting approximately 30 minutes in length to eradicate his severe complaints.
It was cool for him to see that his wrist issues could resolve in a couple visits, but it was cooler for us to see the method of attack that worked for him! I took the fascial lines into consideration when treating his complaints.
Adopted from Thomas Myer’s Anatomy Trains, tissues are seamlessly connected and blended in with each other like one long continuous string. The blue-colored tissues shown on the following images illustrate these connections.
Front Arm Line
I was first introduced to this concept as “Anatomy Trains,” but with updated research and continuous investigations, I’ve found that it has been synonymously referred to as soft tissue continuum or Bioflow.
Superficial Back Arm Line
Regardless of how you want to label it, the symptoms that the patient was experiencing at the wrist were a result of another site being the root cause. In this particular case, I had to work on the soft tissues that were more proximal to the actual symptomatic area. The posterioradial portion of the proximal forearm was the major player versus the tissues that were actually causing all the pain. After initial assessment of ROM and pain level, I treated the aforementioned area, then reassessed. To both our amazement, the patient was able to move the wrist to near end range of motion AND there was no longer any sharp pains when getting there!
MIND BLOWing…
I guess the moral of this story is… as a clinician expand your mind when evaluating and treating. What seems to be the primary insult may just be the victim screaming louder than the villain who’s actually causing all the commotion…
Change your mindset … Change your perspective … life is much better when you have an outlook that creates opportunity.
Thanks for being curious and taking the time to read this! Hope it added value to your life and equips you to become better than you were yesterday!
Dr. Joe Jaime, DC, DACBSP®, ATC, CSCS®, FRC®ms, CES