tendons ligaments arthritis ???

[Norm888]

Hi Everyone
I have only just found this site and from what I can see you're doing a great job! Myself, I am totally lost as to what exactly I have done to myself. I will start at the beginning and I sure hope someone can help.
I'm 59, a floor layer, and prior to May 18, 2011 could not think of having injured my right wrist. On May 18th I was doing a different kind of work that involved a couple of hours of strenuous pushing down and pulling towards myself actions. Then a couple of hours of scraping glue off of the floor with a small hand scraper.During this time there were instances of sharp pain from the top of the thumb through the wrist and up the forearm. At the end of the job (about 5 hours), my hand was sore. Initially I described the sharp pain as coming from the top center of the thumb down through the wrist and up the lower arm.This was from memory not while actually feeling it. I later realized that it would have been best to describe it as being on the palm side.
I saw my doctor and he called it tendonitis right wrist. Tender extensor tendons right wrist involving thumb, swollen wrist. He also thought I had OA and ordered an x-ray. Result by radiologist was a narrowing of the scapho-multiangular joint of the wrist. there is also some spurring and narrowing of the first metacarpo-multiangular joint at the base of the thumb.He added a comment stating that there is osteoarthritis present.
I go to physiotherapy where I am told that the range of motion in my wrist is very poor but noted that there was no pain on movement or at end of ranges. There was some pain to palpate around the attachment of Flexors Carpi radials. Assessment was tendon strain at the right wrist.
One of the exercises that I am given is to grasp a metal bar ( 18 inches long and about 5 lbs.) in the middle but a bit off center and rotate it slowly back and forth for 10 reps 3 times. The idea was to gradually move further off center over the coming weeks. After 10 days of this I found it quite painful. Pain was on the back of the hand along the 1st and from between the 4th and 5th joining at the wrist and up into the forearm. I knew the pain. Until I felt it I had forgotten that 23 years ago my hand was on the floor when a metal bracket fell on it. It was very painful and I had it x-rayed as I was sure I had broken it. No breaks, off work for two weeks though. The pain was intense enough that To put my van into drive I had to lean to the side and use my left hand. This slowed progress and I was referred to a hand clinic.
Pain reported in the volar aspect of the right wrist and distal 1/3 of the forearm. Finkelsteins test is mildly positive. Tenderness over the FCR tendon and mild tenderness over tendons of the 1st dorsal compartment of the wrist.Active ROM at radio-ulnar joint: Pronation is normal:Supination 0-50 I.e. 77% of normal. Active ROM of wrist is 62% of normal.Grip strength is 28 kgs bilaterally, though it is painful on the right.
Ultrasound massage and exercises for 6 weeks. Did one grip test of 49 kg and two days later 44 kg. Both very painful to central wrist area. Tripod pinch R= 7.5 kg L=8.5 kg
Throughout this whole ordeal everyone seems to think that the decreased ROM seems to be an issue with my ability to work even though I've been working without any problem, for years apparently without any problem.
8/11/2011 Now sent over to an occupational rehabilitation program. At this point most of the time there was little to no pain when at rest and the pain along the back of the hand i.e. 1st 4th an 5th up the forearm as mentioned before had probably stopped. Can't of course be certain with regard to the thumb area.
Intake data Wrist flexion--10 degrees actively and 20 passive. Extension full. Ulnar and radial deviation equal bilaterally. Supination is 70 degrees. Pronation us full. Flexion on 1st metacarpophalangeal joint is 80 degrees.Resisted strength testing reveals right wrist flexion 4+/5 which reproduces anterior forearm pain;right wrist extension 4+/5; right thumb ext. 4+/5;right elbow flexion and extension 5/5. Grip strength on right is 38 kg with pain during 2/3 of the repetitions vs. 32 on left. No change to symptoms when the extensor muscles are offloaded with pressure.
Accessory glides of the wrist are decreased as are the accessory glides of the first metacarpophalangeal joint. No neurological findings. Finkestein's test is negative. No pain with resisted 3rd digit extension.Upper extremity index test is 52/80 where higher scores reflect greater perceived ability. score on Tampa scale for kinesiophobia is 45/68 where higher scores are associated with greater fear of movement and re-injury.
Pain recurs during any activity that involves a grip. For instance a shooting pain down the radial aspect of the hand, wrist and forearm when turning on the ignition of my Jeep.
I took part in the program and it was expected that I would return to work mid September. The program started at 7:30-8:00 in the morning and I would finish my routine by about 11:00. This gradually went to about 1:00 as repetitions increased and new tasks were added. Pain also increased. After a few days I would go home and take 3 acetomycin with codeine. After a couple of weeks I would start my day with pain killers. Pain took longer to go away. By Labor Day weekend pain was lasting through 3 days of rest. I had started trying to cut materials as needed when working but pain and a lack of strength made me cut back on repletion's and or stop. I was sent to see a doctor that worked within the occupational rehab program. I went over my symptom with him. He was aware of an x-ray showing narrowing of the scapho-multiangular joint as well as of the first metacarpal-multiangular joint at the base of the thumb.
His exam findings: No obvious swelling or erythema. Definitely has decreased flexion of the right wrist compared to the left. Radial and ulnar deviation are adequate as is wrist extension. Supination and pronation appear normal on both sides. some hypermobility at the IP joint of the thumb. some tenderness through that region as well as into the MCP joint. There is some clicking within the wrist itself particularly on the Watson maneuver at the central wrist and bade of the thumb.
Examination of the tendons is unremarkable. He could not detect and neurological or vascular changes otherwise.
Impression: osteoarthritis right wrist. he felt it clear that I had moderate osteoarthritis with fixed range of motion changes in my wrist that have progressed over the years. He felt it likely that the activity I was performing in May tipped it over the edge.
he felt that the exercised were probably not helping me and a reduction in activity may be of most benefit, as well as a retrial of anti-inflammatory.
Rest of week don't agitate wrist. Following Monday off to see orthopedic surgeon.
Exam that day revealed bilateral radial=sided dorsal radial wrist swelling. Range of motion was 35 degrees of wrist extension: 30 degrees of wrist flexion: 10 degrees of ulnar deviation:less than 5 degrees of radial deviation: full forearm rotation with a lit of tenderness diffusely around the radial side of the wrist. There was no ulnar-sided tenderness.
X-ray showed significantly advanced SLAC wrist which is scapholunate advanced collapse. radio scaphoid arthritis. and capitate lunate arthritis. It is at least a stage 3 SLAC wrist.The left wrist x-ray was very similar, although not quite as advanced, and possibly the dcapholunate interval not quite as wide.
The Doctor showed me the x-rays that were taken that day and pointed out a greater spacing between two bones. He said that there was a missing ligament. I think that the bones were the lunate and the scaphoid. He felt a partial fusion would likely not help partially due to my age. Total fusion he said. To what end I asked? he said that then if the operation was successful I could return to my occupation pain free. I asked him if could do his job with total wrist fusion. Absolutely not he replied. I told him that I had tried making accurate cuts while wearing a brace that held the wrist straight and and could not do it so surgery is not an option as far as returning to my present work. He felt that physiotherapy was likely aggravating my wrist at that time.
Worksafebc decided that the tendonitis had likely resolved and that the pain was solely due to the arthritis. The physio was terminated and they discharged me as fit to return to work with limitations. The limits appear to be to avoid cutting and lifting. Sort of like telling a pilot to go back to work but don't fly!
i tried returning to work to see if I could do it. I knew it would be painful so I took two Tylenol 3's and three Ibuprofen. On the 24th of Nov. I worked for 5 hours. Pain returned. Not only along the palm side through the thumb and into the forearm but also on the back. Down the back side of the thumb and through the wrist and from between the 4th and 5th through the wrist and up the forearm. i have only recently had brief moments of little or no constant pain.
One doctor at the clinic said: Pain dorsiulnar wrist with flexion and grip aggravated volar radial wrist pain.
Back side of wrist pain seems to be gone again or at least is not constant. I still get shooting pain if I move or do the wrong thing.
Recent exam still tender over the thumb tendons extensor and flexor tendons with painful flex and extension of the thumb and wrist.
One more thing that I should mention. I like the work that I have done for so long. I work with others quite often and have become associated with contractors that work for a number of cruise lines. I have travelled over most of the world and been paid to do so ( Australia, Singapore, Canary Islands,Scotland, Cannes,Monte Carlo, Italy etc.). Yes there is work but there is also the enjoyment of seeing different places and meeting new people. i have had to turn down jobs recently that others would have lined up to do. Just prior to being injured last May 18th I was in the Bahamas for three weeks working just about every day for 10 to 12 hours with a group roughly half my age and had no difficulty in setting the pace.
Any help on deciphering this would be greatly appreciated and on any course of action. Sorry for the length.

Thanks Norm

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[Canuck Physio]

Hi Norm,

Sorry you have to deal with WCB. Unfortunately it sounds like it may still be a tendon/synovium issue and that the evidence of bilateraly arthritis is WCBs scapegoat to cut you off.

Do you have access to any further Physiotherapy?

[Norm888]

Hi Norm,

Sorry you have to deal with WCB. Unfortunately it sounds like it may still be a tendon/synovium issue and that the evidence of bilateraly arthritis is WCBs scapegoat to cut you off.

Do you have access to any further Physiotherapy?

i did go back in early Dec. to a hand clinic and told them about the current issue as well as that the surgeon had said that there was a missing ligament. They got a copy of his report and I went back in the following week. They told me to continue isometric exercises and that they could not help me further. They have as a diagnosis SLAC wrist followed by a circled B. I'm not sure if that was their opinion or that of the orthopedic surgeon.

Just got back from a different Dr. He has ordered an MRI adn was surprised that one had not already been done.

Thanks Norm

[pudding_bowl]

Brilliant. A MRI would be very helpful for a more thorough diagnosis.
if a ligament is missing between teh scapholunate then a full write fusion seemes excessive and that a small fusion of those 2 would be debilitating but may help to remove the pain and allow you a significant enough amount of rom ton continue your work. it wouldn't be like wearing a brace.
Really interesting case. Definately a long read. Once you have MRI results get back to us. hopefully surgery isn't actually required.

[Norm888]

MRI at this point is slated for Dec. 3rd.
If there is a missing ligament what further damage could I be doing from now till Dec. and what should I avoid doing.
Thanks
Norm

[Norm888]

Just got MRI results. (I got in early due to a cancellation.) The reason given for the exam was that injury was not responding to therapy, query torn ligament.

Report
comparison is made with the plain radiographs of right wrist from Sep. 16 2011.

Marked degenerative changes are present involbing the proximal and radiocarpal and k=mid carpal joints.

there is marked joint space marrowing presint between the distal radius and the scaphoid and widening of the space between scaphoid and lunate is presint.

There is also marked joint space narrowing present between the capitate and hamate and adjacent lunate with radial subluxation of the capitate and hamate relative to the proximal carpal bones. Large subchondral cysts involvethe distal radius, scaphoid lunate as well as the capitate and hamate. There is also significant degenerative change present between the trapezium and base of the first metacarpal.

Impression

Advanced degenerative change involving the wrist, as described above.


This is the report. Does this imply that there have been obvious changes since Sept. ? Nothing was said of ligaments. Should this be inquired on?

I just noticed that the MRI was non enhanced. Would enhanced have shown more detail?

Thanks again for any thoughts,

Norm

[Norm888]

My new doctor has finally got in touch with the radiologist that read my MRI. He was told that the ligament between the lunate and the scaphoid cannot be seen. It is not there. What kind of physio should now be taken? What should I be doing or not doing?

Thanks Norm