Carpal Instability

I have just seen a lady who works as a masseuse with a 3 month history of carpal pain following an increase in her workload (as well as the size of the clients she is seeing). She reports a gradual onset of pain around the capitate/lunate area, initially this was only provoked with weightbearing ++ through a hyeperextended wrist (she is reasonably hypermobile). Over the past few months this pain has increased to the point where she is now finding it difficult to work effectively.

Objectively she has FAROM that is painfree, pain on OP of extension more than flexion (the pain on flexion has only occurred over the past 3 weeks) full power - no pain on resistance, neurology is all normal. She has a clunking feeling with stabilisation of the ulnar and accessory movements of pisiform and lunate but no pain.

Her GP prescribed a course of anti inflammatories that had no effect followed by a 2week immobilisation in a wrist splint (this actually bought on a new pain betweent he ulna and pisiform that has since disappeared now the wrist splint is no longer worn.

All X-rays and MRI have come back with normal (with the exception of a small amount of fluid noted around the pisiform).

I'm thinking that her hypermobility has been aggravated by the continued extended position of her wirst during work which has caused a carpal instability. Unfortunately there are no hand specialists in the clinic and she is unable to travel to see one due to work and family commitments. Any advice on management would be greatly appreciated or would referral to a hand/ortho specialist ultimately be where this lady is heading?

Thanks for your help.

Hi, We are a U.K. manufacturer of medical devices. The description of your patients carpal tunnel sounds very similiar to many cases of patients that our device 1000/4P has treated. Capal tunnel is a tissue’s reaction to irritation, infection, or injury, marked by localized heat, swelling, redness, pain, and sometimes loss of function.
Usually the patient is advised to reduce the activity that causes the pain. (However, in most cases this means quitting or changing their job.) If this is not an option, the patient is instructed to immobilize their hand with a brace. This limits movement, which usually hinders their work. This also increases the disuse atrophy leading to more problems.Anti-inflammatory medication is usually prescribed (long term use of this is very harmful to the lining of the stomach). Pain medication is used, however, this may hinder patient’s ability to function safely on the job. there is also the fear of addiction with long-term use.
Other methods of treatment have been tried, from hot paraffin to copper bracelets. Although these various types of treatments have been used, there is not a great deal of long-term success. Temporary relief of the pain is generally all that is achieved with these treatments. Even surgery does not give long-term results for most patients, less than 20%. Recovery for many is hard and painful, often resulting in a change of occupation.
QUESTION:HOW DOES THE NEUROCARE HELP?
ANSWER:
The Neurocare™ and associated Neurocare Treatment Program© increases the localized circulation thus relieving the inflammation around the carpal region. The simulated exercise promoted by the Neurocare™ the muscle groups involved in the activity causing this inflammation are “re-educated” and long-term results are achieved. This treatment program is a non-invasive treatment that has proven to be 80+% effective in all cases of diagnosed Carpal Tunnel/ Repetitive Motion Deficit, even bilateral CTS.

If you are interested in our product please contact me on 0115 9501597 or e-mail [email protected] Patricia Forrrester

I wouldn't give up so quickly. Has exercises been done to address the issue at all? Without exercise and stability exercises Of course the wrist would remain weak! Any end range discomfort can be alleviated with an appropriate tensor bandage or tape job as opposed to a full all out splint. As PTs we have to Problem Solve with trial and error. I would not even be considering a specialist until the PT has tried all the appropriate non invasive techniques available at their disposal. Yes, the aggravating factor (work) will be a significant problem. But this can be modified via technique, and appropriate trial and error with soft splints and strengthening before giving up!

problem seems pretty consistent with job. if she had swelling around pisiform it is possible that brace made it worse as it was digging in and irritatiing this locally inflammed area. try a different type of brace. from my expereince braces never make this type of injury, if inflammation secondary to hypermobility is problem, as tissues crying out to be unloaded. splint (as long as comfortable) and until extension with O/P is painfree, take NSAIDs + acupuncture and soft tissue work, plus strengthening and stabilisation, technique modification (ie hand extension of arm and body and not prime mover!).
ps doesnt sound like carpal tunnel, unless she also has neural symptoms in her hand. all these things are short term measures to relieve acute problem so do not think you need to be too concerned with any side effects either

Okay, I'll weigh in with a suggestion. Since she gets clunking painfree on some mobilizations and good power, try finding the nearby carpals that don't move as well.
My theory is that while the lunate and it's one neighbor might be highly mobile (which is normal for her) there may be other nearby carpals not moving as much and this creates an imbalance. Try mobilizing the other joints to her physiological norms.
Crystal
(almost a hand therapist)

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Originally Posted by cformby

I have just seen a lady who works as a masseuse with a 3 month history of carpal pain following an increase in her workload (as well as the size of the clients she is seeing). She reports a gradual onset of pain around the capitate/lunate area, initially this was only provoked with weightbearing ++ through a hyeperextended wrist (she is reasonably hypermobile). Over the past few months this pain has increased to the point where she is now finding it difficult to work effectively.

Objectively she has FAROM that is painfree, pain on OP of extension more than flexion (the pain on flexion has only occurred over the past 3 weeks) full power - no pain on resistance, neurology is all normal. She has a clunking feeling with stabilisation of the ulnar and accessory movements of pisiform and lunate but no pain.

Her GP prescribed a course of anti inflammatories that had no effect followed by a 2week immobilisation in a wrist splint (this actually bought on a new pain betweent he ulna and pisiform that has since disappeared now the wrist splint is no longer worn.

All X-rays and MRI have come back with normal (with the exception of a small amount of fluid noted around the pisiform).

I'm thinking that her hypermobility has been aggravated by the continued extended position of her wirst during work which has caused a carpal instability. Unfortunately there are no hand specialists in the clinic and she is unable to travel to see one due to work and family commitments. Any advice on management would be greatly appreciated or would referral to a hand/ortho specialist ultimately be where this lady is heading?

Thanks for your help.

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Hi there
I have RSI in my right wrist and tenosynovitis in my left wrist. My RSI in my right has pretty much resolved but I have some joint instability and muscle weakness. Can anyone suggest some exercises or point me in the direction of how tostrengthen the extensors and the flexors?

Thank you
Angie