Ch19

Copyright © 2013. F.A. Davis Company
Part IV: Exercise Interventions by Body
Region
Chapter 19
The Wrist and Hand

 Nerve Disorders in the Wrist
– Median nerve-Carpal Tunnel
– Ulnar nerve-Guyon’s Tunnel
 Referred Pain and Sensory Patterns
– Terminal point for C6, C7, and C8 (median, radial
and ulnar nerves)
Major Nerves Subject to Pressure
and Trauma at the Wrist and Hand

MANAGEMENT OF WRIST AND
HAND DISORDERS AND SURGERIES

 Common Joint Pathologies/Impairments
– Rheumatoid arthritis
• covered previously, lets review together! How about
the Swan-neck and Boutonniere deformity
– Osteoarthritis and post-traumatic arthrosis
• Covered previously, lets review together!
– Postimmobilization hypomobility
• Dec’d ROM and jt play, firm end feel, tendon
adhesions, dec’d muscle performance
Joint Hypomobility:
Nonoperative Management

Joint Hypomobility:
Nonoperative Management
 Common Activity Limitations and Participation
Restrictions
– Acute-prehension activities are painful
• Dressing, eating, grooming, toileting
• Any functional activity that requires pinching, gripping
and fine finger dexterity including writing and typing
• Depending upon joint involvement, functional loss may
be minor or significant

 Management: Protection Phase
– Control pain and protect joints
• Patient education
• Pain management
• Splinting
• Activity modification
– Maintain joint and tendon mobility and muscle integrity
• Passive, assistive, or active ROM
• Tendon-gliding exercises
• Multiple-angle muscle setting exercises
Joint Hypomobility:
Nonoperative Management (cont'd)

 Management: Controlled Motion and Return
to Function Phases
– Increase joint play and accessory motions
• Joint mobilization techniques
• Unlocking a subluxated ulnomeniscal-triquetral joint
– Improve joint tracking and pain-free motion
• MWM of the wrist
• MWM of the MCP and IP joints of the digits
Joint Hypomobility:

 Management: Controlled Motion and Return
to Function Phases (cont’d)
– Improve mobility, strength, and function
• Neuromuscular control and strength
• Functional activities
• Conditioning exercises-aquatics or cycling
• Joint protection-Box 19.2
Joint Hypomobility:

Repetitive Trauma Syndromes/
Overuse Syndromes
 Disorders lead to significant loss of hand
function and lost work time
 Repeated movements over an extended
period of time
 Carpal Tunnel Syndrome
 Trigger finger
 De Quervain disease
 Tendinopathy (tendonitis/tenosynovitis)

 Tendinopathy
– Etiology of symptoms
• Pathological breakdown from repetitive use, RA, and
stress overload
– Common structural and functional impairments
• Pain with muscle contraction and tendon gliding in
sheath, warmth and tenderness with palpation,
synovial proliferation and swelling in affected tendon
sheaths (RA), muscle imbalance and poor endurance
Overuse Syndromes

Overuse Syndromes
– Common activity limitations and participation
restrictions
• Inability to perform repetitive or sustained work,
recreational, or leisure gripping activities or hand
motions that require contraction of the muscle
– Management
• Protection phase
– Pt ed, rest, tendon mobility, muscle integrity
• Controlled motion and return to function phases
– Exercise progression, biomechanical assessment, prevention

 First dorsal extensor compartment
 Repeated tension with abd and ext of thumb and/or
medial and lateral deviation of the wrist and
extension of the wrist-creates friction that leads to
swelling and thickening of the connective tissue and
narrowing of the tunnel
 Termed as tendinitis, tenosynovitis or tendinosis
DeQuervain Disease

 Presentation: pain on radial side of wrist-
aggravated with use of the thumb
 Swelling and possible nodules
 Finkelstein test
 Management: activity modification,
immobilization, ice, e-stim (HVPGS),
iontophoresis (questionable benefit), PROM
progress to AROM and strengthening
De’Quervain Disease

 Limits movement of the finger, with extension
movement, the finger will lock or catch before
popping out straight
 Irritation to tendon as it slides through the
tendon sheath tunnel, with irritation the
tendon may thicken and form nodules
Trigger Finger

Dupuytren Disease
 Nodules just below the skin of the palm
 Longitudinal contraction of the underlying
fascia
 Tissue becomes very thick and forms cords
that become firm and tendon-like (affected
digits lose extension)
 Incidence: white males of northern European
descent

 Steroid injections to soften nodules and break down
collagen
 Surgery: fasciotomy
 Management: usually CHT
 Splinting: dorsal blocking splint that allows active
flexion but limits full extension at the MP joints- 2 to
3 weeks then progressed to volar splint to hold the
MP and IP in full available extension-worn for 3
months
Dupuytren Disease

 Nonoperative Management
– Common functional and structural impairments
• Pain at involved site with stretch force on ligament
• Hypermobility or instability in the joint if ligament torn
– Common activity limitations and participation
restrictions
• Pain with functional use when jt is stressed, instability
with significant tears (subluxation/dislocation)
– Management-Chapter 10
Simple Sprain

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