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WRIST-FOREARM PAIN

 GENERAL INFORMATION
WRIST / FOREARM TENDONITIS  - RSI / CTD
BASIC FIRST AID
BASIC STRETCHES
SIGNS & SYMPTOMS
WHEN TO CALL MD
WHEN TO SEE A PHYSICAL THERAPIST
CAUSES /RISK FACTORS /PREVENTION PROPER POSTURE WITH SITTING AT A COMPUTER

General advise on healing

Our wrist is made up of 8 small bones (carpal bones).  These bones are held together by ligaments. 

In addition to the many small muscles in your hand, nerves, tendons and blood vessels pass through the wrist to supply your hand.

The nerves for your arm and wrist leave your spinal cord at
your cervical spine (your neck).
Compression of the nerves any where along their course
can cause pain/tingeing/numbness/burning. 
You can strain or sprain the ligaments or muscles from a sudden movement, improper movement, or through over use.
Compression of the nerves as they leave the spine
at the neck (Cervical Radiculopathy)
or as they leave the chest (thoracic outlet Syndrome)
can cause symptoms any where in the arm
Both of these conditions can fool you because pain is felt in the arm/wrist/hand but not in the neck.

 The nerves can be trapped as they pass through your chest and arm pit into the arm (THORACIC OUTLET SYNDROME OR FIRST RIB SYNDROME) this can cause symptoms any where in the arm. The median nerve can be trapped as it passes through the carpal tunnel (a tunnel formed by the carpal bones that make up the wrist) in the wrist. This produces symptoms in the thumb and first two fingers of the hand.      

The major muscles that move the wrist start at the elbow, therefore improper use of the wrist can cause pain all the way up to the elbow.


WRIST / FOREARM TENDONITIS
Tendonitis is an over use injury that can occur with over use of any muscle. The tendon is the tissue that attaches the muscle to the bone.

Common wrist/forearm problems include tendonitis of the muscles that extend your wrist, (bend wrist back).  The technical name for this is lateral epicondylitis, also known as tennis elbow.  You don't have to play tennis to get tennis elbow. 
           

Lateral epicondylitis (tennis elbow) can cause wrist/ forearm or hand pain. 
Working at the computer with your hand bent up toward you is a common cause of this type of tendonitis.  It is often confused with carpal tunnel syndrome.

See below for detailed information.

 Carpal tunnel syndrome is usually caused by pressure on the medial nerve
(seen in orange above) as it passes through the carpal tunnel (formed by the bones below (gray) & the ligament above( white) 
This is usually caused by sleeping with the wrist in a curled position or sustained direct pressure on the wrist.
Using a gel wrist rest & placing the wrist rest under the forearm, not directly under the wrist is advised.

Remember, the standard approach for joint pain 
is to start with the least 
invasive treatment and progress to more invasive.  

An example of least invasive to most invasive would be:

rest - physical therapy - medication - 
bracing- injections - surgery (usually the last resort)



Many people with tennis elbow think they have Carpal Tunnel Syndrome. 


Tennis Elbow / Wrist Extensor Tendonitis
Test for this syndrome by:

  1. Pressing hard along the outside of the muscular part of the elbow.  Pain is an indication of tendonitis.

  2. Stretching the muscle. 
    click here for picture
    If it feels tight this is an indication of tendonitis.

     Top of page


TREATMENT

  1. Stretching for the extensor muscle.
    click here for picture

  2. First Aid-remember even if you are feeling pain in the wrist the source of pain is at the elbow.  Treat the ELBOW  with ice, massage the muscles just below your elbow, etc as explained in the
    FIRST AID SECTION.
    (CLICK HERE)


A less common problem is tendonitis of the wrist flexors,( muscles that bend wrist forward).  The technical name for this is medial epicondylitis, also known as golfer's elbow.  You don't have to play golf to get golfer's elbow.


Golfer's Elbow / Wrist Flexor Tendonitis
Test for this syndrome by:

  1. Pressing hard along the inside of the muscular part of the elbow.  Pain is an indication of tendonitis.

  2. Stretching the muscle.
     
    click here for picture
    If it feels tight this is an indication of tendonitis.

     Top of page


TREATMENT

  • Stretching for the flexor muscle.
    click here for picture

  • First Aid-remember even if you are feeling pain in the wrist the source of pain is at the elbow.  Treat the ELBOW  with ice, massage the muscles just below your elbow, etc as explained in the
    FIRST AID SECTION.
    (CLICK HERE)


    Tendonitis can also occur in the muscles that move your wrist toward your little finger, toward your thumb, turn your palm up and turn your palm down.  See the wrist stretching section for specific exercises.  


    Common shoulder problems include tendonitis and bursitis. It is common to feel pain in the middle of the upper arm due to either of these conditions.

    RSI (repetitive stress injury) is a condition that


    RSI / CTD

    A condition known as RSI, (repetitive stress syndrome) or CTD, (cumulative trauma disorder) develops from continuous low level stress on any muscle or joint. It is becoming more common in the wrist and arm from the increased use of computers and other motions involving your arms such as working with an espresso machine.

    RSI / CTD is difficult to treat.  It often involves tendonitis of all the wrist muscles, mild carpal tunnel syndrome, as well as problems at the wrist, shoulder and neck.
    Top of page


    RSI /CDT IS PREVENTABLE IF IT IS CAUGHT EARLY. IF YOU HAVE AN ACHE IN YOU HANDS AND THAT LASTS AFTER YOU STOP WORK, KEEPS GETTING WORSE, TAKES LESS AND LESS TO PRODUCE PAIN AND LONGER AND LONGER FOR THE PAIN TO GO AWAY GET IT CHECKED. ONE OR TWO PHYSICAL THERAPY SESSIONS CAN STOP RSI BEFORE IT BECOMES A DISABLING CONDITION.

    Sex or Age Most Affected

    Adults of both sexes, usually between ages 20 and 40.

    SIGNS & SYMPTOMS           Top of page

    • Pain, deep ache, numbness or burning of the hand, wrist, arm or shoulder.
    • limited range of motion (less than normal movement) of fingers, wrist or shoulder. Check your other wrist to find out what is normal for you.
    • Stiffness or soreness of the muscles at the hand, elbow, or shoulder.

    Causes               Top of page

    • Repeated use of the arm or wrist in an awkward position
      • bending the wrist with typing, using the phone, operating a machine or playing sports.
      • Working with your arm held away from your body. (reaching forward or to the side and keeping the arm in this position).
    • Postural strain ( improper position when sitting - reaching )
    • Falling and landing on an out stretched arm. This is a common cause of a wrist fracture.
    • Swelling of the wrist. This can compress the median nerve as it passes through the carpal tunnel.
    • Often there is no obvious cause.

    Risk Increases With

    • Working at a desk for long periods.
    • Repeated bending the wrist or reaching out with the arm.
    • Participation in sports without proper training. Especially golf, tennis, racquetball and baseball.
    • Sharp increase in athletic activity (weekend athlete)
    • Playing musical instruments. Proper training and following a program where you gradually increase the amount of time you play can prevent injury.

    How to Prevent

    REMEMBER - ELBOW CLOSE TO BODY - WRIST STRAIGHT - REST ELBOW, FOREARM OR WRIST ON FIRM SUPPORT

    • Rest your arm in a comfortable position when you are using your arm and wrist
    • Take frequent breaks at work, or when learning a new sport or instrument, to stretch your arms.
    • Get proper training when taking up a new sport or learning a new instrument.
    • Use proper equipment on the job or with sports.
    • Learn how to sit properly.
    •  

    WHAT TO EXPECT WITH IF YOU SEE AN MD:

    Diagnostic Measures

    • Observe your symptoms. (What makes the pain worse/better)
    • Medical history and exam by a doctor  & referral to a physical therapist for persistent symptoms.
    • EMG tests to determine if there is any nerve damage.
    • Testing (see above) is often not done unless the person is not responding to conservative treatment (rest, medications, physical therapy).
    • Treatment will depend on severity of the pain and discomfort. ACUTE vs. CHRONIC
    • ACUTE -sudden onset of pain or severe pain - pain after a fall on your arm - this may require an x-ray. Call your doctor. SELF CARE
    • CHRONIC- slow onset of pain (over months or years) or low grade pain (constant dull ache).   This may be the first sign of RSI. Seek treatment if pain persists.
    • Appropriate Health Care

    • See your M.D. to determine the cause of pain. He/She may or may not take x/rays, schedule tests, prescribe medication or refer you to physical therapy.
    • Physical therapy treatment should address risk factors, prevention & a home exercise program in addition to pain reduction treatments.
    • WHEN TO SEE A PHYSICAL THERAPIST            Top of page

    • Physical therapy should be prescribed when you have been treated by your M.D. but pain  persists beyond 1-2 weeks or if you have had multiple episodes of pain over the past year.  
    • In most states you can go directly to a physical therapist. Depending on the nature of the condition, the therapist may refer you to a physician .  The physician can prescribe medications, order tests and check to be sure you do not have a more serious medical condition that may be causing your symptoms.
    • Physical therapy treatments should address risk factors, prevention & a home exercise program in addition to pain reduction treatments. SELF CARE.
    • A physical therapy evaluation should include:
      1. History( The therapists will ask: How did you hurt yourself, When did the pain first appear? What makes the pain worse/better? Have you had this type of pain before?  What were you doing just before you felt pain?  What does your daily routine involve? etc.)
      2. Physical exam: ( You will be asked to do certain movements to determine what movements increase your pain, Your posture - how you sit & stand - will be evaluated, Your muscles will be palpated (massaged) to look for painful "knots" or spasm (increased tension), The mobility and quality of the motion of your joints will be checked, Your may have your reflexes tested, etc.
    • Physical therapy treatments will vary depending on the condition.  A through treatment will include a few basic elements:
      1. Pain reduction may include use of heat, ice, massage, relaxation, stretches, joint mobilization and other modalities including ultrasound & electric stimulation.
      2. *A home program  may start out as simple as a list of things to avoid.  This should increase gradually as you progress to include exercises, stretches and some type of simple first aid.  The goal is for you to gain control over the symptoms as you gradually eliminate the cause of the problem. * This is where physical therapy differs from traditional chiropractic care. 
      3. Prevention includes:
        • discussing risk factors for your specific condition.
        • exercises to increase strength and flexibility.
        • training in how to sit, stand, bend, move, return to sports, etc. without re-injuring yourself.
        • Suggestions for basic equipment including chairs, lumbar supports, wrist rests, etc.  Depending on the person and the condition this may require purchasing a few items.  Many "lumbar supports" can be made from simple items in the home such as pillows, towels, blankets. ( Your jacket can work as a lumbar support if you are out and you run into an unfriendly chair.)
    • Options are available such as physical therapy, acupuncture, orthopedic care, treatment by a chiropractor, physiatrist or neurologist and others including surgery for damaged disk, or a local injection (epidural). 
    • Massage may help.  Be sure the person is well trained or the massage may cause more harm than help.          top of page

    HOME TREATMENT The goals of self-care are to relieve pain, promote healing and avoid re-injury.   Immediately after an injury and for the next few days, the most important home treatments include:

    • Ice pack or cold massage applied to the shoulder, elbow or wrist.
    • ACUTE STRAINS
    • If you fell or if you have severe pain call your doctor. Get in a comfortable position and apply cold packs or ice for 15-20 minutes three or four times a day or up to once an hour for at least the first three days. Cold decreases inflammation, swelling and pain.
    • Use of a wrist splint or tennis elbow strap. Do not use brace if it causes pain/numbness or any adverse symptoms (problems). Be sure it is not too tight. (Are your fingers numb/cold?) Don't wear for more than one hour at a time. (one hour on and two hours off - you can wear it less often but not more unless you get an ok from your doctor or therapist)
    • CHRONIC STRAINS
    •  Same treatment as for acute. You can also try some basic stretches.
    •  
    • SEE DEFINITION OF ACUTE VS CHRONIC.
      • Take breaks if you have to use your arms with chores around the house or at work.
      • Avoid positions/activities that worsen your symptoms.
    • Which exercises are for you?
    • Discontinue any exercises that increase pain in your arm.
    • Gradually increase any exercise that helps you feel better.

      Top of page  

    FIRST AID FOR ARM PAIN stop any exercise or treatment that increases your pain.

    First aid # 1 ICE As soon as possible, apply an ice pack to the injured area. (10-15 minutes every hour). Cold limits swelling, reduces pain and speeds healing.

    be sure you apply ice at the right place

Evaluate to find the true source of the pain

  • Tendonitis at the elbow 
    Stretch and apply deep pressure to the elbow 
    (more details here)
    Apply ice to this area
    DOES THIS HAVE AN EFFECT ON YOUR SYMPTOMS?

  • Thoracic Outlet syndrome
    Stretch and apply deep pressure to the muscles of the front of the neck (above and below the collar bone) 
    Apply ice to this area
    DOES THIS HAVE AN EFFECT ON YOUR SYMPTOMS?

  • Pinched Nerve in the Neck
    Stretch (more details here) and apply deep pressure to the muscles along the side and back of the neck
    Bend you head toward the side toward the side with arm/hand pain.
    Apply ice to this area
    DOES THIS HAVE AN EFFECT ON YOUR SYMPTOMS?

  • Rotator cuff tendonitis 
    (at the shoulder)
     can produce arm pain but doesn't produce hand pain.
    Reach your arm
    above your head, behind your back or out to the side.  
    Apply ice to the pint of the shoulder.
    DOES THIS HAVE AN EFFECT ON YOUR SYMPTOMS?
    (more details here) 

If Stretching, applying ice etc to an area other than your arm or wrist changes your arm wrist pain chances are that you have found the true source of the arm. wrist pain.  Be sure you treat the SOURCE of pain. 


Wrist and arm pain related to computer use usually originates at:

  • the tendons at the elbow (also known as tennis elbow)

  •  pressure on the nerves as they pass from the body into the arm (also known as thoracic outlet syndrome)

  • pressure on the nerves as they leave the spinal cord in the neck (a "pinched nerve")

Ice should be applied at the source of the wrist/hand pain.  The sources usually are::

THE ELBOW

 THE FRONT OF THE NECK ABOVE THE COLLAR BONE 
or
 THE NECK

It probably won't help( it won't hurt) to apply ice to the wrist because even though you feel pain in the wrist/hand the pain usually originates elsewhere. 


The basics of first aid are:

R = rest ( Reduce your computer use, use a wrist splint at night, use the mouse with your left hand )

I = ice (see above)

First aid # 2 MEDICATION Some medications are available without a prescription.  If the non-prescription dose does not relieve your pain CALL YOUR DOCTOR.  Take aspirin or ibuprofen regularly as directed on the bottle (call your doctor if you've been told to avoid anti inflammatory medication). Acetaminophen  (Tylenol) may also be used. Take these medications sensibly;  never exceed the dosage suggested on the bottle, the maximum recommended dose will reduce the pain. Masking the pain completely might allow movement that could lead to re-injury.

Begin Stretches as tolerated.  ( This means gentle stretches.  Back off if stretches cause increased symptoms.)

First aid # 3  WRIST STRETCHES             When to see M.D.   

  • Your elbow should be straight.
  • Bend wrist up and down then side to side.
  • Hold 5-10 seconds at the end of the movement.
  • Stop if this increases your pain.

click here for picture          Top of page

First aid # 4 FOREARM STRETCHES

  • Your elbow should be in near your chest and you should be sitting.
  • Turn your hand so your palm faces up then turn your arm so that your palm faces down.
  • Hold 5-10 seconds at the end of the movement.
  • Stop if this increases your pain.

click here for picture

First aid # 5 SHOULDER STRETCHES

  • You should be standing.
  • Bend over at the waist and lean your good arm on the edge of a table.
  • Let your sore arm hang down freely.
  • Swing you sore arm in a circle then forward and back and side to side.
  • Repeat 5-15 times in each direction.
  • Stop if this increases your pain.
    (note use caution - forward bending can cause low back pain)

click here for picture

First aid # 6 ROTATOR CUFF STRETCHES

  • Basics
    • Rotator cuff tendonitis is usually caused by impingement ( pinching ) of the tendons.  
    • This is not "no pain no gain."  
    • Feeling a "stretch" and feeling better after is ok.  
    • Feeling a "pinch" in not ok.  If you feel a "pinch" don't go as far into the stretch to avoid the "pinch" or go back to using ice for a day or two.
  • Stretch #1 
    • Stand at a door frame reach up and put your hand at the top of the door frame. ( It is good to use the other hand to help lift your arm up and lower it back down)
    • You should feel a stretch in the arm pit ( no "pinch" or pain at the top of the shoulder)
    • Hold to 10-15 seconds
  • Stretch #2  
    • Reach behind your back with the GOOD arm 
    • Grab the sore arm by the wrist and gently slide your sore arm behind your back until you fee a gentle stretch.  
    • Hold to 10-15 seconds
  • Stretch #3 
    • Stand facing a door frame with your elbow at your side.
    • Bend your elbow to 90 degrees
    • You should be close enough to have your hand and wrist beyond the door frame and resting against the wall. 
    • Turn your body so the wall pulls your arm out to the side (keep the elbow at 90 degrees) until you fee a gentle stretch.  
    • Hold to 10-15 seconds

(Use caution  - sometimes you don't feel pain until the day after you exercise.)

 

Physical therapy is indicated for Acute ( severe ) pain that does not respond to rest or for Chronic ( less severe, but lingers over several weeks/months years) pain.  Physical therapy can be prescribed by your doctor and is generally covered by insurance.  A physical therapist is licensed to treat you without a doctor's prescription but in many cases he/she may advise you to see a M.D. to rule out a more serious problem.  Generally, physical therapists and M.D.'s work together to provide you with the best care. A physical therapist can instruct you in a basic program of arm care including maintenance exercises and a first aid program to prevent a minor injury from becoming a major injury.

DON'T LIVE WITH PAIN - THERE ARE SIMPLE TREATMENTS INCLUDING SLOWLY PROGRESSIVE EXERCISE PROGRAMS THAT CAN HELP MOST EVERYONE WITH CHRONIC ARM OR WRIST PAIN.  THIS IS USUALLY COVERED BY INSURANCE.  IF YOU NEED HELP A PHYSICAL THERAPIST CAN ASSIST WITH REDUCING PAIN AND SETTING UP A HOME PROGRAM.

CALL YOUR DOCTOR IF:           Top of page

  • You fell and landed on your arm and have pain when you try to use the arm. You have a dull ache that came on without an obvious injury and has lasted for a few weeks.
  • New or unexplained symptoms appear.
  • Physical therapy should be prescribed when you have been treated by your M.D. but pain  persists beyond 1-2 weeks or if you have had multiple episodes of pain over the past year.

Probable Outcome

Gradual recovery, but arm symptoms tend to reoccur.  A home program can prevent continued arm pain.

Physical therapy can help you prevent long term problems.

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Back and Body Care
PHYSICAL THERAPY SERVICES
3004 16th Street, # 303
San Francisco, CA 94103
(415) 626-3099

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