Archive for the ‘carpal tunnel’ Category

There was an article in the New York Times recently entitled Sports Injuries: When to tough it out.

The part of the article that stood out involved diagnostic testing. Here is a quote from the article:

“Sometimes going to a doctor for a diagnostic workup can be precarious, with scans that can show all sorts of apparent abnormalities and injuries that are not causing any problems.

For example, in a study reported at a recent meeting of the American Orthopedic Society, Dr. Matthew Silvis, an orthopedist in Palmyra, Pa., did M.R.I.’s of the hips of 21 professional hockey players and 21 college players. They showed abnormalities in 70 percent of the athletes, even though these hockey players had no pain or only minimal discomfort that did not affect their playing. More than half had labral tears, rips in the cartilage that stabilizes the hip.”

“M.R.I.’s are so sensitive,” Dr. Musahl said. “They frequently show little tears or fraying everywhere. And it is very, very common to have a small labral tear in your hip — it doesn’t mean you have to have the particular symptoms.”

The same is true for rotator-cuff tears, rips in the tendons that help stabilize the shoulder. Studies have found that about half of all middle-age people with no shoulder pain have these tears, although they are unaware of them and have no symptoms.

Testing certainly has it’s place but it is important to understand that testing is only one piece of the puzzle. The assessment, symptomatology, mechanism of injury, and experience also play a critical role because:

  • Hockey players are going to have hip labral tears
  • Baseball players are going to have labral fraying
  • Middle aged people are going to have degenerative changes
  • Assembly line workers are going to have tests positive for carpal tunnel and rotator cuff tears
  • Individuals over the ages of 50-60 are going to present with lumbar spine pathology
  • And so on…

And all of these test results could appear in someone who is completely asymptomatic.

It gets interesting when the individual reaches threshold – when symptomatology now presents itself.

Here are a couple of examples to consider from several years ago – both involved individuals diagnosed with carpal tunnel syndrome.

  • One individual fell on their wrist and aggravated their wrist. Within about a week of developing symptoms, an EMG was done and the test came back positive for CTS. So…in 1-2 weeks someone is going to go from not having CTS to now having it???
  • A individual was having significant wrist and shoulder pain – a recent flare-up. They were previously diagnosed with CTS via EMG (chronic case). With the latest flare-up in symptoms, another EMG was ordered since it had been awhile from the previous EMG.  Here this individual was in pretty severe pain and the new EMG results were…EMG results were improved from previous testing and were now within the “normal” range. A person who is in pretty severe pain now is being told that they no longer have CTS???
  • Add your own story or example here.

Everything is fine when 2 and 2 equal 4. It starts to get dicey when things don’t add up as easily. Again, the assessment – the symptoms- mechanism of injury – and your experience as a clinician play a significant role in bringing together the full picture.

As a young athletic trainer, I was under the impression that MRI and other diagnostic testing were the final determinant regarding someone’s injury status. Years of experience, research, professional discussion, and lots of “huh??? This doesn’t make sense” moments have changed that thought process over the years.

Diagnostic testing does have it’s place but it is important to keep testing in the proper perspective. It is a piece of the puzzle and requires putting the other pieces together as well. Diagnostic testing does not slam the door on the case necessarily – plenty of detective work needs to be done so that the entire case can be properly evaluated.

What are your thoughts? Have you had similar experiences when diagnostic testing and reality weren’t quite meshing?

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Have you recently considered if wrist positioning affects grip strength?

Well, in case you have, this post is going to discuss some facts related to grip strength and wrist positioning.

So lets go through this demonstration to see if wrist positioning does affect grip strength. Working in the industrial setting, this is a demonstration that I will use with patients and other individuals to stress the importance of a neutral grip whenever possible.

So let’s take a look at the first example of grip with the wrist held in the neutral position. A neutral grip was able to generate 105 pounds of force. The second example shows the wrist at approximately 30 degrees of wrist flexion. Pay attention to the grip strength that is generated. The grip strength generated in this position is 68 pounds of force. 35% less than in neutral grip. The grip strength generated near end-range of flexion is 39 pounds of force. This is 63% less strength than generated in neutral grip and 43% less grip strength than generated in ~30 degrees of wrist flexion.

The conclusion: Grip strength generated in the flexed position is significantly less than compared to grip in the neutral position. The greater degree of flexion, the less strength that is able to be generated.

So the answer to the question is yes, wrist positioning does affect grip strength. Now, let’s look at some related information. This is of particular interest with those who have or treat carpal tunnel syndrome.

Extremes of wrist flexion and wrist extension can cause compression of the carpal canal and negatively affect intraneural blood flow. In an average person, pressure within the carpal canal is approximately 2 mm Hg.

When pressures reach 20-30 mm Hg, venular blood flow is impacted. Axonal transport is affected at 30 mm Hg. Neurophysiologic changes such as motor and sensory dysfunction begins at 40 mm Hg. At 60-800 mm Hg, complete cessation of intraneural blood flow is noted. Average carpal canal pressure in carpal tunnel patients in neutral wrist position was 32 mm Hg as reported in the study: The carpal tunnel syndrome: A study of carpal canal pressures. The same study goes on to show that extreme ranges of wrist flexion and extension in those with carpal tunnel syndrome increased carpal canal pressure in excess of 90 mm Hg.

One more aside. In the study: Segmental Carpal Canal Pressure in Patients With Carpal Tunnel Syndrome, the greatest pressure in the carpal canal was found 10mm distal to the distal wrist crease.

So as we bring this to a conclusion. Grip performed in a neutral grip is the optimal position for strength and also presents an environment for minimal carpal canal pressure. Grip performed in the flexion and extension is a less efficient movement and does contribute to increased pressure within the carpal canal.

So this is some information that you can store and utilize the next time you encounter someone using inefficient technique for their task or perhaps someone with carpal tunnel syndrome.

What do you think? Any new information that you would like to share? Any similar experiences that you can speak about to the group.

Additional Source: Carpal Tunnel Syndrome by David A. Fuller, MD

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