Carpal Tunnel

[vivlor]

A 67 yo woman came in to see me today who was diagnosed by an MD with carpal tunnel. She fell down 6 months ago and used her right hand to catch the fall. She's seen an orthopedic surgeon and a neurologist and had an MRI and Xray. They showed nothing. She also had 10 sessions of deep tissue massage with no results. My guess is a PT worked on her. She's complaining of pain in the extensors, nerve pain and shoulder pain. She can only flex or extend her wrist to about 15% as opposed to 85%. Her traps are real tight as well as her digitorum extensor on her forearm. She would like to be able to flex and extend her wrist again, but I'm not sure what to do. If you're familiar with Waslawski's arm procedure, that's what I did. She also seems to be a very tense woman who can't relax. I'm also feeling that she tenses that hand and wrist to protect it which makes it a bit difficult to work. This was only our first session. I've suggested 30 min. sessions 3 days a week for 2 weeks. Any suggestions would be greatly appreciated.

 

[atom f]

Sounds like you have some work ahead of you with this case.......

My personal approach would be to use Orthobionomy releases to the wrist that mimicked [sp] as best as possible the positioning of the hand and wrist when she hit the ground. Have had great success with clientele here using such procedures. That in turn helps alleviate the problems, or at least lessen them, further up the arm and shoulder.

OR, for a really novel approach, just hold her wrist sandwiched between your 2 hands with the same light pressure you would use for craniosacral...... that has been known to work too!

Good luck!!

 

[Miss Smith]

Has she seen a chiropractor by any chance? From the description you give the ulna and radius may be out of place causing all the nerve pain. You mentioned that she fell and tried to break her fall with her hand, as a result the bones may be spread or rotated causing all the muscles in the arm to tighten up. Add the problems with the shoulders being tight and you have a big ball of mess to deal with. Just a suggestion.....

 

[walk 112 ??l?]

You may want to check her distal ulna for pain at the TFCC (triangular fibro cartilage complex). This structure is very often over looked on MRI and X-Ray views and can take months to heal even when treated properly (due to the low levels of vascular supply in cartilage tissue). The other symptoms may be a result as you say, "from holding the UE in a protected position" - yes, I agree with that.
Until you can rule out damage to this particular structure, any type of "deep massage" or "ranging" - passive or otherwise, can further damage or prolong this type of injury.
Palpate the distal ulna with her hand in a pronated or neutral position - laterality and superiorly; in the space between the pisiform bone and the distal ulna. Look for tenderness and decreased motion in flex, ext and in radial and ulnar deviation of the wrist. If you find that she has pain in this location send her back to her Ortho or Hand MD to evaluate for suspected TFC tear.
You can still treat her other soft tissue issues without concern; however. You may not find this problem...but your description sounds "Oh so familiar"... I have treated many TFC tears and they can be tricky...especially with the elderly population.

Best of luck,
LG
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[discount.queen]

I agree she probably needs to have her bones set before any long term healing can begin.

If she is so tense, she might respond well to acupuncture treatments along side of your bodywork. Unless of course she is needle phobic.

 

[Little Lyn]

Yes, this does sound like TFCC. I've looked it up on the internet, but I can't find any information for treatment except surgery or resting. What do you recommend? She already had xrays and an mri. Should I suggest that she go back to the ortho and have him check her for TFCC? She and her husband already feel like they have gotten the medical run around and really don't want to have to deal with MDs again. Now I'm really reluctant to treat her. All I've done is myofascial release and not too deep frictioning and some stretching.

 

[mom tree]

This sounds like a challenging case! I agree with dodab's chiro idea, based on what you've said...dodab's right about the bones being out of place and pushing against the nerves, causing the pain. The diagnostic imaging (MRIs, etc) MAY show joints being out of place (though many times it may not) and sometimes radiologists may miss things like that. DCs also have training in adjusting extremities and they can adjust practically any joint in the body. The acupuncture idea rocks, too! Hopefully together, y'all can help this lady

Good luck!
~Jyoti

 

[Beer and TV Olympian]

She's been to the chiropractor who did xrays and they found nothing also. She'e Hispanic with limited English so it's a bit difficult to communicate with her. She can say if it hurts or not and where, but regarding her past medical history involving this injury, I'm having a hard time getting the facts. The husband speaks and understands more, but all I hear from him is the doctors all want money money money and no solution to the problem. I told them I would see them for 5 1/2 hour sessions and I'm on the 4th today. She does have more mobility in the wrist, but now with the subject of TFCC being brought up, I'm a little hesitant to continue doing what I've been doing in case I aggravate the situation.

 

[Thinker]

TFCC

"All I've done is myofascial release and not too deep frictioning and some stretching."

Hi Relaxtheback,
Yes, typical treatment for severe TFCC tear is surgery....if you go to a surgeon for treatment. Many TFCC tears; however, can be managed under a therapists care.

Standard protocol for therapeutic treatment:
- Heat and/or ice or combo (contrast bathing) if edema is present.
- Light massage - with desensitization and edema reduction as the goal (myofascial is also a good choice) distal to proximal. Elevation, etc.
- Patient education focused on resting the limb (very important - no lifting, etc)
- Performing PROM with in comfort level...leading to AAROM then to AROM.
- Eventual strengthening...again within comfort level (when all signs point toward progress)
- Use of either Volar based wrist splint or Circumferential wrist splint.
- Ionotophoresis/phonophoresis
- Electric mods for pain and increased healing

MD/Surgical tx:
- Surgery....debridement of central tears and repair of peripheral tears.
- Cortisone shots (depends on the MD)
- Send to therapist...

There is the quick overview of TFCC tx. The stretching you mentioned, I'm sure is fine if you are referring to her elbow and shoulder...I would be careful with the wrist at this point. As for her tight ext digitorum....heat, massage, manual manip....all ok. This muscle really should not be a factor in her decreased mobility at her wrist. Check her Ext carp radialus L&B as well as her ext carp ulnarus for tightness as these will affect and limit motion.

OK...I think that's enough for now.
Best of luck,
LG

 

[Smileycourt]

I apologize, because I must've missed the fact that it was a tear!

Livgreen's post got me thinking...

There are some REALLY neat new therapies out there, whose early research coming back is pretty promising. (And trust me, even though these therapies have not been heavily researched, don't let that deter you--surgery has NOT been researched and proven effective or beneficial like everyone thinks it is and yet surgeons often cause more harm than good for tens of thousands of dollars every day.)

Therapy #1: Biofeedback
There are a few different types of biofeedback and they're often vastly different (kinda like massage--we all know that "massage" is really an umbrella term!) Most of it involves machines that can generate energy at frequencies that exist between a very tight range that specifically heal tissue faster. These links might be able to help:
http://www.newscientist.com/channel/health/mg19125624.400-to-heal-a-wound-turn-up-the-voleforum.xxxe.html
http://www.senergy.us/

I own the biofeedback machine depicted in the second (Synergy) link for 2 years. I can say that wounds that would take 5 weeks to heal took less than 4 days. I can also say I took care of my own tooth infection in less than 6 days, and thus prevented a $1000 root canal. I can provide several detailed personal myself-as-guinea-pig, turned-out-better-than-i-ever-thought stories if you'd like to hear them I'm not affiliated with the people at all, however, and I have no financial interest whatsoever other than that my MT license in TX covers the use of the machine on clients and I offer it as a service to them during sessions for no extra charge.

The advaneforum.xxxes to electrical biofeedback: a regular massage therapy license covers its use in some states. Check the scope of practice in your state. Also, it's usually painless to the client. Also, treatments usually last less than a half hour, sometimes as little as a few minutes. Also, it's very fast acting! You'll know within the first 1-2 days if it's going to help.

The disadvaneforum.xxxes: Depending on the problem and its severity, the client may have to come see you every day, and often twice a day, for about a week, to receive the full benefits. I can tell you that it's definitely worth it! But some clients may simply be too convenience-minded, or it may be hard for them to budget the time/money. Also, it's NOT real wide-spread. It would put many surgeons out of business, and dentists would no longer do nearly as many root canals! Most people have never heard of this. So you may have a tough time convincing them that it's something real, legit, and genuine. Also, the cost. The machine I own (the one from Synergy) starts at $2k. Other machines for other types I know of can run $18k.

Therapy #2: Cold laser
I know very little about cold laser other than that it's being used to treat patients at our med school. I do know, though, that many people are excited about it, they've seen some awesome results, and I know that our school actually teaches it as a treatment modality. I will know much more about this machine and its results in about 1.5-2 years when I'm in the clinic myself and I get to watch and document patients' progress. And again, depending on the state laws governing scope of practice, MTs may be able to use cold laser on their clients, too! I know in TX we can (same as biofeedback.)

This link may help: http://www.coldlaser.net/index.html
There's a lot of basic info, and they also cite actual research studies and their sources on the website.

The advaneforum.xxxes: same as for biofeedback, except that cold laser has the added benefit of being able to work right through clothes. It doesn't touch the client's skin like many of the biofeedback types. This also helps us to be able to work areas with broken skin, whereas with biofeedback it wouldn't be harmful to work broken skin but it WOULD be uncomfortable to the client. Cold laser overcomes that hurdle.

Disadvaneforum.xxxes: Same as for biofeedback. Cold laser machines can run right around $14k and unfortunately, I don't think there are any modalities that use a $2k machine.

Hope this helps!
Hugs,
~Jyoti