Special Health Reports

Healthy Hands: Strategies for Strong, pain free hands

Tendon trouble

Think of the tendons in your arms and hands as the strings of a marionette, enabling you to lift your wrist and hand and to move your thumb and fingers. For a variety of reasons or for no apparent reason, the tendons or tendon sheaths can become inflamed, causing pain whenever you put any tension on the tendon. Certain tendons and tendon sheaths in the fingers, wrists, and elbows are particularly prone to inflammation, leading to specific types of tendinitis, tenosynovitis, and epicondylitis.

De Quervain's tendinitis

De Quervain's tendinitis (also known as tenosynovitis) is sometimes called "new mother's disease" because it often develops in women with newborn babies, possibly in response to the repetitive movements made while caring for an infant. It affects the tendons along the thumb side of the wrist.

  • Pain on the thumb side of the wrist, especially when pinching, grasping, or making a fist
  • A small knot or tenderness on the thumb side of the wrist

The main symptom is pain over the thumb side of the wrist, which can appear gradually or suddenly and may move up the forearm. The pain worsens when you grasp things or twist your wrist. Picking up a coffee mug may become impossible. You may notice swelling over the affected tendon, and a fluid-filled cyst may arise in the same area. The thumb may occasionally "catch" or "snap" when you move it.

To diagnose de Quervain's, the doctor will ask you to make a fist with your fingers over the thumb and bend your wrist toward the little finger. This maneuver, known as the Finkelstein test, is usually quite painful for a person with de Quervain's. But tenderness over the tendons on the thumb side of the wrist is the most common finding.

Treatments include resting the thumb and wrist by wearing a splint (see "Splints"). Your doctor may also recommend anti-inflammatory medicines to curb pain and reduce swelling. Steroid injections into the tendon compartment may help. If all these measures fail to improve your symptoms, surgery (which releases the tendon sheath) is often successful. A hand therapist can design an exercise program to restore flexibility and strength once the initial symptoms clear up.

Trigger finger

The term trigger finger may conjure up visions of sharpshooters and hunters. Actually, this condition (officially known as stenosing tenosynovitis) is most common in the ring finger and the thumb. It is called trigger finger because of the trigger-like snap that occurs when the finger briefly locks and then suddenly releases when you try to bend or straighten it. The condition affects the tendons that bend the fingers and the pulleys (rings of connective tissue) that hold those tendons close to the finger bones (see Figure 7). If the tendon develops a knot (nodule) or if the lining covering the tendon swells, it has to squeeze through the opening of the tunnel, causing pain, popping, or a catching feeling in the finger or thumb. When the tendon catches, the pulley also becomes swollen and irritated, creating a vicious cycle. Sometimes the tendon becomes stuck in the pulley and the finger can't be straightened or bent.

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An often-painful condition, trigger finger is caused by a narrowing of the sheath that surrounds the tendon and irritation of the pulley, the ring of connective tissue that holds the tendon close to the bone. Trigger finger is most common in people over age 40 who also have rheumatoid arthritis. Symptoms include a sensation of "catching" when trying to bend or straighten the finger. A bump (nodule) may also form.

Trigger finger or thumb often starts with a sense of discomfort at the base of the digit, which may also thicken slightly. If the finger begins to trigger or lock, you may think the problem is at the middle knuckle of the finger or the top knuckle of the thumb, but it's actually inflammation of the pulley at the base of the affected finger. It's not clear what causes trigger finger, but people who are older than 40 and who have rheumatoid arthritis, gout, or diabetes seem to be more susceptible to the problem.

  • Pain and sometimes swelling where the finger or thumb joins the palm
  • When you bend or straighten the affected digit, it may catch and then suddenly release

Wearing a splint, taking anti-inflammatory drugs, and getting a steroid injection in the area around the tendon can all help break the cycle of inflammation and pain. If your symptoms don't improve, surgery is an option. The operation opens the pulley, allowing the tendon to glide through it more easily—a quick procedure that takes only about 10 minutes. Usually, this restores finger movement right away, although some people feel tenderness, swelling, and discomfort for four to six weeks, or possibly longer. A full recovery, meaning your finger feels back to normal, often takes at least three months but can take up to a full year.

Tennis elbow

Why include tennis elbow in a report on hands? Also known as lateral epicondylitis, this condition involves degenerative changes of the fibers that attach your forearm muscles to the outside of the elbow. These muscles lift the wrist and hand. So, every time you use your hand, the tendon attached to your elbow hurts. You may feel mild pain in your outer elbow that gradually worsens over weeks and months, becoming a severe, burning pain. Pressing the outside of the elbow or lifting even very light objects, like a book or coffee cup, can be very uncomfortable.

  • Pain on the outer side of the elbow and down the forearm
  • Worsening of pain if you straighten your wrist or try to pick up a heavy object

Although the problem can occur in people of all ages, it's most common between the ages of 30 and 50. Despite the name, most people with tennis elbow don't play tennis or other racquet sports. They may be involved in work or other activities that require them to use their forearm muscles in repetitive, vigorous ways—shoveling snow, for example. But some have no apparent reason for developing symptoms.

Treatment focuses first on easing pain. Reducing activity and putting ice on your elbow can help; so can anti-inflammatory medications. Your doctor or hand therapist may also recommend certain braces or splints that allow your tendons and muscles to rest and heal (see "Splints"). Massage, stretching, and strengthening may be added to your regimen as your treatment progresses. The exercise program may also include strengthening of your shoulder and core to improve your overall mobility and function.

The basic purpose of a splint is to immobilize an injured or inflamed part of the body, allowing it to heal. Splints can provide pain relief, allow you to function, or realign your joints to a more anatomically correct position. Certified hand therapists are specifically trained to assess your hand and choose or fabricate a splint to meet your needs.

Splints come in a wide range of materials and forms. Prefabricated splints from the drugstore or a medical supply store (such as splints 2 and 3—the MetaGrip and Cool Comfort, respectively) work well for certain hand problems, provided you choose and adjust the splint correctly. Other conditions require specially fabricated splints, which are usually made of thermoplastic materials and molded to fit around the contours of your hand (splints 1, 4, and 5).

Static splints (all five below) hold a joint in one position. Dynamic splints do not. Some are designed to help lengthen tightened joint capsules, muscles, and tendons. Others, which feature elastic or spring-loaded parts, provide for missing motion in the hands and wrists caused by muscle weakness or nerve damage.

Of course, a splint only works if you have the right type for your specific problem and if you use it correctly. For example, splints used to treat carpal tunnel syndrome are intended to be worn only when you're sleeping or resting—not when you're using your wrist. Some common complaints about splints are that they don't look good, they immobilize too many joints (which limits your ability to function), or they fit poorly (which can cause pressure and irritate the skin). If you're experiencing any of these problems, consult a therapist for guidance.

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Your symptoms should improve within six to eight weeks, although complete healing may take a year or longer. A therapist can teach you specific exercises to strengthen the affected muscles and tendons, and show you how to modify your activities so your symptoms don't return. Most people are completely cured with these treatments. But a small percentage end up needing surgery to remove damaged tendon tissues and reattach normal tendon tissue to bone.

Golfer's elbow

You can also develop degenerative changes on the inside of your elbow; this is known medically as medial epicondylitis. This condition usually arises from movements that involve turning the arm down and flexing the wrist, such as during a golf swing, which is why it's also known as golfer's elbow. But any activity that requires you to repeatedly bend your wrist or grip, grab, and turn your hand can cause the condition. The symptoms include tenderness and pain in the inner elbow, which worsen if you bend your wrist. The treatments are essentially the same as those for tennis elbow, but focused on the inner elbow.

  • Pain and tenderness in the inner elbow
  • Worsening of pain if you bend your wrist

Dupuytren's disease

This uncommon hand problem is also known as Dupuytren's contracture because it causes the fingers to slowly contract and curl toward the palm. It results from an abnormal thickening of the fascia—the tissue between the skin and tendons—in the palm. Some people develop a tough cord beneath the skin stretching from the palm to the fingers, which prevents the fingers from fully straightening (see Figure 8).

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A contracture from Dupuytren's disease develops when the palmar fascia (the tissue overlying the tendons in the palm) shortens and contracts, pulling the fingers inward. The first sign may be a nodule near the crease of the hand below the finger. A fibrous cord may develop that extends from the palm to the finger.

Although no one knows exactly what causes Dupuytren's disease, it's almost certainly inherited. Named after the French surgeon who first treated the disease in 1830, Dupuytren's mostly affects people with Northern European heritage and is more common in men than women. Cigarette smoking, epilepsy, and diabetes may increase the risk for Dupuytren's.

  • Small lump or pit in the palm crease closest to the ring and little fingers
  • Inability to flatten the palm on an even surface
  • Fingers may eventually curl toward the palm

The condition often begins with a small lump or pit in the palm, usually near the crease of the hand closest to the base of the ring and little fingers. Dupuytren's disease usually doesn't hurt, but the initial nodules in the palm may be painful. Still, you may not notice the problem until you cannot flatten the palm of your hand on a table or other flat surface, which may not happen for months or even years. In a poem published in The Journal of the American Medical Association, a physician affected by the disease described his father's (and his own) experience with the deformity. He was "puzzled by the stinging and the curl of his fingers about a phantom hardball caught barehanded." In severe cases, when the fingers pull into the palm, it's difficult to do everyday activities such as washing your hands, wearing gloves, and putting your hands in your pockets. With Dupuytren's, it's impossible to straighten the fingers, unlike a trigger finger, which can be intermittently straightened. Often both hands are affected.

In the past, people with Dupuytren's disease were usually treated with surgery to release their bent fingers. Afterward, patients wore splints to keep their fingers straight, followed by therapy to ease swelling and help them regain finger function. But the thickened fascia and cord characteristic of this disease sometimes returned in the same place or elsewhere in the hand. That's also the case for a less-invasive procedure called needle aponeurotomy or percutaneous fasciotomy, in which the doctor uses a small needle to divide and sever the contracting bands in the palm. People usually recover quickly, returning to normal activities within just a few days, without needing bandages or splints. However, despite the initial high success rate, the condition returns in up to 65% of people.

In 2010, the FDA approved a nonsurgical treatment for Dupuytren's disease. Marketed under the name Xiaflex, the drug is made from an enzyme, called collagenase clostridium histolyticum, which breaks down the collagen fibers causing the contracture. A doctor injects the medication directly into the collagen cord in your hand. Two to three days later, your hand is numbed and manipulated to release the cord. Over the following four months, you wear a splint at night that straightens your finger, and you perform exercises several times a day to maintain your finger's range of motion (see Figure 9). The most common side effects include swelling, bleeding, and pain in the injected area. In rare cases, the collagenase can leak into the tendon, causing it to rupture—a serious complication.

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At left, severe contractures of the ring and middle fingers in a person with Dupuytren's disease before treatment with injectable collagenase. At right, the same hand after treatment.

In a study published in The New England Journal of Medicine, 308 people with contractures of 20 degrees or more in the MCP or PIP joint of the ring or little finger received injections of either Xiaflex or a placebo. The following day, the investigators manually extended the fingers (as much as the patients could tolerate) to break the cord and release the contracture. Subjects could receive up to three injections (at intervals of about one month). Nearly 85% of joints injected with collagenase showed some improvement, compared with 12% of those receiving placebo injections. On average, Xiaflex improved range of motion by 37 degrees, compared with a 4-degree improvement in those who got a placebo injection. Other studies show that after two years, recurrence rates were 14% for MCP joints and 23% for PIP joints.

A larger study that included 924 treated joints in nearly 650 people reported a success rate of 67% after three years. Success was defined as close to a full extension of the fingers, or a contracture of 5% or less following treatment. Many other people had less dramatic but still noticeable improvements in their contractures. That's likely why even though just over a third of the procedures were deemed "unsuccessful," only 7% of the participants had a repeat procedure.

Although all the treatments for Dupuytren's contracture are beneficial, none of them cure the disease. The recurrence rate varies, but is highest in people with multiple risk factors.

Ganglion cysts

If you notice a small, firm lump on the back of your wrist or hand, don't be alarmed. Chances are it's a ganglion cyst, a common, harmless growth that develops from inside a joint, like a tiny balloon on a stalk. The balloon may be filled with fluid or a jelly-like substance and can usually be felt underneath the skin. The cyst may be painful and may wax and wane in size, sometimes growing as large as a peach pit. Aside from the back of the hand, ganglion cysts can also form on the underside of the wrist, between the thumb and the pulse point, or at the base of a finger. An old-time treatment for these cysts was to hit them with a heavy book, which is why they're also known as "Bible cysts." Don't try this, however—it's not effective, and you could fracture your wrist!

  • Small, firm lump on the hand that is usually painless, ranging in size from a pea to a peach pit
  • Lumps may disappear and reappear

It's not clear what triggers most ganglion cysts. They're more common in women than in men, and gymnasts (who often put a great deal of pressure on their wrists) seem to be especially susceptible to them.

Often, these cysts simply disappear with time. But if the cyst is painful, affects your daily activities, or is unattractive, you may want to consult a doctor. To diagnose the condition, the doctor will probably press on the cyst to check for tenderness or hold a penlight up to the cyst to see if the light shines through.

Because activity can cause the cyst to hurt, you may be advised to wear a wrist splint (see "Splints") to relieve symptoms. After any pain or discomfort subsides, wrist-strengthening exercises may help (see "Exercises for the hands"). Your doctor can also aspirate the cyst, which involves numbing the area and puncturing the cyst with a needle to draw out the fluid. But the cysts nearly always recur after aspiration. If the entire cyst is surgically removed, recurrence rate is about 10%. The surgery involves removing part of the affected joint capsule or tendon sheath. Recovery time varies, but you should be able to return to your daily activities within two to six weeks.

Next: Exercises for the hands

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