Wrist & Hand (Orthopedic)
Posture: including scapulae position
Rule out cervical involvement: ROM, compression
Special Tests: Phalen's, median nerve compression, Tinel's test
ROM
MMT: hand held dynamometer
Joint mobility
Palpation
Carpal Tunnel
Hand numbness and pain in the median nerve distribution, which may present in the entire hand. Pain can occasionally go up to the shoulder. Symptoms usually worse at night. When the wrist is out of neutral, the carpal tunnel pressure increases. They may have difficulty picking up small objects or c/o dropping items. Increased risk if you have diabetes, obesity, female gender, previous diagnosis of carpal tunnel syndrome, RA, thyroid disease, previous MSK problems. Occupational factors that increase risk: vibration exposure, forceful exertion of hand and wrist, repetitive use of hand/wrist, jobs with non-neutral wrist position.
Interventions: night splint, day and night splint if night splint alone is ineffective, transverse carpal ligament mobilization (refer to PhysioU for techinque), self-massage to transverse ligament, heat pack.
Outcome measures: PSFS, QuickDASH, hand-held dynamometer
Outcome measures: PSFS, QuickDASH, hand-held dynamometer
Carpal Tunnel Release
Release can be performed as an open procedure or endoscopy procedure. PT is usually performed 1-3 weeks after surgery.
Week 1-3 (Inflammatory Phase)
Splinting isn't provided as routinely as in the past.
-Scar mobilization 48 hours after removal of sutures.
-Modalities for inflammation and pain. Measurements of edema can be taken for objective measures.
-AROM of wrist and fingers should be documented, but avoid simultaneous wrist flexion and finger flexion which can cause bowstringing which can cause obstruction to the healing of the transverse carpal ligament and other tissues.
-Use of joint and soft tissue mobilization to restore wrist and hand mobility. Understand that caution needs to be used as the carpal bones may be unstable after the procedure b/c of the ligament being cut.
-Exercises to improve AROM, prevent flexor tendon adhesions, and decrease edema. Exercise for this would be hand in neutral (to prevent bowstringing) and performing metacarpophalangeal flexion with extended phalanges, metacarpophalangeal flexion with phalangeal flexion, and phalangeal flexion. Perform 3-4x/day. I think wrist flexion exercises should be deferred.
-Nerve gliding exercises can be performed. Make sure it's gliding and not tensioners.
-Sensibility testing with monofilaments can be performed to monitor nerve improvement function. 2-point discrimination is usually normal with patients with carpal tunnel syndrome except in advanced cases. Perform as appropriate.
-Muscle testing including pinch and grip strength should be deferred. Avoid neural tension testing and finger dexterity testing at this time.
Splinting isn't provided as routinely as in the past.
-Scar mobilization 48 hours after removal of sutures.
-Modalities for inflammation and pain. Measurements of edema can be taken for objective measures.
-AROM of wrist and fingers should be documented, but avoid simultaneous wrist flexion and finger flexion which can cause bowstringing which can cause obstruction to the healing of the transverse carpal ligament and other tissues.
-Use of joint and soft tissue mobilization to restore wrist and hand mobility. Understand that caution needs to be used as the carpal bones may be unstable after the procedure b/c of the ligament being cut.
-Exercises to improve AROM, prevent flexor tendon adhesions, and decrease edema. Exercise for this would be hand in neutral (to prevent bowstringing) and performing metacarpophalangeal flexion with extended phalanges, metacarpophalangeal flexion with phalangeal flexion, and phalangeal flexion. Perform 3-4x/day. I think wrist flexion exercises should be deferred.
-Nerve gliding exercises can be performed. Make sure it's gliding and not tensioners.
-Sensibility testing with monofilaments can be performed to monitor nerve improvement function. 2-point discrimination is usually normal with patients with carpal tunnel syndrome except in advanced cases. Perform as appropriate.
-Muscle testing including pinch and grip strength should be deferred. Avoid neural tension testing and finger dexterity testing at this time.
Week 3-6 (Reparative Phase)
Wound should be closed or close-to closed. Since epithelial tissue completes its reparative phase by day 10, it should now be entering its maturation phase. Now, the focus shifts from strength and endurance while optimizing healing of transverse carpal ligament.
-Continue with scar mobilization which also aids in organization of scar tissue formation of ligament. Also can aid in desensitization.
-ROM exercises are continued and use of joint mobilization to improve hand and wrist motion can be utilized as indicated. Continued caution should be in place for carpal bones. May now add wrist flexion exercises, forearm stretches, and composite finger and wrist flexion.
-Strength testing may be assessed, as well as isometric wrist flexion and extension exercises. Can start gripping and pinching exercises with light resistance. Example would be pinching puddy between index and thumb. Progression to isotonic exercises can be performed when patient can perform them without pain.
-Make sure no impairments to elbow or shoulder girdle. Make sure bicep/triceps/supinators/pronators are adequate.
-Education regarding ergonomics. The most influential factor is wrist position on keyboard. Non-neutral wrist position on keyboard causes 2x increased risk.
Wound should be closed or close-to closed. Since epithelial tissue completes its reparative phase by day 10, it should now be entering its maturation phase. Now, the focus shifts from strength and endurance while optimizing healing of transverse carpal ligament.
-Continue with scar mobilization which also aids in organization of scar tissue formation of ligament. Also can aid in desensitization.
-ROM exercises are continued and use of joint mobilization to improve hand and wrist motion can be utilized as indicated. Continued caution should be in place for carpal bones. May now add wrist flexion exercises, forearm stretches, and composite finger and wrist flexion.
-Strength testing may be assessed, as well as isometric wrist flexion and extension exercises. Can start gripping and pinching exercises with light resistance. Example would be pinching puddy between index and thumb. Progression to isotonic exercises can be performed when patient can perform them without pain.
-Make sure no impairments to elbow or shoulder girdle. Make sure bicep/triceps/supinators/pronators are adequate.
-Education regarding ergonomics. The most influential factor is wrist position on keyboard. Non-neutral wrist position on keyboard causes 2x increased risk.
Week 6+ (Remodeling Phase)
Most individuals can be discharged from therapy after completion of Reparative Phase if jobs is mostly sedentary. If patient work includes heavy manual labor, like mechanics or assembly line workers, will need therapy during this phase. Ligament has now healed with scar tissue. Scar tissue of incision site is now mature but will has not regained full elasticity or motion as pre-surgery. Expect pinch strength to take up to 6 months to return.
-Continue with scar management. This can take up to a year.
-Progress resistance training meeting the demands of the patient's occupation. Can incorporate aerobic exercises and general body conditioning during this phase.
Most individuals can be discharged from therapy after completion of Reparative Phase if jobs is mostly sedentary. If patient work includes heavy manual labor, like mechanics or assembly line workers, will need therapy during this phase. Ligament has now healed with scar tissue. Scar tissue of incision site is now mature but will has not regained full elasticity or motion as pre-surgery. Expect pinch strength to take up to 6 months to return.
-Continue with scar management. This can take up to a year.
-Progress resistance training meeting the demands of the patient's occupation. Can incorporate aerobic exercises and general body conditioning during this phase.
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