Archive for November, 2011

Wrist Problems: Part 2

Posted on November 2, 2011. Filed under: Exercise, Healing, Joints, Pain | Tags: , , , , , , , , , , , |

by Dr. Gregory Steiner~

Carpal tunnel syndrome is only one of many potential problems associated with the wrist joints. Because it is so common, let’s have a better look at specific symptoms and possible corrections for this very aggravating syndrome.

We touched on this last issue, but the capsule summary of what carpal tunnel feels like is this: there is pain, numbness or tingling on the palm side of the wrist which can be worse at night. The symptoms can be mild to very annoying and painful, and can be short or long term sometimes of month’s duration. It may be that you feel an unusual ‘clumsiness’ when trying to grab something small, as though you can’t quite make your fingers and hand do what you want them to. You might notice shrinkage in the size of the palm just under the thumb.

Just to refresh the memory, the usual people who develop carpal tunnel syndrome include not only computer operators, but carpenters, assembly line workers and……..weight lifters! And, a cautionary note is needed here. Most of the time carpal tunnel syndrome is mechanical in origin, from repetitive strain on the wrist when using the wrist for extended periods of time when it is bent forwards or backwards. In weight training the common causes are incorrect wrist position in presses and curls, or simple overwork.

Sometimes patients present into my clinic with wrist complaints mimicking carpal tunnel, and we can trace the cause back to doing overhead or bench presses with tired forearms which prevent the wrists from holding firm. Without the muscle support the wrist joints bend backwards too much, creating an abnormal stretch on the palm side of the wrist, and a compression of the back side. In such cases—if you feel an abnormal fatigue before training wearing a wrist support or taping the wrist may be helpful. As always though, getting dependent on any kind of support is not a good idea, as support tissues need exercise to strengthen. We used to see this a lot in neck cases associated with whiplash, when people were advised to wear collars. In the early days of care this is not a bad idea, but what we found is that people became scared to do without them and by this time their undamaged neck muscles had weakened which only made things worse. Remember, supports are like supplements—you use them when you need them, but not as a way off life unless you have a long-standing weakness that is impossible to fully correct.

As is often the case with musculoskeletal problems, there is a muscle associated with carpal tunnel syndrome that can contain contributory trigger points. That muscle is called the palmaris longus; which starts on the inner part of the upper elbow and extends into the palm. It is one of the muscles that helps bend the wrist forwards. In persons with normal anatomy there is no problem, but if the muscle is constructed slightly differently it can compress or otherwise irritate the nerve that is responsible for true carpal tunnel syndrome. If a trigger point is present, you can compress it hard for up to 30 seconds. To find the trigger point, draw an imaginary line from your ring finger up to your elbow, just to the inside of the tendon you feel when your arm is bent. Press in that line, about ¼-1/3 of the way from your elbow to your wrist. If the point is active you may feel a sensation in your wrist. The bad news is that if the muscle is anatomically altered, it may require a surgical decompression to sort it out.

Another muscle—the flexor carpi radialis which lies just to the thumb side of the palmaris longus–could contain a trigger point that you may think is carpal tunnel but is really not. In any event, if the trigger point is present it could cause pain on the palm side of the wrist. A typical activity which aggravates the trigger point is using scissors to cut tough material- gripping and squeezing a hand gripper would cause pain as well. To find the trigger point, press just to the thumb side of the palmaris longus trigger point area.

Note: sometime finding trigger points is like going on a fishing expedition. You don’t know whether they are there, and you only have a general notion of where they are. And, you need to look both shallow and deep to locate either fish or trigger points!

It is possible that a problem in the neck could create the symptoms as well. As a chiropractor I always look to the neck when I evaluate an extremity problem, as what I have often found over the years in stubborn cases that have not responded to direct treatment to the involved area are neck problems. In such cases there is often an irritation of one or more of the nerves that give sensation to the wrist and power to the muscles that move it. Usually evaluation of neck-related carpal tunnel requires professional analysis, but a rough test is this: tilt your head sideways, first to one side and then to the other. Then bend it forwards and backwards. Then to the side and back. Make the movements slowly but strongly, and take the motion to the end point of the range of motion. If any of these movements creates a “nervy” sensation down your arm, into your upper back or into the wrist, you may have a neck problem that is creating difficulties farther away from the neck. A useful picture to keep in mind is that of the spine as the fuse box, with the nerves as electrical wires. The muscles are the appliances that run off the electricity provided by the spine, as directed by the nerves.

Let’s say you find a trigger point or two, and take care of it by direct pressure. What next?

If the discomfort is really bad and the power in the wrist or grip is poor, a short-term use of a wrist splint could be of use, especially at night if sleep is a problem. Corrective exercise takes place in stages. First, do some light isometrics. Bend your wrist backwards and hold it there for 7-10 seconds, but for the first two weeks with only moderate force. Then increase the force of the contraction.

The second stage involves the use of wrist extensions, usually called reverse forearm curls. Dumbbells or an EZ curl would be better than a barbell at this stage, because the barbell may force the wrist to internally rotate (also called pronation) too much for a sore wrist to comfortably take. Sit down on a bench and using light dumbbells such as 5 lbs, rest your forearms on your thighs, palm down with the dumbbell hanging in front of your knee. Bend your wrist backwards. Do higher repetitions- perhaps 20 or more per set; do 3 or more sets. An alternate position is to kneel at the side of the bench with your forearms resting on the bench, dumbbells hanging over the opposite side. Another exercise is too make figure eights with the dumbbell, again for higher reps. If the dumbbell is really light, increase the reps up to 50. There is no need to add real weight at this stage as mobility, neuromuscular co-ordination and rehabilitation are being developed, not size or big strength. Daily or nearly daily performance of the programme is fine.

The third and final stage involves continuing these basic exercises, but adding weight and performing them every other day. However, do not rush! When the pain in the wrist is minor and has been that way for 3 weeks, it is probably safe to increase the workload.

As far as nutritional supplementation, some patients have responded well to vitamin B-6, a reduction in salt and use of bromelain. B-6 at no more than 100mg. daily for several weeks may help; as B-6 is associated with proper never function. Salt reduction may reduce any swelling, and bromelain is an enzyme that helps the body metabolise ‘rubbish’ in various musculoskeletal tissue structures, thereby reducing inflammation.

Of course, there is very little point in fixing carpal tunnel syndrome—or any other condition for that matter—if you don’t take steps to prevent recurrence. It would be a waste of time and set a poor pattern for future training to do otherwise. However, the first practical steps to take are to pay real attention to your grip when pressing, and we’re speaking of bench, overhead or any other kind. People get into trouble when they let the bar ride too far back, i.e. the wrist is bent too far back as well, creating tremendous stress on both sides of the wrist. It takes a good body-sense to get the right feel for the bar; it should be gripped firmly and not too loosely, as the slacker the grip, the less the actions of the flexors on the palm side of the forearm, which translates to less of a muscular counteraction to the back bending. A strong grip to some degree protects the wrists from excessive motion.

It could be also that curls with a straight bar annoy your wrists. Your wrists may be congenitally tight, meaning you have to work too hard to externally rotate them just to get the underhand grip. Outside of abnormal wrist stress it could set you up for elbow troubles as well, as both ends of the forearm work double-hard to rotate outwards. I knew a power lifter with this condition who eventually had to quit doing curls; his ability to deadlift was much more important.

We always adhere to the old adage about prevention being better than cure, and carpal tunnel is no exception. If your wrists start to play up, outside of the usual admonitions to ice the sore areas for 10-15 minutes it would be a good idea to start doing specific warm-ups for your wrists. Martial artists in the rappelling styles know very well the importance of this, as their wrists are often bent and otherwise abused. For lifting, the best thing to do is do some forearm curls, reverse forearm curls and figure eights, but with very light weghts. Remember, we are talking about warming up, not building at this point!

Finally, if gripping the barbell seems a real problem to your wrists, try using dumbbells instead for your presses. The subtle change in angles may be just the rest your wrists need. And, don’t forget to sort out our computer desk and keyboard! What you do doing your non-training time you bring with you to training.

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