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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Wrist Pain, Carpal Tunnel, and Driving Problems…

Posted on October 4, 2011. Filed under: Joints, Pain | Tags: , , , , , , |

When I was studying to be a chiropractor, some of my fellow students were quite heavy into lifting weights. One of my classmates was quite an accomplished power lifter; he was about my size, but he was renowned during our early learning days of “hands on” evaluation and treatment as having the thickest low back muscles of anyone in the class.   We used to joke you could hide a CD between them. He worked out hard of course, and certainly deserved the respect he got for his powerful back..

Why do I mention him? Even back then, his wrist would give problems from time to time.  A year or two ago,  I touched base with him to see how he was doing and found out that a nerve-related condition had caused him to practically stop training and his wrist condition had forced him to quit his clinical practice; the profession suffered a great loss without him.  So, it’s clear that wrist problems are not to be taken lightly.

Complicated Anatomy

Few body parts are as anatomically complicated as the wrist, and the wrist and hand as a unit are certainly the most complex musculoskeletal structure. What I mean by anatomically complicated is that two arm bones, the eight wrist bones, and five hand bones and fourteen finger bones by virtue of direct and indirect connections of ligament and tendon form an incredibly flexible, complicated manipulative instrument. From a clinical point of view, the wrist can be affected by conditions in the neck, shoulder and elbow; remembering the principles of primary and secondary conditions we know that dysfunctions or habitual distortions in one part of the body can and do cause dysfunction and distortions in other parts- the “tugging on the chain” situation in which one link tugs on all the rest.

How do you know when there is a problem?

What You Might Feel

As usual, symptoms come in two broad, inclusive categories. There are problems with how your hand or wrist works, and there are negative changes in how you feel. In other words, it could be that your wrist seems weak, extra loose or more likely resistant to moving in one or more directions. This could be indicative of swelling, deep tissue damage, calcification in some of the soft tissues which should be supple and certainly free of hard, immobile calcium; or muscles could be in spasm.

Pain is easier to talk about as it is harder to ignore than something that is painless but doesn’t work just right. The main symptoms to watch out for are persistent tingling and sharp, stabbing pains, though wrists can ache quit a lot, as well as burn, itch or feel tight and hot. Each of these indicates some sort of underlying disorder.

A key symptom to watch for is a deep ache in the middle of the wrist that persists for weeks or more, especially after a fall. I have had patients who have experienced this and upon close x-ray evaluation have been diagnosed with “avascular necrosis” which translates to an abnormally reduced blood supply to an important wrist bone that has allowed the bone to starve and rot away.

Tingling, numbness and burning on the palm-side of the wrist that persists could indicate carpal tunnel syndrome. Carpal tunnel syndrome refers to irritation of the nerve that travels down the palm-side of the forearm, on top of the rows of wrist bones and which splits to innervate the palm of the hand. At the wrist, a band of tissue called the “flexor retinaculum” connects some of the wrist bones and forms a tunnel through which the nerve passes. If the tissue becomes thickened, the bones become dislodged undo irritation of this nerve can take place and the most unpleasant weakness and pain of “carpal tunnel syndrome” can occur.

This syndrome has received much attention in recent years, especially with the increase in computer usage and the many hours at the keyboard required of students and certain professions.

Fortunately surgery isn’t always needed – in our clinic we successfully treat it by acupuncture vitamin B-6, and making sure the whole arm and neck with it’s many nerves are in perfect shape.

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