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R GiONAL PAIN SYNDROM S
Upper Extremity Pain Syndromes: Tests
Adson’s test: The patient is examined standing. The examiner palpates the radial pulse while moving the upper extremity in abduction, extension, and external rotation. The patient rotates his head towards the involved side while taking a deep breath and holding it. A diminished or absent radial pulse = a positive test for thoracic outlet syndrome. Finkelstein’s test: The thumb is folded across the palm with the fingers flexed over the thumb as the hand is pulled away from the involved wrist area. Pain = a positive test for De Quervain’s tenosynovitis. Phalen’s test: The patient flexes both wrists together, and the examiner holds the wrists in this position for at least a minute. Numbness or parasthesia in the median nerve distribution = a positive test for carpal tunnel syndrome. Tinel’s test: The examiner taps over the carpal tunnel. Tingling or parasthesia distal to the site of pressure = a positive test for carpal tunnel syndrome.
abstract: “Upper extremity” is defined as the extension of the body from shoulder to the digits and includes the digits, arm, forearm, hand, as well as shoulder, elbow, wrist, and metacarpophalangeal and carpometacarpal joints. Upper extremity is ideally designed for motion, not to carry heavy loads. Technological advancements have shown us a significant increase in upper extremity pain syndromes with repetitive motion. We describe in this article some of the most common pain syndromes seen in orthopedic, sports, and occupational medicine as well as in primary care clinics. This is a brief overview of the diagnosis and treatment of these syndromes in an outpatient setting; we recommend readers refer to orthopedic and sports medicine literature for further reading.
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CARPAL TUNN L SYNDROM
D QU RVAiN’S T NOSYNOViTiS
Etiology: Carpal tunnel syndrome (CTS) is the entrapment of the median nerve at the wrist, which results in paresthesia of the lateral 3-and-a-half fingers. It can present with moderately severe pain, but paresthesia is the hallmark for diagnosis. One of the common complaints of patients with carpal tunnel is clumsiness. Recent years have seen a rise in incidence rates due to the increase in computer and mobile technology usage.
Etiology: De Quervain’s tenosynovitis is inflammation of the extensor pollicis brevis and the abductor pollicis longus tendons on the side of the wrist at the base of the thumb. It is typically caused by heavy lifting. Diagnosis: De Quervain’s tenosynovitis causes pain and tenderness at the site of the wrist beneath the base of the thumb, with occasional slight swelling and redness in the area. Diagnosis is purely based on the location of pain, and the tenderness of the affected wrist. A positive Finkelstein’s test suggests De Quervain’s tenosynovitis.
Diagnosis: Pain and paresthesia in the lateral 3 to 4 fingers is the common clinical presentation, with the pinky spared. Symptoms usually get worse at night. Physical exam usually reveals a positive Phalen’s test and Tinel’s test at the wrist. Phalen’s test has a higher sensitivity and specificity than Tinel’s test, which has a moderate sensitivity and specificity for CTS. Nerve conduction studies can also be used for diagnosis of CTS, with varying sensitivity for motor vs sensory nerve testing.
CUBiTAL TUNN L SYNDROM
Treatment: Mild CTS can be treated with ergonomic changes, splinting, and symptomatic treatment using oral NSAIDs, topical NSAIDs, and topical local anesthetics. Moderate CTS may respond to cortisone injections, while surgical release is usually reserved for moderately severe to severe CTS.
Etiology: Cubital tunnel syndrome is caused by ulnar nerve entrapment at the elbow resulting from increased pressure usually secondary to leaning on the elbow or sleeping on the elbow. The ulnar nerve lies directly under the skin, near the medial epicondyle, and is easily susceptible to pressure.
Q3 | 2014
Treatment: Treatment involves a combination of rest, splinting, ice, NSAIDs, and/or cortisone injections. Injections are extremely effective, and surgery is rarely necessary.
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www.painweek.org | PWJ | 19