Arm and Hand Pain

Arm and Hand Pain Srinivas Nalamachu, MD

Disclosure  Consultant/Independent Contractor – Endo Pharmaceuticals; Nuvo

 Grant/Research Support – Endo Pharmaceuticals; Nuvo

Learning Objectives  Describe the most common pain conditions in arm and hand (Upper extremity pain)  Describe the etiology and pathology  List the various diagnostic tests available  Cite the various treatment options, both pharmacologic and nonpharmacologic interventions

Common upper extremity pain conditions  Carpal tunnel syndrome  OA of thumb  DeQuervain’s Tenosynovitis  Cubital tunnel syndrome  Lateral Epicondylitis (Tennis elbow)  Medial Epicondylitis (Golf elbow)

Some uncommon ones  Radial nerve entrapment  Pronator Teres Syndrome  Bicipital tendinitis  Ulnar nerve entrapment at the Guyon’s canal  Thoracic outlet syndrome

Upper extremity pain that is radiating from neck and upper back  Cervical radiculopathy  Cervicobrachial syndrome or regional myofacial pain syndrome  Brachial plexopathy

Carpal tunnel syndrome  Median nerve entrapment at the wrist resulting in paresthesias in the lateral 3 and half fingers  May present with moderately severe pain, but paresthesias or the hallmark  Clumsiness is a common complaint  Significant increase in incidence in the past two decades with increase in computer usage

Carpal tunnel syndrome

Carpal tunnel syndrome

Diagnosis of CTS  Clinical presentation: Pain and paresthesias in lateral 4 fingers (Pinky is spared)  Symptoms worse at night  Physical exam: Positive Tinel’s test (moderate sensitivity and specificity), Phalen’s test ( greater sensitivity and specificity)  Nerve conduction studies (Sensitivity is different for motor versus sensory nerve testing)

CTS: Treatment Options  Mild CTS: Ergonomic changes, splinting, symptomatic treatment with oral NSAIDs, topical NSAIDs and topical local anesthetics  Moderate CTS : Cortisone injections  Moderate to severe and severe: Surgical release

OA of thumb  CMC of thumb is the 3rd most common joint in the body for degenerative changes.  Extremely painful, limited ROM interfering with fine movements  Treatment with oral and topical NSAIDs prior to cortisone injections  Joint replacement in patients with pain and functional impairment

DeQuervain’s tenosynovitis  De Quervain's tenosynovitis is inflammation of tendons on the side of the wrist at the base of the thumb.  These tendons include the extensor pollicis brevis and the abductor pollicis longus tendons.

De Quervain’s tenosynvitis  Typical causes include lifting young children into car seats, lifting heavy grocery bags by the loops and lifting gardening pots up repeatedly.  De Quervain's tenosynovitis causes pain and tenderness at the side of the wrist beneath the base of the thumb.  Sometimes there is slight swelling and redness in the area.

De Quervain’s tenosynvitis  De Quervain's tenosynovitis is diagnosed based on the typical appearance, location of pain, and tenderness of the affected wrist.  Is usually associated with pain when the thumb is folded across the palm and the fingers are flexed over the thumb as the hand is pulled away from the involved wrist area. ( Finkelstein’s test )

Treatment options for DeQuervain’s  Treatments for De Quervain's tenosynovitis includes any combination of rest, splinting, ice, NSAIDs, and/or cortisone injections. Injections are very effective and surgery is rarely necessary.

Cubital tunnel syndrome  Ulnar nerve entrapment at the elbow resulting from increased pressure  Ulnar nerve is directly under the skin near the medial epicondyle and is susceptible to pressure (funny bone)  Symptoms include pain and paresthesias in medial one and half fingers

Cubital tunnel syndrome

Treatment options for cubital tunnel syndrome:  Avoiding the pressure on the nerve at elbow, wearing elbow pad will help in cases with minimal entrapment  Topical NSAIDs and Topical anesthetic patches may be of value for symptomatic treatment  In severe cases, surgical intervention with ulnar nerve transposition is recommended

Lateral Epicondylitis  Lateral epicondylitis ( Tennis elbow), is a painful condition involving the tendons that attach to the lateral part of the elbow. The muscles involved are extensors, primarily the extensor carpi radialis brevis which help extend elbow and stabilize the wrist .  There is degeneration of the tendon’s attachment, weakening of the anchor site which places greater stress on the area leading to pain with activities in which the extensors are active, such as lifting, gripping, and/or grasping.  Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise.

Lateral epicondylitis

Etiology of lateral epicondylitis  Overuse, both occupational and otherwise. Any activity that places stress on the tendon attachments, through stress on the extensor muscle-tendon unit, increases the strain on the tendon.

These stresses can be from holding too large a racquet grip or from “repetitive” gripping and grasping activities ( i.e. meatcutting, plumbing, painting, weaving, etc.)  Trauma: A direct to the lateral part of the elbow can result in degeneration and pain.

Medial epicondylitis  Medial epicondylitis is an overuse injury affecting the flexorpronator muscle origin at the anterior medial epicondyle of the humerus  Less frequent compared to lateral epicondylitis  Also commonly referred as Golf elbow

Medial epicondylitis

Etiology  Overuse involving the flexor/pronator group of muscles  Repetitive stress at the musculotendinous junction and its origin at the medial epicondyle leads to tendinitis

Diagnosing lateral/medial epicondylitis  Diagnosis is purely based on physical examination  Imaging and electrodiagnostic would help rule out other causes of pain

Treatment options for lateral and medial epicondylitis  Conservative treatment would involve NSAIDs, activity modification, bracing, shock wave and physical therapy  Refractory to conservative treatment would require cortisone and PRP injections  Severe cases may require surgical intervention, which will involve removing degenerated tissue and reattach healthy muscle to the bone

References  Lidocaine patch 5% for Carpal Tunnel Syndrome: How it compares with injections: Original research article. “ Journal of Family Practice” March 2006  A Comparison of the Lidocaine Patch 5% vs. Naproxen 500 mg Twice Daily for the Relief of Pain Associated With Carpal Tunnel Syndrome: A 6-Week, Randomized, Parallel-Group Study- “Medscape online Journal of Medicine” in 2006  Bisset L, Paungmali A, Vicenzino B, Beller E (July 2005).A systematic review and metaanalysis on physical interventions for lateral epicodylitis. British Journal of Sports Medicine 39 (7): 411–22  Gruchow, William, and Douglas Pelletier. "An epidemiologic study of tennis elbow: Incidence, recurrence, and effectiveness of prevention strategies." American Journal of Sports Medicine. 7.4 (1979): 234238

References  Wilson, JJ; Best, TM (1). Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician 72 (5): 811-8.  E-Medicine: Physical Medicine and Rehabilitation for Epicondylitis, Sharon J Gibbs et al.,  Medscape reference: Nerve Entrapment Syndromes, Amgad Saddik Hanna, MD et al.,  Physical Medicine and Rehabilitation: Principles and Practic, Joel De Lisa et al.,