Sunday, 13 July 2014

It's Only a Little Finger...

An elite level breast stroke swimmer came through the rooms recently. Bart (not his real name) had had surgery to address a wrist injury that had been affecting his ability to train in the pool and in the gym. His rehab went really well, and he was able to get back into training earlier than we'd first expected. Bart's strength and weight bearing tolerance all rapidly came back to pre-injury levels. However something slipped through. 

EDM. Scarring at level of DRUJ
Bart was unable to actively extend his little finger on the affected hand beyond neutral. In fact, he had an extensor lag of that digit, along with a weakness into abduction. In focusing on the wrist, we, and he, had missed tethering of his extensor digiti minimi tendon to scar tissue. Breast strokers touch the wall with both hands at the start of a turn. Whilst there's no real power or heavy pushing required, the hands do need to be flexible enough to absorb and react to the speed with which the swimmer approaches the wall. Bart only realised he lacked this flexibility when he went to touch the wall, and his little finger was not able to actively move into the position it needed to. 

Touch The Wall!!
The lack of movement was minor. It made no difference to his grip strength, nor to his ordinary, every day activities. It didn't directly make his lap times slower. But Bart knew something was different, and that knowledge did make a difference to the activity that mattered the most. We needed to address that so that he could swim with confidence in every part of his body.

Seal with tethered scars. Needs some silicone?
We were able to quickly reverse the tethering of the scar with aggressive massage, stretching, and isolated strengthening. Once we had, Bart said his goodbyes, and resumed his repetitive journey along that endless black line. Good luck for 2016 mate!

Look after those fingers,


Monday, 7 July 2014

Move It or Lose It!!

For whatever reason, hand therapists have been a bit behind the ball when it has come to recognising the influence of proprioception on the joints of the hand and wrist. Proprioception has been poorly defined by brevity in the past; now it is best understood as a word that describes the sensory, motor and processing components that help a joint maintain its' stability during functional movement (Hagert, 2012). Unfortunately that definition doesn't mean much to a lot of people, and it's importance in hand and wrist health is not appreciated. 

So rather than force a patient to sit down with a dictionary, or lecture them until their eyes glaze over, I talk about the act of doing. Because if you are "doing", you are probably involving your proprioceptive skills. And if I can convince you to do your doing in a particular manner, then you can amplify those proprioceptive skills.

Osteoarthritis of the hand joints
Why is this important? Well, take oseoarthritis (OA). The lay understanding of this disease is that it refers to the loss of the layer of cartilage over your bones at the joints. When the cartilage is gone, you have bone on bone which is painful. That's osteoarthritis. Yes... to a point. Osteoarthritis is probably a disease that starts well before the cartilage is gone and the bone is degenerate. A new classification system has recommended that OA in the joints is a direct result of OA in the ligaments (McGonagle, 2010). As the ligaments weaken, they aren't able to provide joint stability, and the joint itself becomes stressed leading to bony OA (Tan, 2006). Follow that thinking, and we're back where we started, at proprioception.

Do circus elephants have better joints than their jungle cousins?
Perhaps, if we can convince patients at risk of developing OA (pretty much everyone), to use their hands in such a way that stress is minimised but importantly maximises proprioceptive input, the ability of ligaments to do their job will be enhanced. It goes beyond strength, and movement through a prescribed range because they are only two points of the triangle. Proprioceptive tasks need to be included to ensure joint stability is maintained, and in the case of injury, rehabilitated. That's the why. The "how" is a different matter all together! 

Look after those fingers,


Hagert, E., Mobargha, N. The role of proprioception in osteoarthritis of the hand and wrist. Current Rheumatology Reviews 2012; 8(4) 278-284

McGonagle, D. The anatomical basis for a novel classification of osteoarthritis and allied disorders. J Anat 2010; 216(3): 279-91.

Tan, AL. Combined high resolution magnetic resonance imaging and histological examination to explore the role of ligaments and tendons in the phenotypic expression of early hand osteoarthritis. Ann Rheum Dis 2006; 65(10): 1267-72