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,

H

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,

Hamish

Refs:
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

All the answers in one little theory... perhaps not!

Simon "The Wiz" Whitlock showing how the DTM should be done!

If there’s a subject close to my hand therapy heart, it is the “Dart-thrower’s motion” or DTM. For the uninitiated, the DTM was coined in an attempt to describe a pattern of wrist movement that most limits motion between two important bones in the wrist, the scaphoid and the lunate. The reason my ears prick up when DTM is mentioned is that when hand surgeons and therapists first started talking about it in the late 2000’s, I started to integrate it into the management of my patients.

My DTM splint

I created a splint that was designed to limit movement to the DTM. I wrote a paper about it for the Australian Sports Physiotherapy magazine, and was an invited speaker at the International Hand Therapy conference in 2010. I also presented my splinting concept and some preliminary results at a couple of conferences in Australia.

I’ve had some great success with applying these principles, especially with those patients who were prepared to stick with the program I devised. The program involved wearing a splint that restricted motion to the DTM plane, and a progressive series of exercises and proprioceptive activities. One patient in particular stands out. I’ll call him Markos.

Markos "the Glassman" Moya (not his real name or picture!)

Markos had diagnosed mid-carpal instability. He didn’t want surgery because typically the surgery restricts wrist motion. Markos had dreams of joining the world senior’s tennis tour in 18 months’ time. He wore the splint, and was religious with his exercises. Importantly, he also addressed aspects of his tennis game, hitting flatter through the ball. I just googled him to find his is now ranked just outside the top fifty in the world for his age group. He’s living the dream, and is proof the principles work… or is he? 

Classic SL dissociation. Not that easy!

It was the IFSSH scientific committee’s report on wrist biomechanics in 2007 that focussed on the DTM. Since that time, research on the DTM has succeeded spectacularly on muddying the waters. In 2013 they updated their report.  What appeared to be so clear cut, and so useful, is now confused with definitions of different planes of DTM; of functional DTM vs pure DTM, and of potential problems with the movement. We aren’t nearly as convinced now that there is any merit in using it in rehabilitation to protect a dysfunctional joint. Questions have been asked, and answers are still being sought. Memo to self; when you think you know it all, you don’t. It’s that’s simple.

Look after those fingers,

Hamish

Making Sense of Therapy

Looks better in Brown & Gold

I've been to a few of David Butler and Lorimer Moseley's talks. Whilst I am by no means a hardened disciple, I think their core message is solid. If you truly understand the nature of what it is that is causing you pain, then you have a better chance at beating it. David's latest blog discussed an article compared the results of traditional therapy for whiplash, and a brief educational intervention. There was no difference between the results. Whilst he is not discounting the usefulness of traditional hands on treatment, he is questioning the importance we place on it.

NOI Group

From a sports medicine perspective, if I think of the athletes who have recovered from something as simple as a thumb collateral ligament tear; those who sat down, and actively listened to me as I reviewed basic anatomy, healing rates, etc have been less likely to have ongoing problems. Now that opinion has no basis other than a very quick chart review of the first 8 footballers that came to mind, but there has to be merit in making a priority of giving the patient the tools to take ownership of their condition.

I'll stop there, spend your time reading David's article.  David Butler, Time for Motor Freedom

Look after those fingers,

Hamish

What would Tommy Say?

Do you think Tommy Hafey would have spent much time concerned about PIP joint volar plate injuries? Would he have given any thought to a player that complained about jarring his wrist, or spraining a collateral ligament? 

Tommy Hafey played and coached Australian Rules Football at the highest level at a time when the game really was ferocious. He was a hard man, and had high expectations of his teamates and himself. Tommy maintained a rigorous exercise regime right up into his 80's; waking a 5:20 every morning to run 7k, swim in the bay, do 250 pushups and then 700 crunches. He died yesterday aged 82.

I think Tommy Hafey the footballer and coach would have put injuries to fingers and hands pretty low down the pecking order. However, from all accounts, Tommy was a man who showed genuine interest in everyone and everything they did, not just how well they played footy.

I saw Tommy occasionally down at Sorrento when I was out running or paddling in the early morning. He always had a smile, and although he didn't know me, always asked how I was going. I think Tommy Hafey the man would not have ridiculed an athlete who complained of a sore finger as long as that athlete showed the same level of commitment to their sport and their health, that Tommy did. Thanks for the smiles mate, and rest in peace Tommy "T-shirt" Hafey.

Look after those fingers,

Hamish

Zebras and Horses and Golf

I gave up playing golf because I figured I could better spend the 4 hours it takes for a round of frustration trying to get up on a surfboard. Whilst the surfing skills have not advanced to the level I might have hoped, I still love golf. Not so much the frustrations of the game, but rather the minutiae that goes into a golf swing. The biomechanics of grip combined with wrist, elbow and shoulder movement add up to a complicated puzzle that is confused even further by injury. Sometimes however, this puzzle is most easily solved by following the "horses are more common than zebras" analogy.

I've seen a particular professional golfer a couple of times now. She too can have the now generic female patient name of Ivy. Ivy initially came in having had a three month history of left wrist and thumb pain that was worst with loaded thumb extension and wrist extension, i.e. down swing and through impact. An MRI showed bruising around the scaphoid and trapezium. Manual muscle testing indicated weakness of the ECRL and FCR, and pinch strength was reduced.

My thinking was that Ivy had developed a mild radial carpal instability, with micro-trauma in FCR impacting on the trapezium as it crosses it, causing the bone stress over time. I've seen this bruising around the trapezium previously in female golfers. Weakness compounds the injury, which forces patterns of the golf swing to alter in a minor way, but perhaps enough to make the pain worse. 

NOT Ivy

In Ivy's case, she knew that if she didn't extend the wrist as much during the swing, she had less discomfort. I gave Ivy a program of wrist proprioceptive exercises, leading onto muscle specific strengthening to the wrist and thumb. Ivy spent some time with her swing coach, rejoined the tour and reported by email great improvements, until that is, she hit a rock, in China.   

Ivy came back into the clinic yesterday. The wrist pain had gone, now what she had was much more specific to the thumb. Probably related, but different. It was apparent Ivy had worked hard on the wrist exercises. Strength was better, and proprioceptively her control was much better also. What she'd let slip though, were the thumb and hand strengthening exercises. 

Ivy's thumb was now feeling unstable, not clinically, but certainly to her. The left thenar eminence was soft compared with her right hand, and pinch strength was again reduced. Neurological testing was negative. This time, the MRI showed nothing. Now, I could have started looking for zebras, but horses are much more common in Australia, so I focused on the strength. If Ivy can make her thumb strong again, she will be able to keep it stable through her swing. It made sense to Ivy, it made sense to her coach, and it made sense to me. I'll let you know how it pans out.

Look after those fingers,

Hamish

How Specific is Specific?

Specific is very specific is the answer. I recently saw an elite level rower for management of a thumb extensor tendon that she had inadvertently severed on the fin of the hull of her boat. Ivy (not her real name but a nice one) had key competition trials coming up, and her rehab had to be squeezed in somehow.

All power to the thumb

I must have seen over a hundred thumb extensor injuries. It's usually not an especially tricky rehabilitation protocol, you just need to understand how to grade things. The extensor pollicis longus (EPL) is the tendon responsible for hyper-extending the tip of your thumb, and is also responsible for allowing thumb retroposition which is lifting the thumb up, up and away from a flat hand. Ivy had cut hers over the top knuckle of her thumb which meant we could get away with  a hand based splint, and an early motion protocol post surgery.

The only issue was that Ivy was very specific about what she needed the thumb to do. As an elite level rower, she had to be able to actively flex the top joint of her thumb to 70 degrees, and maintain an eccentric load through the EPL in order to control her oar accurately. But what was even more important to her, was that her life after rowing was in no way compromised by a thumb that wouldn't straighten. 

Every session for me became a study of the bio-mechanics of rowing. I have had no experience as a rower, with the few seasons I spent racing outrigger canoes counting for naught. We discussed stroke length, grip strength, grip positions, singles vs doubles, and the myriad of other factors that could affect performance at Ivy's level, right down to the specifics of thumb position.

Go "Ivy" GO!!

Ivy did well in rehab,meeting all the treatment goals we set. However she recently sent me an email after performing exceptionally in the trials. The comment that got me was this, "My thumb felt really good with normal race rowing but the confidence and coordination (ie for the final sprint) is still on the improve." Movement, tendon integrity, and strength were no longer a concern, for they were almost 100%. The specifics Ivy now needed were better proprioception and fine motor co-ordination. And not just for training or for the race, but for the final sprint.

Ivy now has additional exercises designed to help her thumb with that final sprint. No doubt they will help her with life once she steps out of the boat. They will definitely help the next person that cuts a tendon who walks up the stairs and into my clinic because even if they aren't an elite athlete, I know that their specifics will be very specific too. Thanks Ivy, and good luck.

Look after those fingers,

H