Thumb Tendonitis – DeQuervain’s Tenosynovitis

Do you experience pain at the base of the thumb after lifting your new child? Does the back of your thumb hurt after typing? Do  repetitive activities such as knitting, gardening, or sports cause severe wrist pain? You may be experiencing DeQuervain’s Tenosynovitis , a common treatable condition resulting from inflammation of the thumb tendons.  The following are activities that commonly result in Dequervain’s tenosynovitis:

  • Knitting
  • Gardening
  • Playing a musical instrument
  • Improperly holding your child (lift with your shoulders and fixed wrists, not by flexing your wrists)
  • Typing
  • Carpentry
  • Walking your pet on a leash
  •  Sporting activity

What is DeQuervain’s Tenosynovitis?

DeQuervain’s Tenosynovitis is a condition where  synovial tissue surrounding the thumb extensor tendons become inflamed as they pass through a tight pulley.  As the synovium becomes inflamed, the process amplifies, exacerbating the painful symptoms.  Eventually all thumb movement become painful.

How is DeQuervain’s Tenosynovitis diagnosed?

The most sensitive test is Finklestein’s test. This is a test which causes exquisite pain at base of the thumb when the thumb is placed in the palm and the wrist ulnarly deviated.

It is important to visit a hand surgeon to help differentiate DeQuervain’s tenosynovitis from other common conditions such as carpal tunnel syndrome, arthritis, nerve injury, or even fracture.

How is DeQuervain’s Tenosynovitis Treated?

The first step is proper identification of the condition and your particular reasons for the inflammation. Activity modifications such properly lifting of your baby can help alleviate symptoms. Bracing, anti-inflammatory medications and steroid injections can also dramatically decrease the inflammation.

Occasionally surgical release of the affected tendons are required to relieve the symptoms of Dequervain’s tenosynovitis, but this is usually reserved for persistent cases. The vast majority of cases I see do not require surgery.

If you would like to schedule an appointment you can contact me or call my office at 206-633-8100.

Common Skiing and Snowboarding Injuries – Hand, Shoulder, and Elbow

Ski season is in full swing, as are skiing injuries. If you ski often, you know that hand, shoulder and elbow injuries are common as you or someone you know likely have experienced one.

Here are a list of many of the injuries I treat throughout the winter season.

Skiier’s Thumb:  The second most common skiing hand injury behind wrist fratures. This injury occurs when the ski pole is held between the thumb and the index finger gets tangled during a fall, placing excess stress on the thumb  bending in a direction opposite to the index finger tearing the ulnar collateral ligament (see figure) Once called “gamekeeper’s thumb” due to its assiciation with the stress placed on the thumb when sacrificing game, this injury can lead to chronic thumb pain with pinch and grasp.

This injury to the ligament can range from a mild sprain to a full rupture, which can be tested by exam, x-ray to rule out frature, and occasionally MRI. If the ligament is completely torn, it sometimes gets caught behind the adductor muscle insertion and is called a “stener lesion” indicating it’s need for surgical treatment.

My treatment algorithm includes casting or bracing for mild to moderate sprains, and surgical repair or reconstruction for complete unstable tears.

Prevention of such thumb injuries usually include eliminating the use of straps on ski poles.

Wrist Fracture: Most common in snowboarders, falling on an outstretched hand can cause injuries to the end of the forearm, wrist, hand and finger bones. Over 25% of snowboarding injuries occur in the wrist. For displaced fractures, often a deformity is seen which requires the bone to be set and even sometimes warrants surgical correction to allign the fracture (a “broken bone” is the same as a “fracture”).

The most common fracture is the distal radius fracture. One of the easiest ways to prevent wrist injuries is to learn how to fall correctly – falling forward should be broken by the knees and the forearm a backwards fall should be in a rolled position.

Shoulder Dislocations:

Shoulder dislocations usually are extremely painful injuries occurring from a fall on an outstretched hand or through a twisting fall.  Usually the shoulder dislocates in a forward direction causing an obvious bulge in the front of the shoulder.  Sometimes the shoulder can be pulled back in  successfully, but many dislocations require an anesthetic for reduction.

Shoulder dislocations are often associated with fractures or tears of the muscles or ligaments surrounding the shoulder which can increase the probability of recurrent dislocations. With documented dislocations, over 85% redislocate in the future, eventually requiring surgery.

I perform most surgeries arthroscopically for such dislocations and the success of shoulder stability after surgery is greater than 90%.

Shoulder Separation

Often confused with a shoulder dislocation, this is a direct fall on the shoulder itself, causing a separation of the clavicle from the shoulder blade. This injury can range from mild to severe, but rarely requires surgery. The pain eventually subsides, but often a mild deformity persists. Surgery is  reserved for severe cases or persistent pain.

Fractures about the Shoulder

The most common fracture is a Clavicle fracture, commonly known as a collorbone fracture. Common in both kids and adults, both snowboarders and skiiers, most people know someone who has had such an injury if they have not already had one themselves.

These collorbone fractures are easy to diagnose by exam and x-ray. Rarely the bone sticks through the skin, requiring surgery.  Most fractures can be treated with a sling quite successfully with a residual bump.

There are recent studies that suggest that severely displaced fractures might be best treated with surgery to restore normal shoulder function, especially in overhead activities.

Other shoulder fractures include fractues of the Upper Humerus. These fractures can either be stable or unstable, with unstable fractures requiring surgery.  Likewise, Elbow fractures can also simply be classified as stable or unstable  and often need surgery if unstable.

Rotator Cuff Tears

The rotator cuff includes four important shoulder muscles acting to stabilize the ball and socket joint of the shoulder. Violent excessive eccentric force to the shoulder can often result in a tear to the tendon of these muscles resulting in significant swelling, pain and weakness.

Rotator cuff tears increase in prevalence with age as the integrity of the tendon and muscle decreases. Maintaining muscle strenthening excercises decrease the probability of a tear.

Rotator cuff tears can be partial or complete and usually require advanced imaging such as an MRI to diagnose. Usually partial thickness rotator cuff tears can be treated with rehabilitation alone, but acute full thickness tears of the rotator cuff usually require surgery.  I treat rotator cuff tears both arthroscopically or through a mini-open incision and can usually be performed in an outpatient setting.

Does Trigger Finger Mean I have Arthritis?

The short answer is, No! In addition,  A trigger finger is also not a dislocating finger or a knuckle being ‘cracked’. But that doesn’t mean that the a trigger finger is trivial – your trigger finger can be annoying, painful and progressive.

What is a Trigger Finger?

A Trigger finger is a finger that gets stuck in a flexed position, taking some force to extend the finger past a particular position.  Usually a click or a pop can be felt at the base of the finger when the finger is extended past the trigger point. Most often, the triggering does not cause pain at first, but progresses over time to cause pain and a stiff finger that often won’t fully extend.

Symptomatic triggering usually occurs in the index, middle or ring finger, but can also occur in the thumb or small finger.  Triggering is inflammation in the finger’s flexor tendon and pulley, analagous to  having a knot in your shoelaces – with some force the knot can be pulled through the shoe, but in the finger, each time the enlarged tendon tries to go through the inflamed pulley, the inflammation is exacerbated. The official name for the condition is called Stenosing Flexor Tenosynovitis, but is commonly referred to as a trigger finger.

Trigger Fingers and Thumbs in Children

Triggering in children is quite different. Young children can have triggering of their thumb that does not allow any extension of their thumb and is usually best treated surgically. Alternatively, triggering in the rest of the fingers of children is usually a separate anatomic anomaly, but still most often requires surgery for correction.

Who Gets Trigger Fingers?

Adult trigger fingers usually occur in those age 40-60 and does not  automatically require treatment. Diabetics and Rheumatoids tend to get triggering at a higher rate, but other causes of triggering include partial tendon laceration and cysts in the tendon sheath. Most triggering, however, occurs in healthy individuals.

What Can Be Done?
Many trigger fingers cause minimal symptoms. When symptoms progress to pain, stiffness and functional difficulties I recommend a steroid injection which quite successful in soften the tendon and pulley due to inflammation. I do not advocate splinting or physical therapy as these are proven to be rarely effective. Injections decrease the symptoms and inflammation in the majority of patients.  However, the symptomatic relief remains long lasting in only about half of patients.

When the triggering returns I offer another injection (no sooner than three months after the first injection) or surgical release of the pulley. This surgery is a simple and highly effective surgery that simply involves longitudinal release of the restrictive pulley.

The outpatient surgical release is nearly always successful and permanent, and many of my patients can return to work the next day. Long term relief is the rule, though other fingers occasionally independently may develop triggering.

If you have questions about this condition or you would like a consultation, contact my office at 206-633-8100 or submit a question that I will answer here. I make it my goal to fit you in promptly so as to get you back to full function and trigger free!

Common Winter Fractures and Ice Safety

FractuWalking in Winterres (or broken bones) of the ankle and wrist are common injuriesduring the winter months. We thought it might be useful to review some of the common injuries that often require urgent treatment.

Wrist (Distal Radius)Fracture
A “Colles” (distal radius) fracture is a particular type of wrist fracture involving the distal radius. This very common fracture occurs with a fall on an outstretched hand, often breaking a fall. Diatal radial fractures also occur during skiing, snowboarding or other falls . This particular fracture type is relatively common and can often be treated in a cast. In our clinic, we can usually treat these with waterproof Goretex casting that allows the cast to get wet during the treatment process However, some cases of Colles’ fractures require surgical intervention when proper alignment is necessary. … read more

Does Your Shoulder Hurt at Night? It could be a Rotator Cuff Tear

Shoulder pain is common, but it is not normal.  Perhaps you have a rotator cuff tear?  How would you know? 

Here are a few questions may highlight common symptoms that are common to those with rotator cuff tears –

Have you recently injured your shoulder?
Do you have pain with overhead activities? 
Do you have shoulder pain at night? 
Does your shoulder feel weak?

Don’t worry, not all rotator cuff tears need surgery, but it is important to identify the particular source of your shoulder painbecause the particular treatment and rehabilitation can drastically reduce your suffering.

One note – there is no anatomic structure called the “Rotatory Cup”!  You are right, the spherical end of the humerus does rotate in the glenoid (cup), and is actually the most mobile joint in the body. However, the “Rotator Cuff” is not directly involved with the joint surface, so problems with your rotator cuff do not necessarily mean that you have shoulder arthritis.

Common demographics of a patient with a rotator cuff tear include age 30-60, a specific traumatic episode or chronic heavy use of the shoulder, specifically difficulty with overhead activity. Symptoms include pain and weakness with initiating activities about the shoulder, night pain, pain on the side of the shoulder radiating down the arm.  Symptoms that suggest another disorder include grinding shoulder or popping shoulder, shoulder dislocation, pain in the front of the shoulder, stiff shouder, numbness, neck pain.

Once again, shoulder pain is common, but not normal. Proper systematic evaluation is critical identify your particular diagnosis to lead you down a rational treatment pathway with maximal chance of success.

For an appointment, call 206-633-8100 or you can submit a question that I will answer here.