The brain is an extremely sensitive organ and is the control centre of our body.  When reflecting on common injuries resulting from sport or daily activities, injuries occurring to the brain are often overlooked.  Injuries to the brain are extremely common, particularly if you partake in sport, and even more so if you partake in a contact sport.  You don’t need to participate in a sport to cause injury to your brain.  Non-sport related injuries to the brain can occur during activities such as falls or motor vehicle accidents.  Injury to the brain from these or similar causes is termed a concussion.  A concussion in the medical world is considered a mild head injury or mild traumatic brain injury (TBI).  Due to the injury the brain cannot function the way it normally does. Your ability to perform your normal activities with the same speed, reaction time, and precision as prior to the injury can be significantly altered.

Fortunately the symptoms of a concussion in most cases are temporary and resolve over time.  With each concussion, however, there is a small chance that permanent brain damage can occur, so proper treatment and sound medical advice regarding management of this injury is crucial.

This guide will help you understand:

• how the condition develops
• how health care professionals diagnose the condition
• what treatment approaches are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What is the anatomy of the brain?

The brain is a soft organ that sits in the hard skull for protection. It is cushioned by cerebrospinal fluid that fills in the space between the skull and the brain.  The cerebrospinal fluid acts like packing foam that protects your fragile items from both the sides of the hard moving box itself and from the rapid or sudden motions that the box may endure.

The brain is the control centre for all of the body’s activities. Damaging the brain can alter your ability to perform tasks both mentally and physically.

What causes a concussion?

Any force that causes the brain to move rapidly within the skull and bang against the inside of the skull can cause a concussion.  In layman’s terms, a concussion can be caused by anything that ‘rattles the brain.’

Typically concussions are thought to be caused by direct blows to the head, such as in boxing or bar fighting, or by hitting your head on the ground during a fall, but indirect forces to the head are also common causes of concussions. For example, a fall onto your buttocks or onto any other part of your body can transmit a force strong enough to your brain to cause a concussion, even if you do not hit your head during the fall.  Similarly, a blow to your neck, face or any other area of your body that is severe enough to transmit the force to your head can cause a concussion.

Motor vehicle accidents often similarly cause concussions due to the whiplash motion of your neck which subsequently forces your brain to rapidly hit the inside of your skull. Shaken baby syndrome is another example of this indirect mechanism of brain injury, as are explosions where your body is rapidly thrown back.

What are the symptoms of a concussion?

Signs and symptoms of a concussion can vary extremely between people.  It is not always obvious that someone has a concussion, so if the mechanism of injury for a concussion was present, a concussion should always be suspected and thoroughly investigated.

You do not need to lose consciousness to suffer a concussion, and in most cases there is no loss of consciousness.  If you do lose consciousness, however, you have most certainly sustained a concussion.  Any loss of consciousness should be taken seriously, and any bouts lasting more than approximately a minute are considered severe.

Signs and symptoms of a concussion can vary extremely between individuals and can last days, weeks, months, or even longer in some cases.  Fortunately, however, in the majority of cases symptoms usually resolve within 7-10 days.

One of the most common symptoms of a concussion is a headache.  Confusion is another common sign. This sign can easily be overlooked by the examiner unless the patient is moderately to severely confused, so ruling out a concussion should not be based on the fact that the patient ‘did not appear confused.’

Other signs and symptoms of a concussion that may be present on their own or in combination are concentration difficulties, decreased attention, difficulty with mental tasks, memory problems, difficulties with judgment, a decrease in balance and coordination, a feeling of disorientation, a feeling of being ‘dazed,’ fatigue, blurred vision, light and/or sound sensitivity, difficulty sleeping or sleeping more than usual, being overly emotional, being irritable or sad, neck pain, a feeling of ‘not being right’, and ringing in the ears.  Amnesia may be another symptom.  Two types of amnesia can occur: Retrograde amnesia which is forgetting events that happened before or during the concussion event, or anterograde amnesia, which is when you do not form new memories about events that occurred after the concussion. In severe concussions, a change in personality may even occur.  If a patient shows even one sign or symptom listed above this should be indicative of a concussion occurring and a full concussion evaluation should proceed.

Signs and symptoms that are even more severe after an injury to the head, such as recurrent vomiting, a change in pupil size, blood or fluid coming from the ears or nose, seizures, or obvious physical coordination or mental difficulties indicate a severe brain injury and require immediate emergency attention.

In most cases signs and symptoms appear immediately after the concussion has occurred, however in some cases the signs and symptoms can be delayed by a few hours or possibly even days.  For this reason if the mechanism of injury suggests a concussion despite a lack of obvious symptoms being immediately present, the patient needs to be thoroughly examined for latent development of concussion signs or symptoms over a reasonable time frame, and a concussion must be thoroughly ruled out before returning to activity.

How do health care professionals diagnose a concussion?

Diagnosing a concussion can be easy in cases where there was an obvious mechanism of injury involving a blow to the head, and when there are immediate signs and symptoms to indicate the brain has suffered an injury.

In many cases, however, a concussion can be overlooked when the mechanism of injury does not directly involve a blow to the head, the signs and symptoms are not obvious, or the signs and symptoms are delayed in their onset.  The patient may initially ‘appear fine.’

Diagnosis of a concussion begins with a complete history of the mechanism of injury. As stated above, any blow to the head or force through the body that is strong enough to transmit a force to the head will lead your health care professional to the suspicion of a concussion.  At a sporting event, often the sideline health care professional is privy to having seen the mechanism of injury, which aids in diagnosing a concussion. Included in the history will be questions regarding any previous concussions that the patient may have incurred.  The more concussions you incur, the higher your chances of sustaining another concussion, and it can more easily occur with decreased force.

Thorough questioning regarding the patient’s symptoms is the next step to diagnosing a concussion.  With sporting events, immediate symptom evaluation should occur on the sidelines by a health care professional or a coach well educated in concussion signs and symptoms.  If neither is available, immediate referral to a doctor should occur.

As symptoms can appear immediately or can be delayed, monitoring of symptoms from the time of concussion for at least a few hours is necessary.  As mentioned above, symptoms may even be delayed a few days so if the mechanism of injury indicates a potential for a concussion, the development of symptoms needs to be monitored for a few days after the injury, and during this time, the patient should not be allowed to participate in sport or challenging cognitive activities. It is important to monitor for not only the initial emergence of any concussion signs or symptoms, but also for the worsening of any existing symptoms, or any decline at all in the patient’s ability to perform physical or cognitive tasks.

The evaluation of cognitive function should occur when initially diagnosing a concussion.  General questions regarding orientation that have traditionally been used such as ‘who are you?’, ‘where are you?’, and ‘what time is it?’, have not been shown to be sensitive enough to pick up a decline in cognitive function.  For this reason diagnosis of a concussion should not be ruled in or out based solely on these general questions.  More advanced questioning can be useful in helping to determine a decline in cognitive function indicating injury to the brain. For instance, at a sporting event questions such as ‘who scored the last goal?’, ‘which team was played last week?’, or ‘how far into the game is it?’ can help to delineate a concussive state.  More advanced sideline concussive cognitive tests are also available and are useful in sports where concussions are common.  Outside of sport, more in-depth questioning such as the exact location of a street, or questions regarding the full date and time of day may assist in determining the patient’s cognitive status.

Whether on field, at the emergency department, or in the medical clinic a thorough physical examination will need to be completed.  This examination is to look for signs such as pain in the neck, which may indicate a concurrent cervical spine injury, amnesia, or soft tissue injury to the skull.

Following the physical examination a clinical neurological examination is completed including tests for strength and sensation, reflexes, coordination, visual and auditory disturbances, and cognitive impairment including deficits to memory or concentration.  A thorough examination of the patient’s balance and gait will also be completed.  Impairment in balance can often be seen as a clinical sign of reduced motor function when a patient suffers a concussion. Balance that is not disturbed, however, does not exclude the diagnosis of a concussion having occurred.

A concussion is a functional injury to the brain rather than a structural injury.  This means that damage to the brain tissue generally cannot be physically seen.  For this reason, neuroimaging tests such as computerized tomography (CT) scans or magnetic resonance images (MRI) that look at brain structure are not needed to diagnose a concussion.  Normal findings are common when imaging is completed in patients who show clinical signs of a concussion. In other words, you can still have a concussion, even a severe one, despite CT scans or MRI results being normal.  For this reason, neuroimaging is not routinely ordered if a concussion is diagnosed, unless true structural damage to the brain is suspected.  X-rays of the skull may be considered to rule out bony injury to the skull itself if the mechanism of injury warrants it.

If structural damage to the brain is suspected a CT scan or MRI is necessary as these are currently the best neuroimages readily available to view the structure of the brain.  Structural damage may be suspected when concussion signs or symptoms are severe.  For example if there has been a significant loss of consciousness (greater than one minute), significant memory loss, a change in pupil size, repetitive vomiting, seizures, or rapidly worsening levels of cognition or physical ability.  Even if the concussion symptoms are not severe, but the mechanism of injury involved enough obvious force to cause structural damage then a neuroimage of the brain is indicated.  For example, concussions due to falling from a height or from a high-speed motor vehicle accident would warrant a neuroimaging test.  Neuroimages may also be more routinely ordered in adolescents or children due to the fragility of their developing brains.

Currently there are no neuroimaging tests used routinely that can identify the changes in the brain that relate directly to the clinical signs and symptoms seen with a concussion.  New MRI neuroimaging testing which is sensitive to brain electrical activity (functional MRIs also knows as fMRI) and MRIs that are more sensitive to minute structural damage (perfusion and diffusion tensor imaging), as well as other types of new imaging technologies are currently being trialed and extensively researched.  These tests show hope in potentially creating a gold standard neuroimage test that identifies a concussive state.  Some major hospitals or clinics may already have these tests available, and if so, these tests add valuable information to diagnosing a concussion and analyzing clinical symptoms.  At this stage, however, not enough research has been completed on these tests to warrant their use as a standard procedure in the diagnosis of a concussion.

What is the treatment for a concussion?

The basis of treatment for all concussions is rest until signs and symptoms resolve.  Once signs and symptoms have resolved then a graduated increase in both cognitive and physical activity is implemented while monitoring symptoms.  Once graduated activity is implemented and tolerated then a graduated return to sport or work schedule can be considered. Rest for a concussion means both a physical rest but also a cognitive rest. This means not only will sporting activities or manual work activities be excluded, but also mental activities requiring attention and concentration such as television watching, computer work, reading, texting, or doing schoolwork.  The brain simply needs time to heal, as with any other injury to the body.  The eyes and ears can be particularly sensitive to sound and light after a concussion and even normal lights and sound can precipitate symptoms so any stimulus of this sort needs to be avoided or limited.

If a concussion is suspected during a sporting event the player should be immediately removed from the game and not be allowed to return to play that day under any circumstance.  Serious injury to the cervical spine should be ruled out and then a full concussion examination should proceed.  An ice pack can be applied to the neck or head if pain is present in either of these areas.  If it is unclear whether a concussion may be present, it is recommended to err on the side of caution and assume a concussion is present until thoroughly ruled out.  The common sporting cliché of “when in doubt, sit them out” should be applied.  In the event of an injury occurring outside of sport that involves significant impact or force, such as a motor vehicle accident or fall from a height, one should assume that a concussion has occurred until this has been thoroughly ruled out.

Immediately after a concussion a patient should not be left alone and should be monitored for any development of new signs and symptoms or any deterioration in existing signs and symptoms over a period of a few hours. If the patient does not exhibit any signs or symptoms indicating a severe concussion and they have not deteriorated over several hours of monitoring them, it is fine to let them sleep, as this will aid their recovery. They do not need to be awoken every few hours unless a doctor has examined them and has specifically suggested that this be done.  In severe cases, some concussed patients may be kept in the hospital for monitoring overnight.

Fortunately the majority of concussions (80-90%) resolve in a short period of 7-10 days.  Several factors, however, may lengthen recovery times and will require typical management of a concussion to be modified.  Severe concussions or those concussions where the symptoms last longer than expected will require a longer recovery period.  Patients who have had a loss of consciousness of greater than one minute also generally require a longer recovery period, as do children and adolescents whose brains are still developing and are therefore more sensitive to injury.  Repetitive concussions create cumulative injury to the brain and therefore generally require a longer period to recover after each time they occur.  There is also a thought that females may incur more severe concussions due to their lesser neck musculature compared to males. The increased male musculature may help to absorb some of the forces that the body (including the brain) endure which may decrease the severity of a concussion.  For this reason females may require a longer recovery period before returning to work or play. Interestingly, patients who suffer from migraines, mental disorders, depression, sleep disorders or attention deficit syndrome may also require a longer period to recover and these factors should be considered when planning return to activity protocols.

Neurocognitive testing (testing one’s ability to think) can be useful as an objective measure of a patient’s cognitive abilities, reaction time, and overall mental processing abilities as they recover from a concussion.  It is not uncommon for a patient to ‘feel fine’ after a concussion, including having their physical symptoms resolve, but for their cognitive abilities to still be deficient.  For many high level sports teams, a baseline neurocognitive test is done pre-season so that if a concussion occurs, test results post-concussion can be compared and used as an evaluation of whether the player is back to pre-concussion status before returning to play.  There are several neurocognitive tests being used and there is not one gold standard test yet identified.  Most tests consist of computer-generated tasks that measure reaction time and cognitive ability.  Tests are available in a variety of languages and normative value ranges are available if a pre-test has not been completed.  Neurocognitive testing should not, however, be used as a sole predictor of return to activity timelines.  All physical symptoms must still be considered, a full medical clearance completed, and then a graduated return to play protocol implemented.

Examples of these tests include The Axon Sports Computerized Cognitive Assessment Tool (CCAT) and The ImPACT test (Immediate Post-Concussion and Cognitive Test.)  Other tests that are designed to be administered once a concussion has occurred, such as the SCAT3, can also be administered pre-season in order to establish baseline information about each individual, however they are not as encompassing as the neurocognitive computerized tests available, therefore when available, a baseline computerized neurocognitive test should be carried out. Post-concussion neurocognitive testing should not, however, be used as a sole predictor of return to activity timelines.  All physical symptoms must still be considered, a full medical clearance completed, and then a graduated return to play and return to learn protocol implemented.

The best treatment for a concussion is prevention.  Regarding concussions from sport, protective equipment such as helmets and mouth guards should be worn to absorb forces, and equipment should be the latest in technology where feasible.  New equipment such as helmets and other protective pieces are continually being researched and tested in order to improve their shock absorbing ability and decrease the severity of concussive forces sent to the brain.

Athletes and non-athletes should maintain their body strength and physical fitness as there is the possibility that stronger musculature might protect against forces transmitted through the body and also better control any abhorrent forces transmitted to the head and neck. This musculature may decrease the severity of any injury sustained.

Patients are also encouraged to decrease risk-taking behavior in their sport or everyday lives and take preventative action against injuries to their head.  Seat belts should be worn at all times when in a vehicle.  Helmets should be worn for biking and hard hats during manual labor tasks.  Ladders should be well secured to avoid falling from a height.  Unnecessary hits during sport and overall sporting risk-taking behaviors should be minimized or avoided.  In addition, athletes should stay well hydrated while partaking in their sport so that their cognitive awareness for injury-causing situations is at peak performance throughout their game.  Even something as simple as removing or securing throw rugs in your home can assist in decreasing the risk of a fall and a resultant concussion.

Can medications help me after a concussion?

Immediately after sustaining a concussion medications should be avoided until a full assessment of the concussion signs and symptoms can be reviewed. Even over-the-counter drugs such as ibuprofen, nurofen, paracetamol, or acetaminophen should not be taken after a concussion until a doctor is consulted.

Once reviewed by a doctor, if medication is prescribed its aim is for one of two reasons:  Firstly, medication may be prescribed to treat the concussion injury itself in an attempt to decrease initial symptoms or duration of symptoms.  Secondly, medication may be used to deal with the symptoms arising from the concussion such as sleep deprivation, or emotional lability.  Many doctors choose not to medicate at all when treating a concussion in order to not mask any symptoms.  If medication is prescribed the doctor who prescribes it should closely monitor the patient and all health care professionals involved in the patient’s care should be aware of how the medication may affect the symptoms of the concussion.

Alcohol and illicit drugs should be strictly avoided when recovering from a concussion.

What will I do to rehabilitate from a concussion?

Returning to sport, work or everyday activities after a concussion requires a specific return to activity plan that is closely monitored for the re-appearance of concussion signs and/or symptoms.  Your Physical Therapist at First Choice Physical Therapy, along with consultation from your treating doctor, can create, implement, and monitor your return to activity plan. If you are a student, it is recommended that your health care professional contact your school to ensure they are aware of the recent concussion and to also ensure they are on-board with Return to Learn and Return to Activity guidelines.  It is pertinent that all involved in the care of a concussed patient follow the same conservative guidelines in order to optimize recovery.

The backbone of rehabilitating from a concussion is rest until symptoms subside, then a graduated return to cognitive and physical activity without creating any symptoms.

Returning to work or sport following a concussion proceeds through a basic sequential process.  Your Physical Therapist will specifically guide you regarding the amount of activity you should engage in and will closely monitor you for signs or symptoms to ensure the healing brain is ready for each progressive level of physical or cognitive activity.

As a general guideline, the steps in this sequential process are:

1. No activity, complete cognitive and physical rest
2. Light aerobic activity; exercise such as walking or stationary cycling and/or light cognitive activity such as reading or computer work for a short period
3. Sport-specific training such as running and/or work/school specific tasks such as working on spreadsheets, solving math problems, or engaging in more mentally challenging tasks
4. Non-contact training drills for athletes, more intensive or longer duration physical activity for non-athletes (longer walks) and mental activities of longer duration or combined mental activities such as reading with the television on
5. Once cleared by a doctor, athletes begin with full-contact training.  Non-athletes are medically cleared to begin back to some regular everyday activity
6. Return to competition for athletes at a graduated level (ie: athlete returns to play in one quarter or only on certain offensive/defensive plays.) Non-athletes return to work/school gradually (ie: half days to start or fewer cognitive tasks during a full day).

Each of the 6 stages of the general return to activity plan will occur over a 24-hour period, which means that for athletes suffering a concussion, full return to sport will not occur earlier than approximately 6-7 days after the initial injury.  If at any stage during rehabilitation signs or symptoms arise, your Physical Therapist will ask you to cease the current activity and return to resting for a minimum of 24-hours, or until all symptoms have resolved.  Activity will begin again once all symptoms have subsided.

Cognitive and physical tasks should begin again at the same level where no symptoms occurred (it is not necessary to return all the way back to stage one unless it is the progression to step two that has caused the symptoms) and proceed then to the next level only once the task at hand has been completed without generating signs or symptoms.  Each step can be progressed if it is undertaken without any symptoms arising during or after the exertion, and your Physical Therapist is content with all aspects of your exertion ability and your physical response to this exertion.  It is worth mentioning again that no step should be progressed earlier than 24-hours after the previous step.  Latent signs and symptoms may appear within this time frame so it is important to allow sufficient time for these to emerge, but also to give the brain time to recover from the exertion it has endured during the rehabilitation process itself.

By following a progressive sequence of increased physical and mental exertion you will be allowed (and encouraged) to exert yourself during rehabilitation as long as this exertion does not bring on signs or symptoms.  In other words, exertion both physically and mentally during rehabilitation should be sub-maximal and below a symptom threshold.  As mentioned above, in some cases a longer rehabilitation with a longer return to activity plan may be necessary; such as when loss of consciousness was greater than one minute, or in patients who have had repetitive concussions.  In these cases, patients may find that they must continue doing activity at one threshold for longer than the 24-hour period while the brain heals.  Allowing an athlete to exercise sub-maximally while recovering from a concussion (rather than not exercising at all) is very beneficial to maintain their fitness and psychological state while sitting out with an injury.

While engaging in your rehabilitation plan, it is important to remember that any additional physical or cognitive activity outside of this plan adds to the stress that the healing brain must endure.  Going to the movies, completing your taxes, or walking around the shopping centre for the day will all add stress to your healing brain.  It is best to report all extracurricular activity that you anticipate engaging in, or need to engage in, to your Physical Therapist so they can take this into account when developing and modifying your rehabilitation plan.

Your Physical Therapist at First Choice Physical Therapy will be fundamental in guiding your rehabilitation and return to activity plan after a concussion.  They will provide you with criteria regarding the levels of physical and mental exercise to work towards, and will also monitor physical exertion signs, such as your heart and breathing rate, in order to appropriately progress your physical exertion levels from light through to heavy.  Your symptoms will be documented in order to monitor for any changes with increasing levels of exertion.  Special tests for balance and physical coordination may be used to give your therapist an indication of your physical ability as you recover.  Your Physical Therapist will also analyze your individual circumstances and specifically tailor your return to activity to incorporate any special circumstances that may apply to you.  For instance, if you are returning to a sport, such as soccer, where the risk of a second concussion is high, your Physical Therapist may delay your return to play for a longer period than if you are returning to a sport such as tennis, or not returning to any sport, but rather a work or scholastic situation where your risk for a second concussion is low or none at all.  Factors such as your gender, your predisposition to migraines, learning disabilities, and any previous concussions sustained will also be taken into consideration when tailoring your individual rehabilitation plan.

If you received any concurrent injuries when you sustained your concussion, such as a soft tissue injury to your neck or any other injury, your Physical Therapist at First Choice Physical Therapy will simultaneously treat this injury.  Your therapist will ensure that not only your brain is ready and prepared to return to your regular activity, but that the rest of your body is also ready to begin.  Manual therapy, massage, electrical modalities and specific exercises may be used to treat your neck.  It should be noted that in some cases hands-on treatment to the neck area after a concussion can bring symptoms on.  Your therapist will closely monitor for this, and treatment will be modified accordingly.

Each patient is unique in both their concussion signs and symptoms, as well as in the sport or job they need to return to, therefore close and frequent monitoring of your return to activity plan by your Physical Therapist is necessary.  Your Physical Therapist at First Choice Physical Therapy will be in close consultation with your doctor and any other health care professionals that have been involved in the care of your concussion injury to ensure you are returning to your regular activity as quickly but also as safely as possible.  Medical clearance from your doctor will be needed before certain levels of activity are undertaken.  For those returning to sport, your therapist may also consult with your coach to discuss implementing a gradual return to activity within your practices and matches.

It is worth mentioning again that full recovery from a concussion involves the ability to both physically as well as cognitively handle complex tasks without creating any symptoms.  Decreased cognitive function is more easily overlooked than physical symptoms and therefore special attention will be paid by your Physical Therapist to your cognitive function as you recover.  Your therapist may use neurocognitive testing to get an objective measure of where your reaction time is at, or to ensure that mentally challenging tasks do not provoke symptoms.

Variables such as stress in a job or the stress of an important sporting event can add to the cognitive demands of any task at hand so these variables will be taken into consideration by your Physical Therapist when your return to activity plan is being implemented.  Other variables such as noise and lights can easily aggravate symptoms so will also be taken into account when in the final stages of returning to full activity.  For instance, the music and lights during a dance/stage performance, the bright lights of a nighttime playoff game, a match within a large busy stadium, or an office/classroom that is lit with fluorescent lighting can aggravate symptoms.  Where possible, your Physical Therapist will attempt to incorporate your regular sporting or work environment into your return to activity plan to ensure the activities you engage in are as similar as possible to those you will incur in your normal environment once you are fully back into action.

If even mild signs or symptoms resulting from the concussion are lingering it is absolutely critical that you do not return to regular activity or sport, particularly where the possibility of incurring another concussion is present.  If you do return to activity, the risk of sustaining a second and more damaging concussion is increased as your lagging cognitive function and reduced reaction time leaves you more vulnerable to a second injury. This is termed Second Impact Syndrome.

Second Impact Syndrome

Second-impact syndrome (SIS) is a condition that occurs when a patient incurs a second concussion before full recovery has occurred from an initial concussion.  The second blow does not need to be forceful in order to cause SIS.  SIS is considered rare but is a very serious condition and can result in death or severe brain damage as the brain rapidly swells and/or bleeds following the second blow.  SIS occurs most often in young athletes under the age of approximately 25 and when it does occur has a high fatality rate among these athletes.  Due to the real possibility of SIS a conservative rather than aggressive return to activity protocol should be implemented following a concussion.

Post Concussion Syndrome

Post concussion syndrome (PCS) is the presence of symptoms from a concussion, which last much longer than expected.  Symptoms may last weeks, months, or occasionally even years.  Symptoms are varied but can be physical, such as a headache or dizziness, or may be cognitive such as difficulty concentrating or performing mental tasks.  Other symptoms such as light sensitivity, or emotional irritability may also occur.

The cause of PCS is unclear.  One belief is that structural damage to the brain causes the ongoing symptoms.  Others believe, however, that the symptoms develop due to a psychological or emotional reaction to the initial injury.  In any case it is considered abnormal and a complication of a concussion.

Fortunately in most cases PCS symptoms resolve in approximately 3 months.

Depression

Depression has been reported as being a potential long-term consequence of concussion and when present, may be considered a symptom of PCS.

Further research is needed to accurately link concussions to a depressed state, however trends in research are focusing on the possibility that the greater the number of concussions sustained, the greater your risk for depression.

The brain is a delicate, sensitive, and complex organ.  Injury to the brain has the potential to affect aspects of both physical and cognitive functioning in activities of daily living as well as during activities of sport and work.  Most signs and symptoms of a concussion resolve relatively quickly, but in some cases signs and symptoms can last longer than anticipated and continue to affect a patient’s ability to function.

The best treatment for concussion is prevention.  When a concussion does occur, however, the seriousness of the event needs to be acknowledged by the patient, the health care professional, and any other caregiver involved.  A prudent and cautious attitude to treatment, recovery, and return-to-activity must be implemented.

This guide will help you understand:

• the headache-related anatomy of the head and neck
• what the most common types of headaches are and their causes
• how your health care professional diagnoses your headache
• what First Choice Physical Therapy’s approach to rehabilitation is

The anatomy of the head, neck and brain is complex and extensive. In regards to headaches, it is important to be aware of some specific anatomical structures within this region.

Although the bones of the skull themselves are not responsible for the pain associated with a headache, it is worthy to know the names and location of the main skull bones when discussing headaches. For instance the frontal bone is the skull bone that lies under the forehead. Health care professionals may refer to headaches as being a ‘frontal headache’. Similarly, most people know where their temples are, which are the soft indentations at the side of the forehead. The temples overlie the temporal and sphenoid skull bones. The occipital bone is at the back of the head.  Headaches in this region are often termed occipital headaches. The maxillary bone is the bone that houses the top row of teeth. The mandible, houses the bottom row and is more commonly known as your jaw bone.  Lastly, the two parietal bones are the large skull bones at the top of your head above your ears.

The temporomandibular joint, or TMJ, is in layman’s terms, the jaw joint. The TMJ connects the mandible bone to the skull itself. The TMJ is a complicated joint that contains a moveable disc. The joint works to open and close your jaw for activities such as speaking, chewing and singing.

The anatomy of the upper neck is also very important in regards to headaches, as irritation of the structures in this area can be the culprit leading to certain types of headaches. The upper three neck (cervical) vertebrae and their related anatomical structures in particular often contribute to pain in the head.  The upper most cervical vertebrae (C1) is called the atlas, and the skull sits directly on this vertebrae.  The next vertebrae (C2), is called the axis. The axis has a protruding piece of bone called the odontoid process that fits into the atlas above; C1 and C2 work together to create rotational movement of the head on the neck, and this joint alone allows 45 degree of left and right rotation of the head.  The third cervical vertebrae (C3) is similar to the rest of the lower cervical vertebrae, but due to its close proximity to the upper neck, it acts more closely in conjunction with the atlas and axis during neck movements.

The main nerves in the body provide sensation (sensory supply), movement (motor supply), or both.  The sensory and motor nerve supply to the upper neck, head and skull come from the nerves that are associated with the upper three cervical vertebrae (C1, C2 and C3) as well as from one of the cranial nerves that originates from inside the brain (the trigeminal nerve).  The nerves associated with the upper three cervical vertebrae originate from the spinal cord deep within in the neck. The C1-3 nerves supply the local neck structures of the upper three vertebrae such as the ligaments, joints, muscles and tendons.  The C1-3 nerves also combine together to create larger nerves, which supply the skin sensation to the occipital and parietal regions of the skull.
The sensory and motor nerve supply to each side of the face and jaw comes from the trigeminal nerve on that same side, which is one of the twelve cranial nerves that originate from deep inside the brain. The trigeminal nerve (also termed the 5th cranial nerve or CN V) has three branches, the ophthalmic branch, the maxillary branch, and the mandibular branch.  These branches together supply the sensation from high above the forehead and temple area all the way down to the jaw including the nose, lips, teeth, gums and sinuses.  The motor supply of the trigeminal nerve includes some of the muscles of mastication (chewing) including the large temporalis muscle and the strong masseter muscle. The trigeminal nerve also supplies nerve input to a number of the blood vessels of the brain as well as the lining of the brain (the meninges). Another important cranial nerve in regards to headaches is the facial nerve (also termed the 7th cranial nerve or CN VII). This nerve supplies motor function to the muscles used to create facial expressions as well as the occipitalis muscle as the back of the head. It also supplies sensation to part of the tongue including the sensation of taste in this area.

In regards to the headache-related muscles of the head, neck and shoulder, there are many muscles that can be associated with headache pain, however a few are more worthy of noting than others. In some types of headaches, muscles may get tight themselves and cause a headache, but in many other cases, the headache pain itself results in associated muscles becoming tight and painful.

As mentioned above, two of the main muscles of mastication, namely the temporalis and the masseter muscles can be related to headache pain. These muscles are in close anatomical proximity to common headache locations and their nerve supply, the trigeminal nerve, also supplies the sensation to the front of the head and temple area.  The temporalis muscle is located on each side of your head under the temples; if you clench your teeth while touching this area you will feel the temporalis muscle bulge under your fingers.  The masseter muscle is located over each jaw. Similarly if you touch this area and again clench your teeth you will feel the masseter muscle bulge.

The occipitalis muscle is located on either side of your head at the back of the skull, behind your ears and towards your neck.  The function of this muscle is to move the scalp backwards.

There are several small muscles at the extreme upper part of the neck, which attach from one vertebrae to the next as well as attach from the top two vertebrae (C1 & C2) up onto the skull. Collectively these muscles are called the suboccipital muscles. They are responsible for some of the movement of the upper two cervical vertebrae as well as some of the movement of the head itself on the neck.

The trapezius muscle is the large muscle at the top of your shoulder, which creates the angle of the neck.  Beneath this muscle are several long muscles of the neck, which attach from the cervical vertebrae down to both other cervical vertebrae and extend even farther down into the thoracic region.

In addition to the nerves, and muscles of the head, neck and jaw there is a network of blood vessels that carry blood to all the structures of this area including the brain. This network of vessels is extremely complex and too extensive to describe but they should be noted as important anatomy that can be related to headache pain.

Lastly, the brain itself is an important structure to discuss in regards to headaches.  The main brain structure that most people think of when the brain is mentioned is termed the cerebral cortex. The cortex assimilates a great deal of the information that is sent to the brain. It plays a major part in memory, attention, perceptual awareness, thought, language, and consciousness.  The cortex is divided into specific lobes, which are named similarly to the skull bones of the same area.  These are the frontal, parietal, temporal and occipital lobes. Each area is specifically responsible for a function of the brain. Although the brain in its entirety is obviously important, the occipital lobe, which is the primary vision center of the brain, is particularly important to note when discussing headaches.  Concurrent visual disturbances occur for many people during headaches and this is thought to have something do with brain input to and from the occipital lobe.

It should be mentioned that the location of your headache pain is not often in the same location as the structures that are causing your pain and this is termed referred pain. Referred pain occurs when an irritated structure causes pain in another location away from the original irritated site.

Headaches can be caused by a large variety of reasons. Those suffering from regular headaches are often aware of the cause of their headache, however in many cases, the cause of a headache may go unknown.

There are two basic categories of headaches, namely primary and secondary. Primary headaches are those headaches that are caused for no specific underlying reason.  They are not the result of any specific disease or process and are commonly thought of as being a result of a problem in brain function rather than a problem with the brain’s basic structure itself.  Primary headaches include migraine & cluster headaches as well as tension-type headaches. Being that there is no underlying brain structural problem with primary headaches, it is important to note that there are no investigative tests such as magnetic resonance imaging tests (MRIs) or computed tomography (CT) scans that can be done to determine an exact reason for the headache. If you suffer from primary headaches, however, some investigative tests may still be used to rule out other causes of your headaches.

Secondary headaches result from another problem, which has a headache as a symptom of the underlying initial problem. Secondary headaches can result from a huge variety of problems including head and neck injuries, inflammatory processes within the body, hormonal issues, as well as more serious causes such as brain tumors or aneurysms.

The main types of primary headaches and some common secondary types of headaches are described in detail below:

Migraines

Migraines are often described as a severe (and often unbearable) throbbing or pulsating pain in one or both sides of the head, often around the temples, front of the head or behind an eye. Approximately 15-20% of migraine headaches are accompanied by a sensory aura, which is a particular sensation that, in adults, precedes the actual headache pain (children sometimes get the aura at the same time as the headache). An aura can present in the form of a variety of sensations such as suddenly smelling a certain smell, seeing spots or zigzags, feeling a twitch, excessive yawning, numbness or tingling in the face or one part of the body, or even weakness on one side of the body. Some migraine sufferers even crave certain foods, such as chocolate, as their aura.

Nausea, vomiting, double vision and an extreme sensitivity to light, sound or smells often accompany migraines. Migraines can also be accompanied by a loss in memory, altered thinking capacity, and altered speech.  Migraines can last anywhere from an hour to, in extreme cases, several days.  Most migraines are severe enough that they cannot be ‘worked through’ and once the headache has passed a ‘headache hangover’ is often felt, which is a feeling of extreme fatigue, dizziness and difficulty concentrating. Neck pain may or may not be present during or after a migraine headache.

Migraine headaches are often familial, meaning that they run in one’s family.  Being depressed can also increase your likelihood of suffering a migraine headache, as can lack of restorative sleep or having chronic sinus problems. Migraines are more common in women than in men.

Migraine headache triggers are not always known but some common food and drinks that may trigger migraines include certain red wines, cheeses, chocolate, excessive caffeine, pickled foods, foods containing monosodium glutatmate (MSG), citrus fruits and sourdough bread.   Other common non-food related triggers include flickering lights, intense exercise, intense smells (such as perfume), weather changes (barometric changes), and menstruation cycles.  Stress is an extremely common trigger of migraine headaches in many sufferers.

The physiology of migraines is still being studied however it is accepted that there is an increased sensitivity in the brain to certain environmental triggers which then sets off a chemical chain of events in the brain. The migraine trigger causes a chemical release in the brain, which in turn affects the blood vessels of the brain, causing them to swell and release further chemicals.  The chemicals released act as an irritant to the pain structures in the head and face including the trigeminal nerve and the area that it supplies, hence causing the headache.  Altered levels of serotonin, which is an important brain chemical that regulates pain and mood, have also been associated with migraines. It has also been shown that during a migraine headache there is an altered blood flow to certain parts of the brain’s cortex such as the occipital (visual) cortex.

Cluster Headaches

Cluster headaches are an extremely painful type of headache, which comes on rapidly and occurs in a cyclic time frame, hence the name. Headaches occur over a specific time frame, usually a two to twelve week period and this is often related to a particular season of the year. During the cluster period, headaches generally occur every day (often more than once in a day) and often occur at the same time during the day. Time between headaches is pain-free.

Cluster headaches often occur at night, generally within a couple of hours of going to sleep.  Most cluster headaches are 30-90 minutes in duration but can be shorter or longer. Sufferers often describe the pain as burning and sharp like a red-hot stick poking through the eye. Cluster headaches occur on one side (and do not switch sides within a cluster period) and they are usually located around an eye but may extend to other areas of the head and neck. Other symptoms can include redness, swelling or tearing of the affected eye, droopiness of the affected eye, sweating of the face, and stuffy or runny nasal passages on the affected side.  Sufferers of cluster headaches often also describe restlessness as a symptom of the headache; due to pain, the headache sufferer just can’t sit still.  Fortunately in most cases, cluster headaches usually dissipate as quickly as they began.

Although the exact cause of cluster headaches are unknown, the cause appears to be related to activation of the trigeminal nerve which supplies sensation to side of the face, jaw and eye. Triggering of the trigeminal nerve appears to occur for an unknown reason by a deep part in the brain called the hypothalamus. The hypothalamus is related to our ‘circadian rhythm’ which regulates our sleep and wake cycles.  Activation of the trigeminal nerve appears to then trigger other cranial nerves in the area, which can lead to the symptoms such as tearing, nasal congestion, and eye redness. Triggers for cluster headaches can be strong smells, high altitudes, bright lights, heavy exercising or becoming overheated.  Alcohol is also a well-known cluster headache trigger. An aura may occur with a cluster headache but it is uncommon.

Cluster headaches are more common in men and are also more common in heavy smokers.  Having a family member who also suffers from cluster headaches increases one’s chance of also suffering from cluster headaches.

Cluster headaches can be described as episodic cluster headaches or chronic cluster headaches. An episodic cluster headache is a period of headaches then a significant period without headaches.  Chronic cluster headache sufferers have very little remission time (less than approximately 14 days a year) that are headache free.

Tension-Type Headaches

Tension-type headaches are the most common type of headache and many people experience them regularly, particularly when under stress.  For this reason, these headaches are also sometimes referred to as ‘stress headaches’.  Aside from stress, tension-type headaches are reported to be commonly triggered by a number of other factors including hunger, fatigue, poor posture and eye strain.

Tension-type headaches can last anywhere from 30 minutes up to even a week! The pain of a tension-type headache is generally described as a mild to moderate dull but constant and diffuse pain, and usually occurs on both sides of your head.  Tension-type headaches are often described as a tight band around the head near the temples, or tightness and pressure at the head and around the lower neck and trapezius muscle.  Tension-type headaches are not associated with any visual disturbances or auras and often the pain of a tension-type headache can be tolerated such that sufferers are able to ‘work through them’.  For some people, however, the pain is more severe, can last a long time, and is unable to be ‘worked through’.  Women are more than twice as likely to suffer from tension-type headaches than men.

The underlying cause of tension-type headaches used to be thought of as increased tension in the muscles of the neck and face which then causes the headache pain. More recently, however, tension-type headaches have been thought to be linked to sufferers being hypersensitive to pain and stress, which then causes the headache.  The neck pain and muscle soreness that results is thus a symptom of the headache rather than a cause of it, which was thought in the past.  For this reason, along with migraines and cluster headaches, tension-type headaches are included in the category of primary headaches, which occur for no specific reason and are not the symptom of another underlying problem but rather thought to be as the result of altered brain function.

Tension-type headaches can also be described as episodic or chronic.  Episodic tension-type headaches occur once to twice a month whereas chronic tension-type headaches occur more than 15 days in a month.

Cervicogenic Headaches

Cervical is the medical term meaning ‘relating to the neck’ and ‘genic’ means originating or coming from.  Cervicogenic headaches are headaches that are associated with neck pain and stiffness; the cause of the headache comes from structures in the neck. As noted in the anatomy section above, the nerves that supply the joints of the upper three cervical vertebrae also supply the skin overlying the scalp, forehead, ears and eyes. Injury to structures in the upper neck such as ligaments, nerves, joints, muscles or other structures can refer pain and cause a headache.

Cervicogenic headaches are most commonly felt on one side of the head but occasionally a cervicogenic headache can cause pain on both sides. These types of headaches typically occur due to excessive strain on the structures of the upper neck, which can occur from a traumatic event such as whiplash. More often than a traumatic event, however, cervicogenic headaches occur as the result of prolonged stress on the upper neck structures such as when sitting at a computer for prolonged periods, especially when sitting with poor posture.  Sufferers of cervicogenic headaches often feel the headache come on right as they are in the aggravating neck position or as they move their neck, but a cervicogenic headache can also be felt hours after aggravating the neck structures.  For instance, a cervicogenic headache may come on in the evening following or the next morning after driving for a long period or sitting in a plane. Pain is felt when the suboccipital structures of the neck or the neck itself is palpated or touched. Secondary pain may be felt down the neck and into the trapezius muscle area. Nerves in the neck that become entrapped or ‘pinched’ may also cause cervicogenic-type headaches.

Sinus Headaches

The sinuses of the face lie in the cheeks, behind the bridge of your nose, as well as in the forehead/brow area. The sinuses help to humidify air and secrete mucus to assist air filtration. Those suffering from a sinus headache often complain of the area ‘feeling full’.  Pressure and fullness felt may even extend into the upper teeth area.

Sinus headaches most often occur after an upper respiratory infection or cold.  The upper respiratory infection or cold causes inflammation of the lining of the sinuses (sinusitis), which prevents draining of the mucus in the sinuses and then causes the build-up of pressure in the area.  Inflammation may also occur as a result of an allergy.  Sinus headaches are not associated with nausea or vomiting nor do they have a related aura.  Often the pain of a sinus headache worsens when the sufferer bends forward, lies down, makes sudden movements, or when they first get out of bed due to the added pressure that the change in position causes.  Sudden temperature changes, such as going from a warm house into the cold outdoors, can also increase the pain of a sinus headache. The face overlying the inflamed sinus may be tender to touch.

Frequent colds, climbing or flying to high altitudes, frequent diving or swimming, or having a history of allergies such as hay fever increases your risk of suffering from a sinus headache.  In addition, having any type of issue with your nasal passages such as polyps or a deviated septum, or can also put you at a higher risk of developing this type of headache.

Sinus headaches are often confused with migraines or tension-type headaches.  Many people who seek medical attention due to what they believe are sinus headaches are actually diagnosed as having migraines or tension-type headaches.

Temporomandibular Joint (TMJ)-Related Headaches

TMJ disorders can commonly cause headaches. As mentioned above, the TMJ joint is a complicated joint and because of this easily becomes injured.  In many cases it is obvious that one has a TMJ disorder because there will be pain around the jaw or ear as well as clicking in the joint or problems opening or closing the jaw itself.  Headaches may develop related to these symptoms. In some TMJ cases, however, local TMJ pain may not be present and headaches may be the only symptom one feels so the TMJ joint gets overlooked as the culprit.

TMJ-related headaches can also closely mimic tension-type headaches, cervicogenic headaches, migraines, and sinus-related headaches therefore a thorough examination of the TMJ should be included in any physical examination for headaches to either rule the TMJ joint in or out.

Other causes

Other secondary type headaches can come on as a result of a number of other causes including:

• dehydration
• poor posture or work biomechanics
• skipped meals
• food sensitivities
• lack of sleep
• head injury/concussion
• inner-ear problems
• excessive noise
• hormones (menstrual-related, pregnancy-related, or other),
• glare from sunlight, computer screens or other screens
• anxiety
• alcohol, particularly from red wine or excessive drinking
• medication
• ice cream or eating/drinking extremely cold items (brain freeze)
• excessive exercise
• brain aneurysm
• brain tumour

Your healthcare professional will need to ask a variety of questions to determine the cause of your headache(s).  Firstly, when determining the reason for a headache it should be noted that any sudden and severe headache is indicative of a serious problem and should be treated as a medical emergency, which needs to be investigated immediately.

Most people will only seek professional assistance in determining the cause of a headache once their headache becomes regular, constant, or causes pain that is affecting their ability to function. In order to determine the cause of your headaches your health care professional will want to know when your headaches began, if you feel they are related to any specific event or trigger, how severe they get, how long they last, if they come with an aura, and if they are consistently in one area of your head. They will ask you questions about what aggravates your headache pain and whether or not you can do anything to relieve your headache such as take medication, or massage your muscles. They will also want to know about your general health, any medications you are taking, any history of headaches in your family, and any other symptoms you may be experiencing such as neck, ear, eye or jaw pain.

In order to determine if your headache is being caused by or aggravated by your neck, your Physical Therapist at First Choice Physical Therapy will assess your cervical spine.  They will determine if there is any related muscular or fascial tension affecting your pain, whether there are any stiff or loose joints in your neck, or if there is any nerve tension in the area that could be related to your headaches.  They will specifically assess the upper cervical region (C1-3) but will also need to assess your lower neck and may also assess your thoracic spine area.  Your Physical Therapist will also assess your TMJ to determine if there is any dysfunction in this joint that could be the direct cause of your headaches or may be contributing to your symptoms.

In most cases investigations such as x-rays, MRIs, CTs, or other investigative tests will not show up any structural damage to the brain or neck and therefore in most cases, these tests are not recommended particularly when dealing with primary type headaches. These types of tests (or others) however, may be requested particularly in secondary type headaches in order to rule out specific diseases or processes, which may be related to the ongoing headaches. Investigative tests may be used to look for issues such as hormonal problems, brain aneurysms or brain tumors.

It may be recommended that you obtain a professional examination of your eyes and ears as well as a dental exam in order to help determine the cause of your headaches as some disorders of these areas can cause headaches as a symptom.

Some headaches are easier to treat than others.  Obviously knowing the cause of a headache makes the required treatment much easier to define.

For many headache sufferers, medication is the mainstay of treatment.  The three most common medications available over the counter are acetaminophen/paracetemol based, acetylsalicylic acid based, or ibuprofen based.  Each medication has its own contraindications therefore you should check with your doctor or pharmacist before using any to treat your symptoms.

For migraines, cluster or tension-type headaches some prescription drugs can be useful and should be discussed with your doctor.  In many cases if an aura occurs and the patient takes the medication during the time of the aura, a full-blown headache can be avoided or the intensity of the impending headache can be decreased.

In severe or chronic headache cases, patients and healthcare professionals may choose to resort to more invasive procedures in order to manage symptoms and allow the patient to function.  Treatments such as botox injections for migraine headaches or nerve ablations for cervicogenic headaches may be options that can be discussed with your doctor.  Other types of injections or surgeries may also be options depending on your symptoms, severity, and the types of treatments you have already tried.

For some types of headaches, Physical Therapy can be a very effective form of treatment. Physical Therapy can be used either on its own or in conjunction with medication.

In certain types of headaches, such as tension-type headaches, cervical headaches, or TMJ-related headaches Physical Therapy treatment can be very useful to alleviate your symptoms and to help prevent recurrent headaches.

Your Physical Therapist will first need to confirm that your headaches and associated symptoms are connected to issues related to your neck, your jaw, or other structures in the head or face which can be assisted by Physical Therapy treatment.  Your Physical Therapist will ask you several questions related to your headaches symptoms in order to confirm the cause of your headache (see Diagnosis above). In addition to asking a wide variety of questions they will need to do a physical assessment to confirm that Physical Therapy will be able to assist your headaches. They will examine the posture and alignment of your neck, shoulders, and upper back as well as check your neck and TMJ joint range of motion, and associated muscle flexibility and strength. Your Physical Therapist will feel your neck to determine if the joints in your neck are stiff or loose and to determine which areas around your neck, shoulders, face and scalp are tender or painful.  They will do the same to your TMJ and its related muscles. Your Physical Therapist may also check the overall strength in your upper extremities, as well as check your sensation, reflexes, and the functioning of your cranial nerves.

If it is determined that your headaches are indeed from a cause which Physical Therapy treatment can assist, then your therapist will proceed with treatment. Again, depending on your symptoms and the cause of your headaches, a variety of techniques may be used. Manual therapy including massage, as well as joint mobilization or manipulation for the neck, upper back or TMJ commonly improve symptoms. Your therapist may also stretch out any tight muscles contributing to your headaches and will also teach you how to do this yourself.  In addition, they will teach you how to strengthen the appropriate muscles around your head, neck, shoulders and TMJ in order to ease your symptoms and avoid headaches in the future. They will also encourage strengthening of the core muscles of your trunk and neck in order to support your head and assist with symptoms.

Your Physical Therapist will discuss your posture and alignment and ensure you are aware of the posturing positions that may contribute to your headache pain or related symptoms.  In some cases modalities such as ice, heat, ultrasound, interferential current, laser, transcutaneous electrical muscle stimulators (TENS) or muscle stimulators may be used to ease your headache pain or other related symptoms.  Tape or strapping may also be used to relieve tension on muscles that may be tight, elongated, or weak.  Braces that assist with posturing may also be useful in some cases.

Your Physical Therapist will also provide education for self-managing your headache and related symptoms when they occur.  They will discuss techniques such as retreating to a quiet and dark room, using self-massage of the head, neck, jaw and temples, applying ice or heat to the painful area or the neck and shoulders, avoiding computer or other screens, drinking water, or eating a small amount of food once symptoms appear.

If after a thorough examination your Physical Therapist does not feel that your headaches are being caused by a reason that is amenable to Physical Therapy treatment then they will refer you to your doctor for further investigation.  Similarly, if your symptoms worsen significantly or Physical Therapy treatment is not improving your symptoms as your Physical Therapist expects it should, they will also refer you on to your doctor for further investigation.

Headaches are caused from a variety of reasons. Delineating the cause of a headache makes the treatment easier to determine. Physical Therapy treatment can be very effective in specific types of headaches and should always be considered as an option in order to decrease headache pain frequency as well as related symptoms.

Dupuytren’s contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. Although the exact cause is unknown, it occurs most often in middle-aged, white men and is genetic in nature, meaning it runs in families. This condition is seven times more common in men than women. It is more common in men of Scandinavian, Irish, or Eastern European ancestry. Interestingly, the spread of the disease seems to follow the same pattern as the spread of Viking culture in ancient times. The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn’t cause symptoms until after the age of 40.

This guide will help you understand:

• how Dupuytren’s contracture develops
• what the symptoms are
• how the disorder progresses, and how you can measure its progression
• what options for treatment are available
• what First Choice Physical Therapy’s approach treatment is

What part of the hand is affected?

The palm side of the hand contains many nerves, tendons, muscles, ligaments, and bones. This combination allows us to move the hand in many ways. The bones give our hand structure and form joints. Bones are attached to other bones by ligaments. Muscles allow us to bend and straighten our joints. Muscles are attached to bones by tendons. Nerves stimulate the muscles to bend and straighten.

Blood vessels carry needed oxygen, nutrients, and fuel to the muscles to allow them to work normally and heal when injured. Tendons and ligaments are connective tissue. Another type of connective tissue, called fascia, surrounds and separates the tendons and muscles of the hand.

Lying just under the skin of the palm is the palmar fascia; a thin sheet of connective tissue shaped somewhat like a triangle. This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. The fascia separates into thin bands of tissue at the fingers. These bands continue into the fingers where they wrap around the joints and bones. Dupuytren’s contracture forms when the palmar fascia tightens, causing the fingers to bend.

The condition often first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren’s contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

Why do I have this problem?

No one knows exactly what causes Dupuytren’s contracture. The condition is rare in young people but becomes more common with age. When it appears at an early age, it usually progresses rapidly and is often very severe. The condition tends to progress more quickly in men than in women.

People who smoke have a greater risk of having Dupuytren’s contracture. Heavy smokers who abuse alcohol are even more at risk. Recently, scientists have found a connection with the disease among people who have diabetes. It has not been determined whether or not work tasks can put a person at risk or speed the progression of the disease.

What does Dupuytren’s contracture feel like?

Normally, we are able to control when we bend our fingers and how much. How much we flex our fingers determines how small an object we can hold and how tightly we can hold it. This control  is lost as the disorder develops and the palmar fascia contracts, or tightens. The contracture is like extra scar tissue just under the skin. As the disorder progresses, the bending of the finger becomes more and more severe, which limits the motion of the finger.

Without treatment, the contracture can become so severe that you cannot straighten your finger, and eventually you may not be able to use your hand effectively. Being that our fingers are slightly bent when our hand is relaxed, many people put up with the contracture for a long time. Patients with this condition usually eventually seek medical advice for cosmetic reasons or because they lose use of their hand. At times, the nodules can be very painful. For this reason many patients are worried that something serious is wrong with their hand.

How do health care providers identify the problem?

When you visit First Choice Physical Therapy, our Physical Therapist will ask you the history of your problem, such as how long you have had it, whether you’ve noticed it getting worse, and whether it has kept you from doing your daily activities. We will then examine your hand and fingers.

Our Physical Therapist can tell if you have a Dupuytren’s contracture by looking at and feeling the palm of your hand and your fingers. Usually, special tests are unnecessary. Abnormal fascia will feel thick. Cords and small nodules in the fascia may be felt as small knots or thick bands under the skin. These nodules usually form first in the palm of the hand. As the disorder progresses, nodules form along the finger. These nodules can be felt through the skin, and patients can usually feel them themselves. Depending on the stage of the disorder, your finger may have started to contract, or bend.

The amount you are able to bend your finger is called flexion. The amount you are able to straighten the finger is called extension. Both are measured in degrees. Normally, the fingers will straighten out completely. This is considered zero degrees of flexion (no contracture). As the contracture causes your finger to bend more and more, you will lose the ability to completely straighten out the affected finger. The loss of ability to straighten out your finger is also measured in degrees.

Measurements we take at follow-up visits to First Choice Physical Therapy will tell us how well our treatments are working or how fast the disorder is progressing. The progression of the disorder is unpredictable. Some patients have no problems for years, and then suddenly nodules will begin to grow and their finger will begin to contract.

Our Physical Therapist may also do the tabletop test. The tabletop test will show if you can flatten your palm and fingers on a flat surface. You can follow the progression of the disorder by doing the tabletop test yourself. Our Physical Therapist will tell you what to look for and when you should return for a follow-up visit.

What can be done for the condition?

There are two types of treatment for Dupuytren’s contracture: nonsurgical and surgical. The best course of treatment is determined by how far the contractures have advanced.

Nonsurgical Treatment

The nodules of Dupuytren’s contracture are almost always limited to the hand. If you receive regular examinations, you will know when to proceed with the next treatment step. Dupuytren’s contracture is a progressive disease, early treatment, determined by the stage of the disease, is important to release the contracture and to prevent disability in your hand. Treatment is determined based on the severity of the contracture.

Enzymatic FasciotomyOngoing research of this condition has resulted in a less invasive nonsurgical method of treatment called an enzymatic fasciotomy.  If it is the main knuckle of the finger (at the base of the finger) that is contracted, and there are only one or two cords involved, this procedure may be possible. For this treatment, a new injectable drug, Xiaflex, which is gaining popularity and approval for use around the world, is used. By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken, most often the patients are able to break apart the cord by themselves.

With the injection of this new drug generally patients return within 24 hours for a recheck. If the cord hasn’t broken apart, your physician may have to numb the finger and then stretch it to break apart the cord and regain full motion of the finger. This technique sounds dramatic, but it’s not! The treatment so far has been deemed to be safe and effective.

There are a few possible (minor) side effects but very few major or long-term complications with this new treatment. During the control trials conducted with patients, most people had a local skin reaction (redness, skin tears, itching or stinging) where the injection went into the skin. A small number of more serious problems developed in a few patients including tendon rupture, finger deformity, and hives that had to be treated with medication. Further studies are needed to assess the long-term effects of this new treatment, especially to determine any recurrence rates.

Injection of this drug may eventually replace surgery. Until then, surgical release of the cords and removing a portion of the fascia will likely remain the gold standard.

The ability of nonsurgical treatments to slow or actually reverse the contracture is not all that promising. The contracture usually requires surgery at some point.
In the early stages of this disorder, frequent examination and follow-up is recommended. In addition to your Physical Therapy treatments at First Choice Physical Therapy, your doctor may want to inject cortisone into the painful nodules. Cortisone can be effective at temporarily easing pain and inflammation.

Heat and stretching treatments given by our Physical Therapist may also be done to control pain and to try to slow the progression of the contracture. Our Physical Therapist may advise you to wear a splint that keeps the finger straight. This splint is usually worn at night. The combination of heat, stretching, and a finger splint seem to be the most effective non-surgical treatments for Dupuytren’s contracture.

Although recovery times among patients varies, as a general rule, you may be advised to

attend our Physical Therapy sessions a few visits per week for up to six weeks. After that, our Physical Therapist will instruct you to continue using the splint and do the stretches as part of a home program for several months.

The nodules of Dupuytren’s contracture are almost always limited to the hand. If you attend Physical Therapy regularly and follow our Physical Therapist’s advice, you may be able to slow the problems caused by this disorder. Dupuytren’s contracture, however, is known to progress, so surgery may be needed at some point to release the contracture and to prevent disability in your hand.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

No hard and fast rule exists as to when surgery is needed. Surgery is usually recommended when the joint at the knuckle of the finger reaches 30 degrees of flexion. When patients have severe problems and require surgery at a younger age, the problem often comes back later in life. When the problem comes back or causes severe contractures, surgeons may decide to fuse the individual finger joints together. In the worst case, amputation of the finger may be needed if the contracture restricts the nerves or blood supply to the finger.

Surgery for the main knuckle of the finger (at the base of the finger) has better long-term results than when the joint in the middle of the finger is affected. A contracture is more likely to return after surgery for the middle joint.

Tissue Release

The goal of tissue release surgery is to release the fibrous attachments between the palmar fascia and the tissues around it, thereby releasing the contracture. Once released, finger movement should be restored to normal. If the problem is not severe, it may be possible to free the contracture simply by cutting the cord under the skin. If the palmar fascia is more involved and more than one finger is bent, your surgeon may take out a large portion of the sheet of fascia.

Palmar Fascia Removal (partial palmar fasciectomy)

This remains the gold standard of treatment for Dupuytren’s contracture. Removal of the diseased palmar fascia will usually give a very good result. The cure is often permanent but depends a great deal on the success of doing the Physical Therapy post surgically as prescribed. Removing the palmar fascia causes little ill effect, although the fingers may bend backward slightly more than normal. If you decide to have this surgery, it is pertinent that you commit to doing the therapy needed to make your surgery as successful as possible.

Removal of the entire palmar fascia (radical fasciectomy) requires extensive removal of involved and non-involved palmar and digital (finger) fascia. This approach may be required but it has higher complications rates without providing better success rates so it is no longer done commonly.

Needle Aponeurotomy

A less invasive procedure called a needle aponeurotomy (also referred to as a percutaneous fasciotomy) is available when the disease is at an early stage. Under local anesthesia, the surgeon inserts a very thin needle under the skin. The sharp needle cuts a path through the cord, weakening it enough to stretch and extend it, or rupture it.
The advantage of this procedure is that it can be done on older adults who have other health issues that might make surgery under general anesthesia too risky. The disadvantage is a high recurrence rate and the potential for nerve injury, infection, and hematoma (pocket of blood) formation.This procedure, however, has replaced the fasciectomy in many practices.

Skin Graft Method

A skin graft may be needed if the skin surface has contracted so much that the fingercannot relax as it should and the palm cannot be stretched out flat. Surgeons graft skin from the wrist, elbow, or groin. The skin is grafted into the area near the incision to give the finger extra mobility for movement.

Your hand will be bandaged with a well-padded dressing and a splint for support after surgery. As stated above, your Physical Therapy at First Choice Physical Therapy is a very important part of your recovery. Physical Therapy treatments after surgery can make the difference to a successful result. The treatments applied by our Physical Therapist may include a program of heat, soft tissue massage, and vigorous stretching, as well as a home program which includes similar exercises that you will be required to do on your own.  Your Physical Therapist will keep a close watch on how your recovery is going, and will take ongoing measurements to mark the progress of your recovery.

Generally Physical Therapy at First Choice Physical Therapy occurs without any issues, and full recovery occurs provided our advice is closely followed. If, however, your recovery is not progressing as your Physical Therapist feels it should, we will ask you to return to your surgeon for a follow-up visit to ensure there are no complications, which are impeding your recovery.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be solely in charge of doing your own exercises as part of an ongoing home program.

Arthritis of the Finger Joints

When you stop to think about how much you use your hands, it’s easy to see why the joints of the fingers are so important. Arthritis of the finger joints has many causes, and arthritic finger joints can make it hard to do daily activities due to pain and deformity. Unbearable pain or progressive deformity from arthritis may signal the need for surgical treatment.

This guide will help you understand:

• how arthritis of the finger joints develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

How do the finger joints normally work?

The bones in the palm of the hand are called metacarpals. One metacarpal connects to each finger and thumb. Small bone shafts called phalanges line up to form each finger and thumb.

The main knuckle joint is formed by the connection of the phalanges to the metacarpals. This joint is called the metacarpophalangeal joint (MCP joint). The MCP joint acts like a hinge when you bend and straighten your fingers and thumb.

The three phalanges in each finger are separated by two joints, called interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint). The thumb only has one IP joint between the two thumb bones. The IP joints of the digits also work like hinge joints when you bend and straighten your hand.

The finger and thumb joints are covered on the ends with articular cartilage. This white, shiny material has a rubbery consistency. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to facilitate motion. There is articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate.

Articular Cartilage

Hand Anatomy Introduction

Causes

What causes arthritis?

Degenerative arthritis is a condition in which a joint wears out, or degenerates, usually slowly over a period of many years. Degenerative arthritis is usually called osteoarthritis. The term arthritis means joint inflammation (pain, redness, heat, and swelling). The term degenerative arthritis means inflammation of a joint due to wear and tear. You may also hear the term degenerative arthrosis used. Degenerative arthritis is usually called osteoarthritis.

Degenerative Arthritis

Injury to a joint, such as a bad sprain or fracture, can cause damage to the articular cartilage. An injury to any of the joints of the fingers, even if it does not injure the articular cartilage directly, can alter how the joint works. After a fracture, the bone fragments may heal in slightly different positions. This may make the joints line up differently. When an injury changes the way the joint lines up and moves, force can start to press against the surface of the articular cartilage. This is similar to how a machine that is out of balance wears out faster.

Articular Cartilage Damage

Over time, this imbalance in the joint can lead to damage to the articular surface. Since articular cartilage cannot heal itself very well, the damage adds up. Eventually, the joint can no longer compensate for the increasing damage, and symptoms begin. The damage in the joint starts well before the symptoms of arthritis appear.

Symptoms

What does arthritis feel like?

Pain is the main problem with arthritis. At first, the pain usually only causes problems when you begin an activity. Once the activity gets underway, the pain eases. But after resting for several minutes the pain and stiffness increase. When the arthritis condition worsens, pain may be felt even at rest. The sensitive joint may feel enlarged and warm to the touch from inflammation.

In rheumatoid arthritis, the fingers often become deformed as the disease progresses. The MCP joints of the fingers may actually begin to point sideways (towards the little finger). This is called ulnar drift. Ulnar drift can cause weakness and pain, making it difficult to use your hand for daily activities.

Ulnar Drift

Both rheumatoid arthritis and osteoarthritis can affect the IP joints of the fingers. The IP joints may begin to flex (bend) or hyperextend (over straighten), causing characteristic finger deformities. Swan neck deformity occurs when the middle finger joint (the PIP joint) becomes loose and hyperextended, while the DIP joint becomes flexed. When the PIP joint flexes and the DIP joint extends, a boutonniere deformity forms.

Swan Neck Deformity

Boutonniere Deformity

Both forms of arthritis can cause enlarged areas over the back of the PIP joints. These areas tend to be sore and swollen. They are known as Bouchard’s nodes.

Bouchard’s Nodes

Osteoarthritis causes similar enlargements over the DIP joints, called Heberden’s nodes.

Heberden’s Nodes

Diagnosis

How do health care providers identify arthritis?

The diagnosis of arthritis of the finger joints begins with a history of the problem. When you visit First Choice Physical Therapy, our Physical Therapist will want details about any injuries that may have occurred to the hand. This information is important because it may suggest other reasons why the condition exists.

Following the history, we will do a physical examination of the hand and possibly other joints in the body. Our Physical Therapist will need to see how the motion of each joint has been affected.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Treatment usually begins when the joint first becomes painful. This may only occur with heavy use and may simply require mild anti-inflammatory medications, such as aspirin or ibuprofen. Reducing the activity, or changing from occupations that require heavy repetitive hand and finger motions, may be necessary to help control the symptoms.

Our primary goal is to help you learn how to control symptoms and maximize the health of your hand and fingers. When you visit First Choice Physical Therapy in Lynn Haven and Panama City Beach, our Physical Therapist will instruct you in ways to calm pain and symptoms, which might include the use of rest, heat, or topical rubs.

We will then begin range-of-motion exercises for your finger after your pain eases, followed by a program of strengthening to improve your finger movement. Strengthening exercises for the arm and hand help steady the hand and protect the finger joints from shock and stress. Our therapist may also use dexterity and fine motor exercises to get your hand and fingers moving. We will go over tips on how you can get your tasks done with less strain on the joint.

Your Physical Therapist may recommend a custom finger brace or splint to support your finger joints. These devices are designed to help reduce pain, prevent deformity, or keep a finger deformity from getting worse.

Post-surgical Rehabilitation

Your hand will be bandaged with a well-padded dressing and a finger splint for support after surgery. Although time required for recovery varies among patients, you may need to attend our physical or occupational therapy sessions after surgery for up to eight weeks.

When you begin your First Choice Physical Therapy post-surgical Physical Therapy program, the first few treatments will be used to help control the pain and swelling after surgery. Some of the exercises that our Physical Therapist will have you do help strengthen and stabilize the muscles around the finger joint. We’ll recommend other exercises to improve the fine motor control and dexterity of your hand. Our Physical Therapist will also give you tips on ways to do your activities while avoiding extra strain on the finger joint.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, improve your range of motion, and maximize strength and control in your finger. When your recovery is well under way, regular visits to our office will end. Our Physical Therapist will give you tips on keeping your symptoms controlled. We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Surgery

Fusion

A fusion (or arthrodesis) of any joint is designed to eliminate pain by allowing the bones that make up the joint to grow together, or fuse, into one solid bone. Fusions are used in many joints and were very common before the invention of artificial joints for the replacement of arthritic joints. Even today, joint fusions are still very commonly used in many different joints for treating the pain and potential deformity of arthritis. Fusions are more commonly used in the PIP or the DIP joints in the fingers. A fusion of these joints is far easier and more reliable than trying to save the motion by replacing the joint.

Artificial Joint Replacement

Artificial joints are available for the finger joints. These plastic or metal prostheses are used by some hand surgeons to replace the arthritic joint. The prosthesis forms a new hinge, giving the joint freedom of motion and pain relief. The procedure for putting in a new joint is called arthroplasty.

Arthritis of the Thumb

When you stop to think about how much you use your thumbs, it’s easy to see why the joint where the thumb attaches to the hand can suffer from wear and tear. This joint is designed to give the thumb its rather large range of motion, but the tradeoff is that the joint suffers a lot of stress over the years. This can lead to painful osteoarthritis of this joint that may require surgical treatment as the arthritis progresses.

This guide will help you understand:

• how arthritis of the thumb develops
• how it is diagnosed
• what can be done for the condition

Anatomy

Where is the CMC joint, and what does it do?

The CMC joint (an abbreviation for carpometacarpal joint) of the thumb is where the metacarpal bone of the thumb attaches to the trapezium bone of the wrist. This joint is sometimes referred to as the basal joint of the thumb. The CMC is the joint that allows you to move your thumb into your palm, a motion called opposition.

Carpometacarpal Joint

Trapezium Bone

Several ligaments hold the CMC joint together. These ligaments can be injured, such as when you sprain your thumb. The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily.

Articular Cartilage

Causes

What causes arthritis of the thumb?

Arthritis is a condition in which a joint becomes inflamed (red, swollen, hot, and painful). Degenerative arthritis is a condition in which a joint wears out, usually slowly over a period of many years. Doctors sometimes also describe this same condition as degenerative arthrosis. It is also called osteoarthritis.

Degenerative Arthritis

Injury to a joint, such as a bad sprain or fracture, can cause damage to the articular cartilage. An injury to the CMC joint of the thumb, even if it does not injure the articular cartilage directly, can alter how the joint works. After a fracture of the thumb metacarpal, the bone fragments may heal in slightly different positions. The joints may then line up differently. This is also true when the ligaments around the CMC joint are damaged by a sprain. When an injury results in a change in the way the joint moves, the injury may increase the forces on the articular cartilage surfaces. This is similar to any mechanical device or machinery. If the mechanism is out of balance, it tends to wear out faster.

Over many years this imbalance in the joint mechanics can lead to damage on the articular surface. Since articular cartilage cannot heal itself very well, the damage adds up. Eventually, the joint is no longer able to compensate for the increasing damage, and it begins to hurt. Damage has occurred well before the pain begins.

Symptoms

What does arthritis of the thumb feel like?

Pain is the main problem with degenerative arthritis of any joint. This pain occurs at first only related to activity. Usually, once the activity gets underway there is not much pain, but after resting for several minutes the pain and stiffness increase. Later, when the condition worsens, pain may be present even at rest. The most noticeable problem with CMC joint arthritis is that it becomes difficult to grip anything. It causes a sharp pain at the base of the thumb in the thick part of the heel of the hand.

Base of Thumb

When the articular cartilage starts to wear off the joint surface, the joint may make a squeaking sound when moved. Doctors refer to this sound as crepitus. The joint often becomes stiff and begins to lose motion. Moving the thumb away from the palm may become difficult. This is referred to as a contracture.

Osteoarthritis may cause the CMC joint of the thumb to loosen and to bend back too far (hyperextension). If the middle thumb joint (MCP joint) becomes flexed and the furthest thumb joint also becomes hyperextended, the deformity is named a thumb swan neck deformity. A similar finger deformity sometimes occurs in people with finger arthritis.

Thumb Swan Neck Deformity

Diagnosis

When you visit First Choice Physical Therapy, our diagnosis of CMC joint arthritis of the thumb begins with our Physical Therapist taking a detailed history of the problem. Specifics about any injuries that may have occurred to the hand are important because they may suggest other reasons why the condition exists.

Following the history, our Physical Therapist will examine your hand and possibly other joints in your body. We will need to see how the motion of the CMC joint has been affected.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

What can be done for CMC joint arthritis?

The treatment of degenerative arthritis of the CMC joint of the thumb can be divided into the nonsurgical means to control the symptoms and the surgical procedures that are available to treat the condition. Surgery is usually not considered until the symptoms have become impossible to control without it.

Non-surgical Rehabilitation

Treatment usually begins when the CMC joint first becomes painful. This may only occur with heavy use and may simply require mild anti-inflammatory medications, such as aspirin or ibuprofen. Ensure that you consult with your doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication. Reducing the activity, or changing from occupations that require heavy repetitive gripping with the hand, may be necessary to help control the symptoms.

If you don’t need surgery, your Physical Therapist at First Choice Physical Therapy will first work with you to obtain or create a special thumb brace or splint when needed. These devices are designed to help reduce pain, prevent deformity, or keep a thumb deformity from getting worse. A thumb stabilizer is a type of thumb splint that is often custom-made of heat-moldable plastic. It is designed to fit the forearm, wrist, and thumb. Our patients with CMC joint arthritis usually only wear the splint at night and when the joint is flared up. It should also be worn to protect the thumb during heavy or repeated hand and thumb activities.

Our primary therapeutic goal is to help you learn how to control symptoms and maximize the health of your thumb. Our Physical Therapist will teach you ways to calm pain and symptoms, which might include the use of rest, heat, or topical rubs.

We will begin instructing you in range-of-motion and stretching exercises to improve your thumb motion. Our program then advances to include strength exercises for the thumb and fingers. We use dexterity and fine motor exercises to get your hand and thumb moving smoothly. Your Physical Therapist will also go over tips on how you can get your tasks done with less strain on the joint.

Although the time required for recovery varies among patients, as a guideline, you may expect to progress to a home program within four to six weeks.

Post-surgical Rehabilitation

After surgery, your hand will be bandaged with a well-padded dressing and a thumb splint for support. When you begin your Physical Therapy program, the first few treatments are used to help control the pain and swelling after surgery.

Our Physical Therapist will have you begin doing exercises to help strengthen and stabilize the muscles around the thumb joint. We’ll use other exercises to improve the fine motor control and dexterity of your hand. Our Physical Therapist will also provide tips on ways to do your activities while avoiding extra strain on the thumb joint.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Physician Review

Your doctor may take X-rays to see how much the joint is damaged.

X-Rays

This test usually determines how bad the degenerative arthritis has become. How much articular cartilage remains in the joint can be estimated with the X-rays.

An injection of cortisone into the joint can give temporary relief. Cortisone is a very powerful anti-inflammatory medication. When injected into the joint itself, it can help relieve the pain. Pain relief is temporary and usually only lasts several weeks to months. There is a small risk of infection with any injection into the joint, and cortisone injections are no exception.

Cortisone Injection

Surgery

The surgical treatment for arthritis of the CMC joint includes several options. At one time, joint replacement with an artificial joint made with silicon was very popular. Problems with silicon implants in other parts of the body have led many surgeons to return to more traditional operations such as fusion and excision arthroplasty instead. Newer artificial joints are being developed, and in the future we may see more surgeons using them.

CMC Joint Fusion

A fusion, or arthrodesis, of any joint is designed to eliminate pain by allowing the bones that make up the joint to grow together, or fuse, into one solid bone. Fusions are used in many joints and were very common before the invention of artificial joints for the replacement of arthritic joints. Even today, joint fusions are still commonly used in many different joints for treating the pain of arthritis.

A fusion of the CMC joint of the thumb is done quite often in younger people who need a strong grip or pinch more than they need the fine motion of the thumb. People who use their hands for heavy work will probably prefer a fusion over an arthroplasty (described below).

Artificial Joint Replacement (Arthroplasty)

Artificial joints are available for the CMC joint. These plastic or metal prostheses are used by some hand surgeons to replace the joint. The prosthesis acts as a spacer to fill the gap created when the arthritic surfaces of the two bones that make up the CMC joint are removed.

Excision Arthroplasty

The traditional operation for treating CMC joint arthritis is excision arthroplasty. This method has been used for many years and has withstood the test of time. The purpose of excision arthroplasty is to remove the arthritic joint surfaces of the CMC joint and replace them with a cushion of material that will keep the bones separated. Most surgeons use a piece of tendon that has been rolled up and placed into the space created by removing the bone surfaces. During the healing phase after surgery, this tendon turns into tough scar tissue that forms a flexible connection between the bones, similar to a joint.

This operation is also combined with a reconstruction of the joint where tendons in the area are used to create a ligament sling between the metacarpal bone of the thumb and the carpal bone of the index finger. This helps hold the thumb in place and keeps the space between the bones from collapsing.

Boutonniere Deformity of the Finger

The tendons that allow each finger to straighten, the extensor tendons, at first appear to be relatively simple. But as the extensor tendon runs into the finger, it becomes a complex and elegantly balanced mechanism that allows very fine control of the motion of each joint of the finger. When this mechanism is damaged in certain areas, this balance can be destroyed. The result is a finger that doesn’t work properly. Over time, the imbalance can lead to contractures (tightening of the tendons) and other changes that result in a permanently crooked finger. The boutonniere deformity is one such problem that affects the extensor tendons of the finger.

This guide will help you understand:

• what parts of the finger are involved
• what causes the boutonniere deformity
• how the problem is treated
• what to expect from treatment

Anatomy

What parts of the finger are involved?

The extensor tendons begin as muscles that arise from the backside of the forearm bones. These muscles travel towards the hand, where they eventually connect to the extensor tendons before crossing over the back of the wrist joint. As they travel into the fingers, the extensor tendons become the extensor hood. The extensor hood flattens out to cover the top of the finger and sends out branches on each side that connect to the bones in the middle and end of the finger. When the extensor muscle contracts, it shortens and pulls on these attachments to straighten the finger.

Extensor Tendons

Small ligaments also connect the extensor hood with other tendons that travel into the finger to bend the finger. These connections help balance the motion of the finger so that all the joints of the finger work together, giving a smooth bending and straightening action. Problems arise when these ligaments become too tight or too loose.

Extensor Hood

The fingers are actually made up of three bones, called phalanges. The three phalanges in each finger are separated by two joints, called interphalangeal joints (IP joints). The joint near the end of the finger is called the distal IP joint (DIP joint). (Distal means further away.) The proximal IP joint (PIP joint), is the middle joint between the main knuckle and the DIP joint. (Proximal means closer in.) The IP joints of the fingers work like hinge joints when you bend and straighten your hand.

A boutonniere deformity occurs when disease or injury causes the PIP joint to become flexed (bent) and the DIP joint is pulled up into too much extension (hyperextension).

Causes

How does this condition occur?

The boutonniere deformity happens when the extensor tendon attachment to the middle phalanx is injured. This area is called the central slip. This tendon attachment may be injured in many ways. The central slip may simply be damaged when a cut occurs over the back of the middle finger joint (PIP joint). More commonly the central slip tears or pops off its attachment on the bone when the finger is jammed from the end, forcing the PIP joint to bend.

Central Slip

When a small amount of bone is pulled off with the tendon, doctors call it an avulsion fracture. The central slip can also be torn when the PIP joint is dislocated and the middle phalanx dislocates towards the palm.

Middle Phalanx Dislocates

Other conditions that affect the central slip can cause the boutonniere deformity. For example, prolonged inflammation in the PIP joint from rheumatoid arthritis stretches and eventually ruptures the central slip. A severe burn on the hand can damage the central slip. Another problem affecting the hand, called Dupuytren’s contracture, can weaken the central slip and produce the boutonniere deformity.

Related Document: First Choice Physical Therapy’s Guide to Dupuytren’s Contracture

The boutonniere deformity may not occur right away. It is the imbalance in the extensor hood that results from the torn tendon that eventually causes the deformity. Because the middle phalanx no longer is pulled by the central slip, the flexor tendon on the other side begins to bend the PIP joint without resistance. The lateral bands begin to slide down along the side of the finger where they continue to straighten the DIP joint. Eventually the finger becomes stiff in this position.

Symptoms

What do boutonniere deformities look and feel like?

Initially, the finger is painful and swollen around the PIP joint. The PIP joint may not straighten out completely under its own power. The finger can usually be straightened easily with help from the other hand. Eventually, the imbalance leads to the typical shape of the finger with a boutonniere deformity.

Typical Shape of Finger

Diagnosis

When you visit First Choice Physical Therapy, our Physical Therapist will take a history and do a physical examination of your finger. Usually the diagnosis is evident just from the physical examination.

Some patients may be referred to a doctor for further testing. X-rays may be required to see if there is an associated avulsion fracture, since this may change the recommended treatment. No other tests are required normally.

Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

What can be done for a boutonniere deformity of the finger?

Treatment for boutonniere deformity depends on whether the injury to the central slip is recognized immediately or if the deformity has been present for a long time. When the injury is the result of a laceration of the finger, a surgeon will usually repair the tendon as well as suture the skin.

Non-surgical Rehabilitation

If the injury to the central slip results from a simple avulsion (tearing) of the tendon from the bone, your Physical Therapist at First Choice Physical Therapy may recommend splinting of the PIP joint for approximately six weeks to allow the bone to heal and prevent the boutonniere deformity from occurring. The splint does allow the DIP joint to move throughout this period and it can be exercised to prevent stiffness.

While a simple homemade splint will work, there are many special designs that make it easier to wear your splint at all times. There are also splints that have been designed to be similar to springs. These splints can be used to gently stretch out a contracture of the PIP joint over several weeks. The spring applies gentle pressure all the time, and the PIP joint slowly straightens.

A splint may also be needed to keep the DIP joint from hyperextending. Newer styles are shaped like jewelry rings and are available in stainless steel, sterling silver, or gold.

Splinting and a rigorous exercise program may even work when the condition has been present for some time. Often our Physical Therapists will try six weeks of splinting with the spring-type splint and exercise to see if the deformity lessens to a tolerable limit before considering referring you for surgical evaluation. This is desirable before surgery to stretch out a PIP contracture before repairing or reconstructing the extensor hood.

Although time required for recovery is different for each patient, if nonsurgical treatment is successful, you may see improvement in eight to 12 weeks. After wearing a finger splint for up to eight weeks, our Physical Therapist may have you continue wearing the splint at night for at least another month. It is important during this time that the joints on either side of the splint be moved. Your Physical Therapist can design a personalized exercise program to allow you to properly and safely exercise your finger.

Post-surgical Rehabilitation

You’ll wear a splint or brace after surgery. A protective finger splint holds the PIP joint straight and is typically used for at least three weeks after surgery. We may apply a dynamic splint to help gradually straighten the PIP joint, and our Physical Therapy or occupational therapy treatments usually start three to six weeks after your surgery.

Although the time needed for recovery varies among patients, it is likely that you will need to attend Physical Therapy sessions for three to four months, and you should expect full recovery to take up to six months.

Our first few Physical Therapy treatments will focus on controlling the pain and swelling from surgery. Then our Physical Therapist will begin gentle range-of-motion exercise. Strengthening exercises usually follow eight to 10 weeks after surgery. We’ll instruct you in ways to grip and support items in order to do your tasks safely and with the least amount of stress on your finger joint. As with any surgery, you need to avoid doing too much, too quickly.

Eventually, our Physical Therapist will have you begin doing exercises designed to get your hand and fingers working in ways that are similar to your work tasks and daily activities. We will help you find ways to do your tasks that don’t put too much stress on your finger joint. Before your Physical Therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

Our goal is to help you keep your pain under control, improve your strength and range of motion, and regain your fine motor abilities with your hand and finger. When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Surgery

Surgery is required in some cases of boutonniere deformity. Best results occur when the PIP joint is limber, rather than stuck in a bent position. If the PIP joint is stuck in a bent position, surgeons usually wait before doing surgery to see if splinting will help stretch and straighten the PIP joint.

Joint Fixation

When the deformity is the result of a dislocation of the PIP joint, surgery may be required to repair the damaged structures and prevent the later development of a boutonniere deformity. A pin is usually placed through the PIP joint to fix the joint in place for up to three weeks. Patients wear a splint to protect the joint for another three weeks after surgery.

Soft Tissue Repair

In cases where the balance cannot be restored to a tolerable limit with splinting or by simply pinning the PIP joint, surgery may be required to reconstruct and rebalance the extensor hood. There are numerous types of operations that have been designed to try and rebalance the extensor hood. None is completely successful.

Surgery to repair the soft tissues that are contributing to a boutonniere deformity carries a relatively high risk of failure to achieve completely normal functioning of the extensor mechanism of the finger. All of the repair and reconstruction procedures are dependant on a well designed and rigorous exercise program following the surgery. A Physical Therapist or occupational therapist will work closely with you during your recovery.

Fusion

If past treatments, including surgery, do not stop inflammation or deformity in the joint, finger joint fusion may be recommended. Joint fusion is a procedure that binds the two joint surfaces of the finger together, keeping them from moving. Fusing the two joint surfaces together eases pain, makes the joint stable, and prevents additional joint deformity.

Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.

This article will help you understand:

• where the carpal tunnel is located
• how CTS develops
• what can be done for the condition

Anatomy

Where is the carpal tunnel, and what does it do?

The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the wrist on one side and the transverse carpal ligament on the other. (Ligaments connect bones together.) This opening forms the carpal tunnel.

The median nerve passes through the carpal tunnel into the hand. It gives sensation to the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the thenar muscles of the thumb.

Median Nerve

The thenar muscles help move the thumb and let you touch the pad of the thumb to the tips each of each finger on the same hand, a motion called opposition.

Opposition

The median nerve and flexor tendons pass through the carpel tunnel. The median nerve rests on top of the tendons, just below the transverse carpal ligament. The flexor tendons are important because they allow movement of the fingers, thumb, and hand, such as when grasping. The tendons are covered by a material called tenosynovium. The tenosynovium is a slippery covering that allows the tendons to glide next to each other as they are worked.

Causes

What causes CTS?

Any condition that makes the area inside the carpal tunnel smaller or increases the size of the tissues within the tunnel can lead to symptoms of CTS. For example, a traumatic wrist injury may cause swelling and extra pressure within the carpal tunnel. The area inside the tunnel can also be reduced after a wrist fracture or dislocation if the bone pushes into the tunnel.

Any condition that causes abnormal pressure in the tunnel can produce symptoms of CTS. Various types of arthritis can cause swelling and pressure in the carpal tunnel. Fractured wrist bones may later cause CTS if the healed fragments result in abnormal irritation on the flexor tendons.

Other conditions in the body can produce symptoms of CTS. Pregnancy can cause fluid to be retained, leading to extra pressure in the carpal tunnel. Diabetics may report symptoms of CTS, which may be from a problem in the nerve (called neuropathy) or from actual pressure on the median nerve. People with low thyroid function (called hypothyroidism) are more prone to problems of CTS.

The way people do their tasks can put them at more risk for problems of CTS. Some of these risks include:

• force
• posture
• wrist alignment
• repetition
• temperature
• vibration

One of these risks alone may not cause a problem. But doing a task that involves several factors may pose a greater risk. And the longer a person is exposed to one or more risks, the greater the possibility of having a problem with CTS. However, scientists believe that other factors such as smoking, obesity, and caffeine intake may actually be more important in determining whether a person is more likely to develop CTS.

In other instances, CTS can start when the tenosynovium thickens from irritation or inflammation. This thickening causes pressure to build inside the carpal tunnel. But the tunnel can’t stretch any larger in response to the added swelling, so the median nerve starts to squeeze against the transverse carpal ligament. If the pressure continues to build up, the nerve is eventually unable to function normally.

When pressure builds on the median nerve, the blood supply to the outer covering of the nerve slows down and may even be cut off. The medical term for this is ischemia. At first, only the outside covering of the nerve is affected. But if the pressure keeps building up, the inside of the nerve will start to become thickened. New cells (called fibroblasts) form within the nerve and create scar tissue. This is thought to produce the feelings of pain and numbness in the hand. If pressure is taken off right away, the symptoms will go away quickly. Pressure that isn’t eased right away can slow or even stop the chances for recovery.

Symptoms

What does CTS feel like?

One of the first symptoms of CTS is gradual tingling and numbness in the areas supplied by the median nerve. This is typically followed by dull, vague pain where the nerve gives sensation in the hand. The hand may begin to feel like it’s asleep, especially in the early morning hours after a night’s rest.

Sometimes pain may even spread up the arm to the shoulder. If the condition progresses, the thenar muscles of the thumb can weaken, causing the hand to be clumsy when picking up a glass or cup. If the pressure keeps building in the carpal tunnel, the thenar muscles may begin to shrink (atrophy).

Atrophy

Touching the pad of the thumb to the tips of the other fingers becomes difficult, making it hard to grasp items such as a steering wheel, newspaper, or telephone.

Diagnosis

How do health care providers identify the condition?

When you visit First Choice Physical Therapy, our Physical Therapist in Lynn Haven and Panama City Beach begins the evaluation by obtaining a history of the problem, followed by a thorough physical examination. Your description of the symptoms and the physical examination are the most important parts in the diagnosis of CTS. Commonly, patients will complain first of waking in the middle of the night with pain and a feeling that the whole hand is asleep.

Careful investigation usually shows that the little finger is unaffected. This can be a key piece of information to make the diagnosis. If you awaken with your hand asleep, pinch your little finger to see if it is numb also, and be sure to tell our Physical Therapist if it is or isn’t. Other complaints include numbness while using the hand for gripping activities, such as sweeping, hammering, or driving.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

When you begin your Physical Therapy in Lynn Haven and Panama City Beach, our Physical Therapist will recommend that you change or stop the activities that are causing your symptoms if at all possible. Avoid repetitive hand motions, heavy grasping, holding onto vibrating tools, and positioning or working with your wrist bent down and out. If you smoke, talk to your doctor about ways to help you quit. Lose weight if you are overweight. Reduce your caffeine intake.

Our Physical Therapist will often have you wear a wrist brace. This sometimes decreases the symptoms in the early stages of CTS. A brace keeps the wrist in a resting position, not bent back or bent down too far. When the wrist is in this position, the carpal tunnel is as big as it can be, so the nerve has as much room as possible inside the carpal tunnel. A brace can be especially helpful for easing the numbness and pain felt at night because it can keep your hand from curling under as you sleep. The wrist brace can also be worn during the day to calm symptoms and rest the tissues in the carpal tunnel.

The main focus of our treatment is to reduce or eliminate the cause of pressure in the carpal tunnel. Our Physical Therapist may check your workstation and the way you do your work tasks. We may provide suggestions about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems. Our Physical Therapist may also begin treatments to reduce inflammation and to encourage normal gliding of the tendons and median nerve within the carpal tunnel.

Although time required for recovery is different for every patient, as a general rule, you may see improvement in four to six weeks. We may ask you to continue wearing your wrist splint at night to control symptoms and keep your wrist from curling under as you sleep. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions, heavy grasping, and vibration in the hand.

Post-surgical Rehabilitation

It generally takes longer to recover after open carpal tunnel release. Pain and symptoms usually begin to improve, but you may have tenderness in the area of the incision for several months after surgery.

Patients who wait too long to seek medical advice sometimes have difficulty adjusting after surgery. Poor coping skills in the presence of persistent pain and numbness may result in disappointment or dissatisfaction with the results of surgery. Recovery may take longer than expected when nerve damage is severe. In some cases, symptoms are not entirely alleviated.

When the stitches are removed, you may begin your Physical Therapist program. Our treatments are used at first to ease pain and inflammation. Our Physical Therapist may apply gentle massage to the incision to help reduce sensitivity in and around the incision and limit scar tissue from building up. We will show you some special exercises that you can do to encourage normal gliding of the tendons and median nerve within the carpal tunnel.

As you progress, our therapist will give you exercises to help strengthen and stabilize the muscles and joints in the hand, wrist, and arm. We use other exercises to improve fine motor control and dexterity of the hand. Our Physical Therapist will also work with you to help you do your daily and work activities safely and with the least amount of strain on your wrist and hand.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Physician Review

If your symptoms started after a traumatic wrist injury, your doctor may order X-rays to check for a fractured bone.

If more information is needed to make the diagnosis, electrical studies of the nerves in the wrist may be requested by your doctor. Several tests are available to see how well the median nerve is functioning, including nerve conduction velocity (NCV) test. This test measures how fast nerve impulses move through the nerve.

Anti-inflammatory medications may also help control the swelling and reduce symptoms of CTS. Ensure that you consult with your doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication. These include common over-the-counter medications such as ibuprofen and aspirin. Oral steroid medication may also offer some relief. In some studies, high doses of vitamin B-6 have been shown to help in decreasing CTS symptoms. Some types of exercises have also shown to help prevent or at least control the symptoms of CTS.

If these simple measures fail to control your symptoms, an injection of cortisone into the carpal tunnel may be suggested. This medication is used to reduce the swelling in the tunnel and may give temporary relief of symptoms.

A cortisone injection may help ease symptoms and can aid your doctor in making a diagnosis. If you don’t get even temporary relief from the injection, it could indicate that some other problem is causing your symptoms. When your symptoms do go away after the injection, it’s likely they are coming from a problem within the carpal tunnel. Some doctors feel this is a signal that a surgical release of the transverse carpal ligament would have a positive result.

Surgery

If all attempts to control your symptoms fail, surgery may be suggested to reduce the pressure on the median nerve. Surgery may not be advised if there is advanced nerve damage. Persistent pain and numbness may not go away with surgery. If you have muscle atrophy and weakness and/or loss of sensation, you may not be a good candidate for surgery.

And surgery may not be advised if electrodiagnostic studies show normal results. In such cases, patients seeking pain relief will be advised to continue with conservative (nonoperative) care.

When surgery is needed, several different surgical procedures have been designed to relieve pressure on the median nerve. By releasing the pressure on the nerve, the blood supply to the nerve improves, and most people get relief of their symptoms. However, if the nerve pressure has been going on a long time, the median nerve may have thickened and scarred to the point that recovery after surgery is much slower.

The standard surgery for CTS is called open release. Open surgical procedures use a small skin incision. In open release for CTS, an incision as small as one inch can be made down the front of the wrist and palm. By creating an open incision, the surgeon is able to see the wrist structures and to carefully do the operation. The surgeon cuts the transverse carpal ligament in order to take pressure off the median nerve.

After dividing the transverse carpal ligament, the surgeon stitches just the skin together and leaves the loose ends of the transverse carpal ligament separated. The loose ends are left apart to keep pressure off the median nerve. Eventually, the gap between the two ends of the ligament fills in with scar tissue.

Dividing Transverse Carpal Ligament

Endoscopic Release

Some surgeons are using a newer procedure called endoscopic carpal tunnel release. The surgeon merely nicks the skin in order to make one or two small openings for inserting the endoscope. An endoscope is a thin, fiber-optic TV camera that allows the surgeon to see inside the carpal tunnel as the transverse carpal ligament is carefully released.

Upon inserting the endoscope, the surgeon can see the wrist structures on a TV screen. A special knife is used to cut only the transverse carpal ligament. The palmar fascia and the skin over the wrist are not disturbed.

As in open release, the loose ends of the transverse carpal ligament are left apart after endoscopic release to keep pressure off the median nerve. The gap eventually fills in with scar tissue.

Guyon’s Canal Syndrome

Guyon’s canal syndrome is an entrapment of the ulnar nerve as it passes through a tunnel in the wrist called Guyon’s canal. This problem is similar to carpal tunnel syndrome but involves a completely different nerve. Sometimes both conditions can cause a problem in the same hand.

This guide will help you understand:

• how Guyon’s canal syndrome develops
• how doctors diagnose the condition
• what can be done to treat the problem

Anatomy

Where is the ulnar nerve, and what does it do?

The ulnar nerve actually starts at the side of the neck, where the individual nerve roots exit the spine through small openings between the vertebrae. The nerve roots then join together to form three main nerves that travel down the arm to the hand, one of which is the ulnar nerve.

Nerve Roots

After leaving the side of the neck, the ulnar nerve travels through the armpit and down the arm to the hand and fingers. As it crosses the wrist, the ulnar nerve and ulnar artery run through the tunnel known as Guyon’s canal.

Guyon’s Canal

This tunnel is formed by two bones (the pisiform and hamate) and the ligament that connects them. After passing through the canal, the ulnar nerve branches out to supply feeling to the little finger and half the ring finger. Branches of this nerve also supply the small muscles in the palm and the muscle that pulls the thumb toward the palm.

Tunnel Formed by Two Bones

The hamate bone forms one side of Guyon’s canal. This bone has a small hook-shaped spur that sticks out to provide an attachment for several wrist ligaments. Known as the hook of hamate, this small bone can break off and press against the ulnar nerve within Guyon’s canal.

Causes

Why do I have this problem?

Guyon’s canal syndrome has several causes. Overuse of the wrist from heavy gripping, twisting, and repeated wrist and hand motions can cause symptoms. Working with the hand bent down and outward can squeeze the nerve inside Guyon’s canal.

Constant pressure on the palm of the hand can produce symptoms. This is common in cyclists and weight lifters from the pressure of gripping. It can also happen after running a jackhammer or when using crutches.

Pressure or irritation of the ulnar nerve can cause symptoms of Guyon’s canal syndrome. A traumatic wrist injury may cause swelling and extra pressure on the ulnar nerve within the canal. Arthritis in the wrist bones and joints may eventually irritate and compress the ulnar nerve. In rare cases, the ulnar artery that travels right beside the nerve may be damaged and form a blood clot. The symptoms caused by the clot mimic Guyon’s canal syndrome. The lack of blood supply to the ulnar nerve is believed to cause the symptoms.

As mentioned earlier, a fractured hamate bone in the wrist can pinch the nerve inside Guyon’s canal. This bone is sometimes fractured when golfers club the ground instead of the golf ball and when baseball players are batting.

Fractured Hamate Bone

Symptoms

What does Guyon’s canal syndrome feel like?

Symptoms usually begin with a feeling of pins and needles in the ring and little fingers, which is often noticed in the early morning when first awakening. This may progress to a burning pain in the wrist and hand followed by decreased sensation in the ring and little fingers. The hand may become clumsy when the muscles controlled by the ulnar nerve become weak. Weakness can affect the small muscles in the palm of the hand and the muscle that pulls the thumb into the palm. Gradual weakness in these muscles makes it hard to spread your fingers and pinch with your thumb.

This syndrome is much less common than carpal tunnel syndrome (CTS), yet both conditions can occur at the same time. The numbness caused by these two syndromes affects the hand in different locations. When the median nerve is compressed in CTS, pain and numbness spread into the thumb, index finger, middle finger, and half of the ring finger. Compression of the ulnar nerve in Guyon’s canal syndrome usually causes numbness in the pinky and half of the ring finger.

Diagnosis

When you visit First Choice Physical Therapy, diagnosis of Guyon’s canal syndrome begins with a careful history and physical examination by our Physical Therapist. Compression can occur at several areas along the ulnar nerve, and we will test to find exactly where the nerve is being affected.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

When you begin your Physical Therapy program, our Physical Therapist will recommend that you change or stop the activities that might be causing your symptoms if at all possible. Avoid repetitive hand motions, heavy grasping, resting your palm against hard surfaces, and positioning or working with your wrist bent down and out.

We may have you wear a wrist brace to decrease the symptoms in the early stages of Guyon’s canal syndrome. A brace keeps the wrist in a resting position (neither bent back nor bent down too far). It can be especially helpful for easing the numbness and pain felt at night because it can keep your hand from curling under as you sleep. The wrist brace can also be worn during the day to calm symptoms and rest the tissues within the canal.

We may also recommend anti-inflammatory medications. Common over-the-counter medications, such as ibuprofen and aspirin, can also help control the symptoms of Guyon’s canal syndrome.

The main focus of your First Choice Physical Therapy treatment is to reduce or eliminate the cause of pressure on the ulnar nerve. Our Physical Therapist may check your workstation and the way you do your work tasks. We will provide suggestions about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems.

Although the rate of recovery is different for each patient, if nonsurgical treatment is successful, you may see improvement in four to six weeks. We may recommend that you continue wearing your wrist splint at night to control symptoms and keep your wrist from curling under as you sleep. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions, heavy grasping, and pressure on the palm of the hand.

Post-surgical Rehabilitation

Your hand will be wrapped in a bulky dressing  following surgery. When you begin your recovery, our Physical Therapist will advise you to take time during the day to support your arm with your hand elevated above the level of your heart. We will encourage you to move your fingers and thumb occasionally during the day. Keep the dressing on your hand until you return to the surgeon. Avoid getting the stitches wet. Your stitches will probably be removed 10 to 14 days after surgery.

Pain and numbness generally begin to improve after surgery, but you may have tenderness in the area of the incision for several months.

Although each patient recovers at a different rate, you will probably need to attend our occupational or Physical Therapy sessions for six to eight weeks, and you should expect full recovery to take several months. We will start by having you begin doing active hand movements and range-of-motion exercises. Our Physical Therapistss also use ice packs, soft-tissue massage, and hands-on stretching to help with your range of motion. When your stitches are removed, we may suggest that you start carefully strengthening your hand by squeezing and stretching special putty.

As you progress, our Physical Therapist will give you exercises to help strengthen and stabilize the muscles and joints in the hand. We use other exercises to improve fine motor control and dexterity. Some of the exercises you’ll do are designed get your hand working in ways that are similar to your work tasks and sport activities.

Our Physical Therapist will help you find ways to do your tasks that don’t put too much stress on your hand and wrist. Before your Physical Therapy sessions end, your Physical Therapist will teach you a number of ways to avoid future problems.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Physician Review

If it is unclear on physical examination where the nerve is being squeezed, electrical studies may be ordered to try to find the area of compression.

Nerve conduction velocity (NCV) is a test  that measures how fast nerve impulses travel along the nerve.

Your doctor might want this test to be done to help pinpoint your problem. Special tests may be required to study the nerve.

The NCV is sometimes combined with an electromyogram (EMG). The EMG is done by testing the muscles of the forearm that are controlled by the ulnar nerve to determine if they are working properly.

If the test shows a problem with the muscle, the nerve that goes to the muscle might not be working correctly.

This is similar to checking whether the wiring in a lamp is working.

If the light still doesn’t work after you’ve put in a new bulb, you can begin to tell if there’s a problem in the wiring.

If your symptoms started after a traumatic wrist injury, X-rays may be needed to check for a fractured or dislocated bone.

Surgery

If all attempts to control your symptoms fail, surgery may be suggested to reduce the pressure on the ulnar nerve.

The surgery can be done using a general anesthetic (one that puts you to sleep) or a regional anesthetic.

A regional anesthetic blocks the nerves going to only a portion of the body. Injection of medications similar to lidocaine are used to block the nerves for several hours.

This type of anesthesia could be an axillary block (only the arm is asleep) or a wrist block (only the hand is asleep).

The surgery can also be performed by simply injecting lidocaine around the area of the incision.

Once you have anesthesia, your surgeon will make sure the skin of your palm is free of infection by cleaning the skin with a germ-killing solution.

A small incision is made in the palm of the hand over the spot where the nerve goes through the canal.

The incision makes it possible for the surgeon to see the ligament that crosses over the top of the ulnar nerve.

This ligament forms the roof over the top of Guyon’s canal.

Once in view, this ligament is reduced by using a scalpel or scissors.

Ligament is Reduced

Care is taken to make sure that the ulnar nerve is out of the way and protected. By cutting the ligament, pressure is taken off the ulnar nerve.

Upon releasing the ligament, the surgeon sutures just the skin together and leaves the loose ends of the ligament separated. The loose ends are left apart to keep pressure off the ulnar nerve. Eventually, the gap between the two ends of the ligament fills in with scar tissue. This surgery can usually be done as an outpatient procedure, meaning you can leave the hospital the same day.

Mallet Finger Injuries

When you think about how much we use our hands, it’s not hard to understand why injuries to the fingers are common. Most of these injuries heal without significant problems. One such injury is an injury to the distal interphalangeal, or DIP, joint of the finger. This joint is commonly injured during sporting activities such as baseball. If the tip of the finger is struck with the ball, the tendon that attaches to the small bone underneath can be injured. Untreated, this can cause the end of the finger to fail to straighten completely, a condition called mallet finger.

This article will help you understand:

• what parts make up the DIP finger joint
• what types of injuries affect this joint
• how the injury is treated
• what to expect from treatment

Anatomy

What parts of the finger are involved?

The finger joints work like hinges when the fingers bend and straighten. The main knuckle joint is the metacarpophalangeal joint (MCP joint). It is formed by the connection of the metacarpal bone in the palm of the hand with the first finger bone, or proximal phalanx. Each finger has three phalanges, or small bones, separated by two interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint).

Finger Joints

The extensor tendon is attached to the base of the distal phalanx. When it tightens, the DIP joint straightens. Another tendon, the flexor tendon, is attached to the palm of the finger. When it pulls, the DIP joint bends.

Extensor Tendon

Causes

How do these injuries of the DIP joint occur?

A mallet finger results when the extensor tendon is cut or torn from the attachment on the bone. Sometimes, a small fragment of bone may be pulled, or avulsed, from the distal phalanx. The result is the same in both cases: the end of the finger droops down and cannot be straightened.

Symptoms

What do mallet finger injuries look and feel like?

Initially, the finger is painful and swollen around the DIP joint. The end of the finger is bent and cannot be straightened voluntarily. The DIP joint can be straightened easily with help from the other hand. If the DIP joint gets stuck in a bent position and the PIP joint (middle knuckle) extends, the finger may develop a deformity that is shaped like a swan’s neck. This is called a swan neck deformity.

Swan Neck Deformity

Diagnosis

What tests will my health care provider do?

When you visit First Choice Physical Therapy, our Physical Therapist will take a history and do a physical examination. Usually the diagnosis of mallet finger is clearly evident from the physical exam.

Some patients may be referred to a doctor for further diagnosis. X-rays may be required to see if there is an associated avulsion fracture since this may change the recommended treatment. No other tests are normally required.

Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Treatment for mallet finger is usually nonsurgical. If there is no fracture, then the assumption is that the end of the tendon has been ruptured, allowing the end of the finger to droop.

When you begin your Physical Therapy program, our Physical Therapist may recommend continuous splinting for approximately six weeks followed by six weeks of nighttime splinting.

Usually this will result in satisfactory healing and allow the finger to extend.

The key is continuous splinting for the first six weeks.

The splint holds the DIP joint in full extension and allows the ends of the tendon to move as close together as possible.

As healing occurs, scar formation repairs the tendon.

If the splint is removed and the finger is allowed to bend, the process is disrupted and must start all over again. The splint must remain on at all times, even in the shower.

While a simple homemade splint will work, your Physical Therapist can provide you with a recommendation for the type that will be most beneficial to your recovery. There are many splints that have been designed to make it easier to wear at all times. In some extreme cases where the patient has to use the hands to continue working (such as a surgeon), a metal pin can be placed inside the bone across the DIP joint to act as an internal splint allowing the patient to continue to use the hand. The pin is removed at six weeks.

Splinting may even work when the injury is quite old. In this case, we will usually splint the finger for about eight to 12 weeks to see if the drooping lessens to a tolerable amount before considering surgery.

When the injury is new, we may recommend that the DIP joint be splinted nonstop in full extension for six to eight weeks. A mallet finger that is up to three months old may require splinting in full extension for eight to 12 weeks. The splint is then worn for shorter periods that include nighttime splinting for six more weeks.

Skin problems are common with prolonged splinting. We advise that you monitor the skin under your splint to avoid skin breakdown. If problems arise, our Physical Therapist may recommend new or different splint. Nearby joints may be stiff after keeping the finger splinted for this length of time. Your Physical Therapist can design a program of Physical Therapy and exercise to assist in finger range of motion and to reduce joint stiffness.

Post-surgical Rehabilitation

Rehabilitation after surgery for mallet finger focuses mainly on keeping the other joints mobile and preventing stiffness from disuse. Our Physical Therapy and occupational therapists can teach you home exercises to make sure your other joints do not become stiff. After the surgical pin has been removed, we may gradually introduce exercises to strengthen the finger and increase flexibility.

At First Choice Physical Therapy, our goal is to help speed your recovery so that you can more quickly return to your everyday activities. When your recovery is well under way, regular visits to our office will end. We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program..

Surgery

DIP Fixation

Surgical treatment is reserved for unique cases.

The first is when the result of nonsurgical treatment is intolerable.

If the finger droops too much, the tip of the finger gets caught as you try to put your hand in a pocket.

This can be quite a nuisance. If this occurs, the tendon can be repaired surgically, or the joint can be fixed in place.

A surgical pin acts like an internal cast to keep the DIP joint from moving so the tendon can heal.

The pin is removed after six to eight weeks.

Fracture Pinning

The other case is when there is a fracture associated with the mallet finger.

If the fracture involves enough of the joint, it may need to be repaired.

This may require pinning the fracture. If the damage is too severe, it may require fusing the joint in a fixed position.

Pinning the Fracture

Finger Joint Fusion

If the damage cannot be repaired using pin fixation, finger joint fusion may be needed. Joint fusion is a procedure that binds the two joint surfaces of the finger together, keeping them from rubbing on one another. Fusing the two joint surfaces together eases pain, makes the joint stable, and prevents additional joint deformity.

Few structures of the human anatomy are as unique as the hand. The hand needs to be mobile in order to position the fingers and thumb. Adequate strength forms the basis for normal hand function. The hand also must be coordinated to perform fine motor tasks with precision. The structures that form and move the hand require proper alignment and control in order for normal hand function to occur.

This guide will help you understand:

• what parts make up the hand
• how those parts work together

There are 27 bones within the wrist and hand. The wrist itself contains eight small bones, called carpals. The carpals join with the two forearm bones, the radius and ulna, forming the wrist joint. Further into the palm, the carpals connect to the metacarpals. There are five metacarpals forming the palm of the hand. One metacarpal connects to each finger and thumb. Small bone shafts called phalanges line up to form each finger and thumb.

The main knuckle joints are formed by the connections of the phalanges to the metacarpals. These joints are called the metacarpophalangeal joints  (MCP joints). The MCP joints work like a hinge when you bend and straighten your fingers and thumb.

The three phalanges in each finger are separated by two joints, called interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the  proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint). The thumb only has one IP joint between the two thumb phalanges. The IP joints of the digits also work like hinges when you bend and straighten your fingers and thumb.

The joints of the hand, fingers, and thumb are covered on the ends with articular cartilage . This white, shiny material has a rubbery consistency. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to facilitate motion. There is articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate.

Ligaments are tough bands of tissue that connect bones together. Two important structures, called collateral ligaments, are found on either side of each finger and thumb joint. The function of the collateral ligaments is to prevent abnormal sideways bending of each joint.

In the PIP joint (the middle joint between the main knuckle and the DIP joint), the strongest ligament is the volar plate. This ligament connects the proximal phalanx to the middle phalanx on the palm side of the joint. The ligament tightens as the joint is straightened and keeps the PIP joint from bending back too far (hyperextending). Finger deformities can occur when the volar plate loosens from disease or injury.

The tendons that allow each finger joint to straighten are called the extensor tendons. The extensor tendons of the fingers begin as muscles that arise from the backside of the forearm bones. These muscles travel towards the hand, where they eventually connect to the extensor tendons before crossing over the back of the wrist joint. As they travel into the fingers, the extensor tendons become the extensor hood. The extensor hood flattens out to cover the top of the finger and sends out branches on each side that connect to the bones in the middle and end of the finger.

The place where the extensor tendon attaches to the middle phalanx is called the central slip. When the extensor muscles contract, they tug on the extensor tendon and straighten the finger. Problems occur when the central slip is damaged, as can happen with a tear.

Most of the small muscles that work the thumb and pinky finger start on the carpal bones. These muscles connect in ways that allow the hand to grip and hold. Two muscles allow the thumb to move across the palm of the hand, an important function called thumb opposition

The smallest muscles that originate in the wrist and hand are called the intrinsic muscles. The intrinsic muscles guide the fine motions of the fingers by getting the fingers positioned and holding them steady during hand activities.

All of the nerves that travel to the hand and fingers begin together at the shoulder: the radial nerve, the median nerve, and the ulnar nerve. These nerves carry signals from the brain to the muscles that move the arm, hand, fingers, and thumb. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature.

The radial nerve runs along the thumb-side edge of the forearm. It wraps around the end of the radius bone toward the back of the hand. It gives sensation to the back of the hand from the thumb to the third finger. It also supplies the back of the thumb and just beyond the main knuckle of the back surface of the ring and middle fingers.

The median nerve travels through a tunnel within the wrist called the carpal tunnel. This nerve gives sensation to the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the thenar muscles of the thumb. The thenar muscles help move the thumb and let you touch the pad of the thumb to the tips each of each finger on the same hand, a motion called opposition.

The ulnar nerve travels through a separate tunnel, called Guyon’s canal. This tunnel is formed by two carpal bones, the pisiform and hamate, and the ligament that connects them. After passing through the canal, the ulnar nerve branches out to supply feeling to the little finger and half the ring finger. Branches of this nerve also supply the small muscles in the palm and the muscle that pulls the thumb toward the palm.

Ulnar Nerve

The nerves that travel to the hand are subject to problems. Constant bending and straightening of the wrist and fingers can lead to irritation or pressure on the nerves within their tunnels and cause problems such as pain, numbness, and weakness in the hand, fingers, and thumb.

Traveling along with the nerves are the large vessels that supply the hand with blood. The largest artery is the radial artery that travels across the front of the wrist, closest to the thumb. The radial artery is where the pulse is taken in the wrist. The ulnar artery runs next to the ulnar nerve through Guyon’s canal (mentioned earlier). The ulnar and radial arteries arch together within the palm of the hand, supplying the front of the hand, fingers, and thumb. Other arteries travel across the back of the wrist to supply the back of the hand, fingers, and thumb.

The hand is formed of numerous structures that have an important role in normal hand function. Conditions that change the way these structures work can greatly impact whether the hand functions normally. When our hands are free of problems, it’s easy to take the complex anatomy of the hand for granted.

Our feet are constantly under stress. It’s no wonder that 80 percent of us will have some sort of problem with our feet at some time or another. Many things affect the condition of our feet: activity level, occupation, other health conditions, and perhaps most importantly, shoes. Many of the problems that arise in the foot are directly related to shoes, so it is very important to choose shoes that are good for your feet.

The foot is an incredibly complex mechanism. This introduction to the anatomy of the foot will not be exhaustive but rather highlight the structures that relate to conditions and surgical procedures of the foot.

This guide will help you understand:

• what parts make up the foot
• how the foot works

The important structures of the foot can be divided into several categories. These include:

• bones and joints
• ligaments and tendons
• muscles
• nerves
• blood vessels

Bones and Joints

The skeleton of the foot begins with the talus, or ankle bone, that forms part of the ankle joint. The two bones of the lower leg, the large tibia and the smaller fibula, come together at the ankle joint to form a very stable structure known as a mortise and tenon joint.

The mortise and tenon structure is well known to carpenters and craftsmen who use this joint in the construction of everything from furniture to large buildings. The arrangement is very stable.

The two bones that make up the back part of the foot (sometimes referred to as the hindfoot) are the talus and the calcaneus, or heelbone. The talus is connected to the calcaneus at the subtalar joint.

The ankle joint allows the foot to bend up and down. The subtalar joint allows the foot to rock from side to side.

Foot Rocks Side to Side

Just down the foot from the ankle is a set of five bones called tarsal bones that work together as a group. These bones are unique in the way they fit together. There are multiple joints between the tarsal bones. When the foot is twisted in one direction by the muscles of the foot and leg, these bones lock together and form a very rigid structure. When they are twisted in the opposite direction, they become unlocked and allow the foot to conform to whatever surface the foot is contacting.

The tarsal bones are connected to the five long bones of the foot called the metatarsals. The two groups of bones are fairly rigidly connected, without much movement at the joints.

Finally, there are the bones of the toes, the phalanges. The joints between the metatarsals and the first phalanx is called the metatarsophalangeal joint (MTP). These joints form the ball of the foot, and movement in these joints is very important for a normal walking pattern.

Not much motion occurs at the joints between the bones of the toes. The big toe, or hallux, is the most important toe for walking, and the first MTP joint is a common area for problems in the foot.

Ligaments and Tendons

Ligaments are the soft tissues that attach bones to bones. Ligaments are very similar to tendons. The difference is that tendons attach muscles to bones. Both of these structures are made up of small fibers of a material called collagen. The collagen fibers are bundled together to form a rope-like structure. Ligaments and tendons come in many different sizes, and like rope, are made up of many smaller fibers. The thicker the ligament (or tendon) the stronger the ligament (or tendon) is.

Collagen

The large Achilles tendon is the most important tendon for walking, running, and jumping. It attaches the calf muscles to the heel bone to allow us to raise up on our toes. The posterior tibial tendon attaches one of the smaller muscles of the calf to the underside of the foot. This tendon helps support the arch and allows us to turn the foot inward. The toes have tendons attached that bend the toes down (on the bottom of the toes) and straighten the toes (on the top of the toes). The anterior tibial tendon allows us to raise the foot. Two tendons run behind the outer bump of the ankle (called the lateral malleolus) and help turn the foot outward.

Many small ligaments hold the bones of the foot together. Most of these ligaments form part of the joint capsule around each of the joints of the foot. A joint capsule is a watertight sac that forms around all joints. It is made up of the ligaments around the joint and the soft tissues between the ligaments that fill in the gaps and form the sac.

Muscles

Most of the motion of the foot is caused by the stronger muscles in the lower leg whose tendons connect in the foot. Contraction of the muscles in the leg is the main way that we move our feet to stand, walk, run, and jump.

There are numerous small muscles in the foot. While these muscles are not nearly as important as the small muscles in the hand, they do affect the way that the toes work. Damage to some of these muscles can cause problems.

Most of the muscles of the foot are arranged in layers on the sole of the foot (the plantar surface). There they connect to and move the toes as well as provide padding underneath the sole of the foot.

Nerves

The main nerve to the foot, the tibial nerve, enters the sole of the foot by running behind the inside bump on the ankle, the medial malleolus.

Tibial Nerve

This nerve supplies sensation to the toes and sole of the foot and controls the muscles of the sole of the foot. Several other nerves run into the foot on the outside of the foot and down the top of the foot. These nerves primarily provide sensation to different areas on the top and outside edge of the foot.

Blood Vessels

The main blood supply to the foot, the posterior tibial artery, runs right beside the nerve of the same name. Other less important arteries enter the foot from other directions.

One of these arteries is the dorsalis pedis that runs down the top of the foot. You can feel your pulse where this artery runs in the middle of the top of the foot.

Welcome to First Choice Physical Therapy’s patient resource about Fibromyalgia.  The following is an educational overview of Fibromyalgia and common treatment options.

Fibro = fibrous tissues (ligaments that attach to bone and tendons that attach muscle to bone)
myo = muscle
algia = the Greek word for pain

Fibromyalgia, though common, is a disease that’s not well understood. It involves pain throughout the body, with especially tender spots near certain joints. The pain stops people with fibromyalgia from functioning normally, partly because they feel exhausted most of the time. Fibromyalgia is a chronic (meaning long-lasting) condition that usually requires many years of treatment. It can occur along with other forms of arthritis or all by itself. It can occur after an injury or out of the blue. Most people diagnosed with fibromyalgia are women in their middle years.

This guide will help you understand:

• how doctors diagnose fibromyalgia
• what can be done for the condition

Where does fibromyalgia develop?

Pain in fibromyalgia is present in soft tissues throughout the body. Pain and stiffness concentrate in spots such as the neck and lower back. The tender spots don’t seem to be inflamed. Most tests show nothing out of the ordinary in the anatomy of people with fibromyalgia.

Why does fibromyalgia develop?

The causes of fibromyalgia are unknown, but one thing is for sure: you’re not making it up. Many sufferers have been told that it’s all in your head by family members or other doctors. It is true that people with fibromyalgia are often depressed, and that stress worsens symptoms. But depression and stress don’t seem to be the driving forces behind the disease.

Fibromyalgia often occurs along with other conditions, such as other forms of arthritis, Lyme disease, or thyroid problems. It can also develop after a serious injury. These problems may cause the fibromyalgia to develop.

About 80 percent of all fibromyalgia patients report serious problems sleeping. Because fibromyalgia is so strongly connected to sleep disturbance, in some cases it is possible that the sleep disturbance is the major cause. In fact, studies have produced fibromyalgia-like symptoms in healthy adults by disrupting their sleep patterns.

There is some evidence that fibromyalgia is linked with autoimmune disorders, in which your immune system attacks the tissues of your own body. Sufferers have lower pain thresholds and lower levels of serotonin, a brain chemical involved in pain, sleep, and mood. However, it’s unclear whether these conditions cause the fibromyalgia or are a result of the disease.

What does fibromyalgia feel like?

The symptoms of fibromyalgia are long lasting and intense. However, they can vary from day to day. Symptoms include:

• pain and stiffness throughout the body, with especially tender points near certain joints
• a feeling of exhaustion that sleep often does not help
• sleep problems
• tension headaches
• numbness or tingling in the arms, hands and/or feet
• a feeling of swelling in the hands, although this is not confirmed in physical exams
• constipation and diarrhea along with abdominal pain (known as irritable bowel syndrome)
• intense PMS pains in women
• depression
• interrupted sleep or awakening still feeling tired
• tiredness
• morning stiffness
• swelling sensation
• bothered by light, odors, and/or noise
• poor concentration and memory loss
• irritable bowel syndrome
• changes in vision
• sore glands

How do health care providers identify fibromyalgia?

Blood tests and X-rays don’t show fibromyalgia in your body. However, your health care provider may do these tests to rule out other conditions. There are really only two tools used to diagnose fibromyalgia. One is your history of symptoms. The other involves putting pressure on eighteen tender point sites. If you feel pain in eleven of these eighteen sites, you are considered to have fibromyalgia. (However, it is still possible that you can have the disease with pain in fewer sites.)

In some patients, doctors may recommend X-rays to look at the bones near painful spots. The X-rays will not show fibromyalgia but are used to make sure there are no other causes of your pain. Other special tests such as electromyograms, which measure the contraction of muscles, may be used to try to determine if the muscles show abnormalities. Most of the time these tests are negative. A sleep history, and possibly a sleep study, could be important to the diagnosis.

Chronic fatigue syndrome (CFS) may need to be ruled out. CFS is another disease that is difficult to diagnose and has puzzled doctors for many years. CFS and fibromyalgia share many symptoms, especially the severe exhaustion. The major difference is that CFS causes flu-like symptoms, such as low-grade fevers, sore throats, and swollen lymph nodes.

What can be done for the condition?

When you visit First Choice Physical Therapy, the first step in the treatment of your fibromyalgia is to help you understand this complex and frustrating disease. Many patients are relieved to learn that the disease is not all in their head, and that our Physical Therapists can develop a program to help manage pain and exhaustion.

It is uncertain whether fibromyalgia is ever cured. Like many chronic diseases, the symptoms of the disease can be controlled. The successful treatment of fibromyalgia is very much a joint effort between doctor, Physical Therapist and patient.

You must be willing to make lifestyle changes as well as give attention to your psychological health to help control the symptoms. Other treatments or lifestyle changes we may recommend include:

• exercise
• biofeedback
• meditation
• acupuncture
• pain medication
• anti-inflammatory drugs
• cortisone injected into painful points
• ultrasound treatments
• massage
• heat for temporary pain relief
• counseling to help deal with the symptoms

Any treatment program will likely last for many years but patients do get better. At First Choice Physical Therapy, our goal is to help you keep your pain under control so that you can enjoy your normal activities and lifestyle. Recent studies show that about 25 percent of patients treated for fibromyalgia were in remission at the end of two years. Many others have reduced their pain to tolerable levels.