Wrapping up the “Tour of the Upper Extremities”

Erik Dalton, PhD

Happy New Year! Boy, they just seem to go faster every year. Let’s begin the January/ February 2007 newsletter brigade with a twist of irony–wrapping up the last edition of our 2006 “Tour of the Upper Extremities”. I’d planned on starting again with the shoulder and writing on soft tissue techniques that follow the mobilization routines but have decided to surprise you (and me) in the next issue.

Wrist and Hand

Both professional and recreational athletes depend on their hands, wrists and fingers for proper strength, grip and range of motion for optimal performance. Sprains commonly occur during active sports or household falls. The severity of minor injuries is often minimized under the blanket category of a “sprain” causing clients to not seek help for their problem. Sadly, a true sprain can take weeks to heal leaving adherent scar tissue that glues bony structures and causes structural malalignments that are often difficult to fix.

Computer programmers, writers, artists, researchers, and machinists often suffer overuse syndromes familiar to most therapists such as trigger fingers, carpal tunnel and de Quervain syndromes. Traditional bodywork often focuses only on the soft tissue aspect of wrist and hand injuries when a more holistic approach may prove more successful. Restoration of proper wrist and hand biomechanics is crucial in preventing formation of secondary inflammatory responses caused by shearing forces as tendons move across malaligned bony structures. Bracing, including wrist supports, only conforms to postural abnormalities creating further tightness resulting in capsulitis, tendinosis, loss of flexibility and function. Any bony malalignments affecting tendons crossing the wrist can lead to compensatory problems such as carpal tunnel and elbow strains such as medial and lateral epicondylitis. The Myoskeletal goal is to restore joint play and alignment to the 27 bones in the hand and wrist allowing better soft tissue glide. The use of bones as levers to mobilize fibrotic ligaments and tendons is a very effective and safe way to create joint play and relieve hand and wrist pain.

Testing Made Easy

Many tests currently exist to identify motion restricted joints but I wish to share a few I have found particularly effective for treating the most common pain generators. To assess mobility (glide) of the triquetrum and pisiform bones, ask the client to touch the tip of the little finger (5th digit) with the tip of the thumb.

Next test the ring finger (4th digit) to the thumb. Weakness in ring finger’s opposition to the thumb results from malalignment of triquetrum and lunate. Weakness in the third finger’s opposition to the thumb indicates a malalignment of the scaphoid and lunate combination; whereas, weakness of the index finger’s opposition to the thumb indicates malalignment of the scaphoid bone.

newsletter Jan 2007

Phase two of the evaluation process requires that the client repeat each of the above tests. But this time the client holds each digit tightly to the thumb as the therapist (using moderate force) tries to separate the two. If this separation maneuver allows the circle of opposition to be broken, one should suspect a high clinical probability for bony misalignment.

After performing all the ‘digit-pulling’ tests to determine which carpals have lost glide and joint play, the therapist proceeds with the appropriate corrections. Since the lunate is the only carpal bone that tends to “stick” (and sometimes dislocate palmarly), it often compresses the flexor tendons and the median nerve. So, if the 4th digit (lunate) test was positive, start with the following correction.

newsletter Jan 2007

Lunate and Triquetrum Alignment

With the client’s elbow and wrist slightly flexed (palm up), therapist and clients’ fingers interlace allowing the therapist’s right thumb to glide superiorly past the pisiform until it bumps into the ulna.

By moving slightly medially—staying away from median nerve and transverse carpal ligament, the thumb contacts the proximal edge of the triquetrum and lunate. Concurrently, the left thumb glides superiorly to the scaphoid/radius junction.

Therapist extends and gently tractions the elbow while flexing the client’s wrist with the intention of driving a “wedge” between the radius/ulna and the proximal carpal row.

Holding with mild sustained anterior/inferior pressure, the client gently attempts wrist extension against therapist’s resistance to a count of five and relaxes.

Again, the therapist gently tractions the entire arm and hand while depressing the proximal row against the distal row to restore glide and joint play to all the carpals. Tough adhesions may require side to side wiggling of the arm and hand while maintaining traction.

This technique mobilizes the lunate dorsally while helping to separate scaphoid from the radius. Repeat three to five times and retest the ring fingers ability to oppose the thumb.

Mobilizing Proximal Carpal Row

Once motion has been restored to adhesive ligaments and the lunate repositioned, pronate the hand to mobilize the triquetrum, pisiform, and scaphoid.

Technique begins by grasping the client’s hand and extending the arm and wrist so the therapist’s thumbs butt up against the radius at the scaphoid-lunate junction. Therapist’s hands and hooked thumbs traction the entire arm holding a gentle sustained pressure as the client slowly attempts wrist flexion to a count of five against therapist’s resistance.

Upon relaxation, the therapist brings the wrists into more extension to restore carpal glide and bony alignment. This routine is repeated three to five times. The therapist’s thumbs then begin examining for any bony fixation along the radioulnar ridge…correcting any newly discovered bony/ligamentous fixations. Test all fingers with the ‘digit-pulling’ technique.

newsletter Jan 2007

Metacarpal Alignment

Once the proximal row has been successfully mobilized, using a slight force, distract the metacarpal phalangeal joints one at a time with client’s hand in a neutral position. This maneuver helps separate the metacarpals from the distal carpal row while restoring carpal glide and joint play.

Now that the metacarpals have been mobilized, the proximal and distal phalanges can be retracted to a neutral position similar to when one pulls the fingers and causes joints to “pop”.

newsletter Jan 2007

Handshake Assessment

The handshake technique helps determine if the carpal rows are now gliding without resistance.

Therapist’s left hand grasps the client’s forearm and his right hand holds her right hand as if shaking hands.

The client is asked to relax while the therapist glides her hand in radial and ulnar abduction while bracing the forearm.

Any resistance encountered may indicate further mobilization of the proximal row should be repeated.

newsletter Jan 2007

Metacarpal-Phalangeal Release

Repeat this repositioning by again releasing the metacarpal phalangeals and distal phalangeals. Finalize with the handshake abduction motion of the radius and ulna to ensure that the proximal carpals are properly repositioned.

The scaphoid-trapezium complex is often more difficult than the triquetrum-pisiform complex to mobilize. Recall that the scaphoid should have the greatest mobility (up to one centimeter) but is commonly fixated forming a hard knot on the back of the hand.

Check your own scaphoid…can you get it to move?

Many of your true carpal tunnel clients present with a cupped hand caused by a fibrotic transverse carpal ligament and fixated carpals.

Soft tissue work alone often ends in frustration until joint play is restored to all wrist and hand bones.

Additional wrist and hand mobilization techniques are covered in my Volume III, Myoskeletal Shoulder, Arm and Hand video set.

newsletter Jan 2007

Take care…

Erik