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Elbow/Wrist/Hand Pain

Physical Therapist’s Guide to Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a common condition of the wrist and hand that can affect the use of the whole arm. It is caused by pressure on the nerve at the base of the palm (median nerve). Because of the demands that people place on their hands and wrists, CTS is a common condition affecting 1 out of 20 Americans. Surgery for this condition is commonly performed on the wrist and hand. Fortunately for most people who develop CTS, physical therapist treatment can often relieve pain and numbness and restore normal use of the hand, wrist, and arm without the need for surgery.


What is Carpal Tunnel Syndrome?

About the width of your thumb, the carpal tunnel is a narrow channel on the palm side of your wrist. The tunnel protects the median nerve and the tendons that bend your fingers. Pressure on the nerve can cause pain and weakness in your wrist and hand and numbness or tingling in some of your fingers. This pressure is caused by crowding or irritation of the median nerve in the carpal tunnel and can lead to CTS.

Extreme wrist positions, as well as a lot of finger use, especially with a lot of force or vibration (such as holding the steering wheel when driving heavy machinery), can all contribute to CTS.

CTS is common in professions such as assembly-line work, particularly meat packing; and jobs requiring the use of hand tools, especially tools that vibrate. Although excessive keyboard and computer use is often associated with CTS, those performing assembly line work are 3 times more likely to develop CTS than those who perform data entry work. Some leisure activities can also create CTS, such as sewing, sports such as racquetball and handball, and playing string instruments such as the violin.

The following health conditions can also lead to CTS in some individuals:

  • Inflammation and swelling of the tendons of the wrist
  • Injuries to the wrist (strain, sprain, dislocation, fracture)
  • Hormone or metabolic changes (pregnancy, menopause, thyroid imbalance)
  • Fluid retention (eg, during pregnancy)
  • Diabetes
  • Certain medicine use (eg, steroids)
  • Degenerative and rheumatoid arthritis
Carpal Tunnel Syndrome: See More Detail

Signs and Symptoms

CTS usually starts gradually, with symptoms such as burning, tingling, “pins and needles,” or numbness in the palm of the hand and fingers. Often the symptoms are more noticeable during the night, and individuals often report being wakened with symptoms. Many people feel the need to “shake out” their hands to try to relieve the symptoms.

As the condition progresses, the symptoms are noticed during the daytime and are often worse when holding items such as a heavy book or a hairbrush.  Weakness of the hand and more constant numbness may occur if the pressure on the nerve continues. You may find that you drop objects unexpectedly or have a weakness in your grip.

How Is It Diagnosed?

Physical therapists work closely with other health care professionals to accurately diagnose and treat CTS. Symptoms of CTS are typical, and it is often possible to diagnose it without extensive testing.  Physical therapists are experts in the movement and function of the body and will conduct an evaluation to determine all of the factors that may be contributing to your condition.

These are several tests that may be used to help diagnose CTS:

  • Examination of your neck and entire upper extremity to rule out other conditions. Many patients have been told they have CTS, only to find out that the pain is coming from another body area.
  • Grip strength of fingers and thumb
  • Sensory tests
  • Wrist and hand range-of-motion
  • Wrist flexion (Phalen) test: Your physical therapist will have you push the backs of your hands together for 1 minute.  Tingling or numbness in your fingers that occurs within 60 seconds may be an indication of CTS.
  • Tinel’s Sign: Your physical therapist will use a reflex hammer or finger to tap over the median nerve at your wrist. Tingling in the thumb and index and middle fingers may indicate CTS.
  • Electrical studies (electromyogram/EMG) and nerve conduction velocity (NCV): These tests determine the transmission of the nerve and the severity of the CTS.
  • X-rays: When trauma has occurred or if there is reason to suspect anatomical abnormality, x-rays may be ordered.

In some cases, your physical therapist may refer you to a physician or other health care professional for additional testing or treatment.

How Can a Physical Therapist Help?

After the evaluation, your physical therapist will prescribe your treatment plan based on your specific case.

Conservative Care

If your evaluation confirms early-stage CTS, conservative care will be recommended as a first step. Physical therapy treatment can be effective in reducing your symptoms and getting you back to performing normal activities. During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Depending upon the causes of your CTS, your therapy program may include:

  • Education regarding:
    • changing wrist positions (ie, avoiding prolonged bent wrist positions)
    • proper neck and upper back posture (ie, avoiding forward head or slouching)
    • safe use of sharp utensils, tools, or other implements, if sensory changes are identified
    • “stretch breaks” during your work or daily routine
  • Exercises to increase the strength of the muscles in your hand, fingers, and forearm—and in some cases, the trunk and postural back muscles
  • Stretching exercises to improve the flexibility of the wrist, hand, and fingers
  • Use of heat/cold treatments to relieve pain
  • Use of a night splint to reduce discomfort
  • A worksite visit to assess your work area. For example, if you sit at a desk and work on a computer, it’s important for the keyboard to be in proper alignment to help avoid working in a bent wrist position.
  • Increasing the size of tool and utensil handles by adding extra material for a more comfortable grip
  • Anti-vibration gloves or anti-vibration wraps around tool handles, if vibration is a factor at your workplace

Your physical therapist will also consider your home and leisure activities, with recommendations such as wearing gloves to keep the wrist/hands warm and limiting sports that aggravate the condition, such as racquet sports, until symptoms resolve.

The goals of physical therapy are to reduce your symptoms without the need for surgery, to enable you to be as active and functional as possible, and to help you resume your normal work, home, and leisure activities.

Physical Therapy Following Surgery

If the evaluation reveals that your CTS is more severe, or if your symptoms persist, your physical therapist may refer you to a physician for a surgical consultation. If necessary, surgery will be performed to release the band of tissue that is causing pressure on the median nerve. Physical therapy treatment is important after surgery to help restore strength to the wrist and to learn to modify habits that may have led to symptoms in the first place. Your physical therapy treatment may include:

  • Exercises to improve the strength of the wrist/hand muscles and improve function
  • Stretching to improve mobility of the wrist/fingers and improve function
  • Scar management to keep the skin supple and flexible
  • Education regarding appropriate posture and wrist position to avoid carpal tunnel compression in home/leisure activities
  • A worksite visit or simulation to optimize postures and positions

Physical Therapist’s Guide to Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease that affects approximately 1% of the United States population. RA often results in pain and inflammation in joints on both sides of the body, and can become disabling due to its effect on the immune system. A physical therapist can help manage the symptoms of RA, enhancing an individual’s quality of life.

Other Arthritis Resources:


What is Rheumatoid Arthritis?

RA is classified as an autoimmune disease—a condition where the body’s immune system attacks its own tissues. Although the exact cause of RA is not known, multiple theories have been proposed to identify who is most likely to develop it. The cause may be related to a combination of genetics and environmental or hormonal factors. Women are more likely to develop the disease; women are diagnosed with RA 3 times more than men. Although RA may begin at any age, most research suggests it often begins in midlife.

How Does it Feel?

RA symptoms can flare up and then quiet down (go into remission). Research shows that early diagnosis and treatment is important for easing symptoms and flare-ups.

People with RA may experience:

  • Stiff joints that feel worse in the morning.
  • Painful and swollen joints on both sides of the body.
  • Bouts of fatigue and general discomfort.
  • Fever.
  • Loss of joint function.
  • Redness, warmth, and tenderness in the joint areas.

How Is It Diagnosed?

RA is generally diagnosed by a rheumatologist. Diagnosis is based upon factors, such as inflammation of the tissues that line the joints, the number of joints involved, and blood-test results. A physical therapist may be the first practitioner to recognize the onset of RA; the physical therapist will refer an individual with suspected symptoms to an appropriate clinician for further tests.

How Can a Physical Therapist Help?

Physical therapists play a vital role in improving and maintaining function that may be limited by RA. Your physical therapist will work with you to develop a treatment plan to help address your specific needs and goals.

Because the signs and symptoms of RA can vary, the approach to care will also vary. Your physical therapist may provide the following recommendations and care:

Aerobic Activities. Studies have shown that group-based exercise and educational programs for people with RA have beneficial effects on individual strength and function.

Goal-Oriented Exercise. Studies also show that achievement of personal physical activity goals helps reduce pain and increase the general quality of life in people diagnosed with RA.

Modalities. Your physical therapist may use modalities, such as gentle heat and electrical stimulation to help manage your RA symptoms.

Physical Therapist’s Guide to Wrist Tendinitis

Wrist tendinitis is a condition that most commonly occurs in individuals who perform repetitive activities using the hand and arm. These include computer users, factory workers, and athletes who throw and catch balls and play racquet sports. In the United States, the incidence of tendinitis as an occupational injury in people who work full time is 1.1 per 100,000. Overuse tendinitis is responsible for 25% to 50% of all sports injuries in the United States. Older individuals are often more at risk for wrist tendinitis due to a loss of elasticity in the wrist tendons. Physical therapists help people with wrist tendinitis reduce their pain, increase their wrist flexibility and strength, and return to their previous functional activities and sports.


What is Wrist Tendinitis?

Wrist tendinitis is a condition where 1 or more tendons in the wrist become inflamed and irritated. There are several tendons in the wrist that connect the muscles of the forearm and hand to the bones of the wrist and hand. These tendons are the small rope-like structures that you can see connecting to the fingers on the back of your hand. There are a number of conditions that can affect the tendons in this area.

  • Wrist tendinitis applies to the early stages of tendon inflammation and irritation.
  • Tendinopathy is the name given to the condition when it persists over time, is not treated, and becomes chronic.
  • Tenosynovitis is the term given to an irritation that develops when the synovial sheath (through which some of these tendons glide) thickens and restricts the tendon.
  • De Quervain’s Tendinitis applies to tendinitis that develops on the thumb side of the wrist.

How Does it Feel?

Several tendons in the wrist can become irritated with wrist tendinitis. Pain symptoms associated with the condition include:

  • Pain where the arm meets the hand, which can radiate up into the elbow.
  • Pain on the thumb side of the wrist (radial) or the little-finger side of the wrist (ulnar).
  • Pain that only occurs when the wrist is under strain, which can become constant pain when left untreated.
  • Pain when putting pressure on the hand, such as using the arms to push yourself up out of a chair to stand.

Besides pain, other symptoms include:

  • Stiffness of the wrist, and a decreased ability to bend and extend the wrist.
  • Inflammation or swelling in the wrist area.
  • Tenderness to touch in the wrist and/or forearm muscles.

How Is It Diagnosed?

Your physical therapist will conduct a thorough evaluation of your entire arm to include the shoulder, elbow, wrist, and hand. The therapist will ask you to describe the types of activities you normally perform using your arm at home, at work, and for recreation, and which of these activities causes pain or stiffness in the area. You will be asked how long the pain has been occurring and how it is affecting your regular activities of daily living. Your physical therapist will check your range of motion and strength in your entire upper arm. Your therapist will gently touch specific areas of your wrist and forearm to determine which wrist tendons are involved, and check for any swelling in the area.

How Can a Physical Therapist Help?

Physical therapy is a highly effective treatment for wrist tendinitis. You will work with your physical therapist to devise a treatment plan that is specific to your condition and goals. Your individual treatment program may include:

Pain Management. Your physical therapist will help you identify and avoid painful movements, and show you how to correct abnormal postures to reduce stress on the wrist. Your therapist may recommend resting the wrist short-term, and applying ice to the area to help alleviate pain. Your physical therapist also may apply a wrist brace to restrict wrist movement, allowing the tendons to heal.

Manual Therapy. Your physical therapist may use manual techniques, such as gentle joint movements, soft-tissue massage, and wrist stretches to get your wrist moving properly.

Range-of-Motion Exercises. You will learn exercises and stretches to reduce stiffness and help your wrist, hand, and forearm begin to move properly.

Strengthening Exercises. Your physical therapist will determine which strengthening exercises are right for you, depending on your specific areas of weakness. The entire arm, including the shoulder, elbow, and wrist, can potentially be weakened and contribute to the movement dysfunction that causes tendinitis. Your physical therapist will design an individualized home-exercise program to meet your specific needs and goals, which you can continue long after you have completed your formal physical therapy.

Patient Education. Depending on the specific activities you plan on resuming, your physical therapist will teach you ways to perform actions, while protecting your wrist and hand. For example, keeping the wrist in a neutral position to reduce excessive force while performing repetitive tasks, and taking frequent breaks are ways to decrease your chances of reinjury.

Functional Training. As your symptoms improve, your physical therapist will teach you how to correctly perform functional movement patterns using proper wrist mechanics, such as typing on a computer or swinging a racquet. This training will help you return to pain-free function on the job, at home, and when playing sports.


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