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Hand Muscle Power Deficits
ICD-9-CM codes:
ICF codes:
727.03 Radial styloid tenosynovitis
727.04 Trigger digits
Activities and Participation Domain codes: d4301 Carrying in the hands; d4400
Picking up; d4401 Grasping; d4452 Reaching; d4453 Turning or twisting
the hands or arms
Body Structure code: s73012 Muscles of forearm
Body Functions code: b7300 Power of isolated muscles and muscle groups
Common Historical Findings:
Thumb abductors/extensors musculotendinous involvement:
Pain in dorso-radial wrist that is most noticeable with pinching and wrist
movements
Onset associated w/repetitive thumb and wrist movements or trauma to the area
(e.g., blow to lateral wrist)
Finger flexors musculotendinous involvement:
Pain, stiffness, and swelling of the volar surface of finger and palm
Snapping or locking with attempted movement
Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restriction:
Thumb abductors/extensors musculotendinous involvement:
Symptoms reproduced with:
Resisted APL and EPB tests (weak & painful)
Stretch to APL/EPB tendons (Finklestein’s)
Palpation/provocation of the APL and EPB tendons
Finger flexors musculotendinous involvement:
Symptoms reproduced with:
Resisted FDP and FDS tests (weak and painful)
Palpation/provocation of the FDP and/or FDS tendon
Physical Examination Procedures:
Manual Resistive Test
Abductor Pollicis Longus
Manual Resistive Test
Extensor Pollicis Brevis
Cues: Abduction of the thumb is a movement perpendicular to the palm-away from the palm
Extension of the thumb is a movement parallel to the palm - away from the palm
Cuong Pho DPT, Joe Godges DPT
Loma Linda U DPT Program
KPSoCal Ortho PT Residency
2
Provocation of APL and EPB Tendons
Cues: If acute - gentle palpation reproduces symptoms
If sub acute - stronger provocation may be required to reproduce the symptoms
In normals - firm pressure is painfree
Finkelstein’s Test
Cues: Stretch of APL and EPB
Instruct patient to grab thumb with fingers - then slowly ulnarly deviate the wrist
(demonstrate motion to the patient)
Perform test slowly to avoid further tissue injury and pain
Cuong Pho DPT, Joe Godges DPT
Loma Linda U DPT Program
KPSoCal Ortho PT Residency
3
Wrist Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with wrist
Radial Styloid Tenosynovitis the vernacular term “DeQuervain’s Syndrome”
Description: Pain, tenderness and swelling over the first dorsal compartment, increased with
thumb and/or wrist motions. Pain is worse with passive stretch into wrist ulnar deviation with
the thumb held in neutral (Finklestein’s test) or repetitive active thumb abduction and extension.
The aggravating stress is greatest when radial deviation is combined with a gripping motion of
the thumb because of the angulation of the tendons causes tearing stress to the extensor
retinaculum. Pain may radiate either proximally or distally toward the thumb or elbow. There
may be decreased abduction range in the carpometacarpal joint of the thumb, and palpable
thickening of the extensor sheath and the tendons distal to the extensor tunnel.
Etiology: A stenosing tenosynovitis of the first dorsal compartment. The compartment is
approximately 1 in. in length and is formed by the osseous groove in the radial styloid and the
overlying extensor retinaculum. This first dorsal compartment houses the tendons of abductor
pollicis longus (APL) and extensor pollicis brevis (EPB). It usually affects women between the
ages of 30 and 60 years old, and those who participate in wheelchair sports. It is most common
in repetitive activities such as keyboarding, filing, carpentry, assembly-line work, and golfing. It
may also occur transiently during pregnancy and breast feeding.
Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7101.3 SEVERE impairment of mobility of several joints
•
•
•
•
•
•
Palpable crepitus is occasionally present moving through the extensor sheath
Symptoms reproduced with provocatory pressure over the first compartment
Triggering of thumb may imply excessive stenosis or a nodule formation on APL or EPB
Weakness in the wrist radial deviation, EPB, APL
Tenderness is usually felt in the “anatomical snuff box” along radial side of wrist with
palpation. Pain can radiate distally into thumb/hand, and proximally to elbow.
Pain may limit thumb active extension and abduction
Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7101.2 MODERATE impairment of mobility of several joints
As above – but with the following differences
• The movement limitations are decreased
• Strength deficits are less
• Provocatory pain is less intense, and provoked closer to end range of motion
Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7101.1 MILD impairment of mobility of several joints
As above – but with the following differences
• Movement limitations are less
• Strength deficits are minimal
• The provocatory pain is elicited primarily with overpressure at end range
Cuong Pho DPT, Joe Godges DPT
Loma Linda U DPT Program
KPSoCal Ortho PT Residency
4
Intervention Approaches / Strategies
Acute Stage / Severe Condition:
Goals: Control pain and symptoms, and decrease inflammation
•
Physical Agents
Ultrasound or phonporesis to aid reduction of inflammation over the first dorsal
compartment
Iontophoresis may also be used to aid reduction of inflammation
•
External Devices (Taping/Splinting/Orthotics)
A thumb spica short-arm splint may help position the wrist and decrease the use
and irritation of the first dorsal compartment
•
Manual Therapy
Soft tissue mobilization to restricted myofascial tissue (e.g, extensor retinaculum,
APL, and EPB) that may be causing restriction, or in muscle spasms
Mobilizations with movement (MWM) of active movements of the thumb and
wrist superimposed on a passive radial glide of the proximal row of carpal
bones
•
Therapeutic Exercise
Gentle passive range of motion of thumb and wrist
•
Medications
Anti-inflammatory medications (NSAIDS), and pain relievers. After 2 weeks if
unsuccessful at pain relief, corticosteroid injections.
•
Ergonomic Instruction
Modify or avoid aggravating activities during work or recreational environments,
postures and tasks (e.g., hand/wrist position while filing, golfing, or doing
assembly line work)
Sub Acute Stage / Moderate Condition
Goals: Restore normal and pain free range of motion
As above with the following differences: Inflammation is controlled, so mobilization phase
begins.
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•
•
More aggressive with repetitive activities of the thumb especially at end range
Progressive resistive exercise begin when 80-85 % of painless range of motion is attained
Less use of modalities for treatment, and only for post exercise pain, and inflammation
management
Cuong Pho DPT, Joe Godges DPT
Loma Linda U DPT Program
KPSoCal Ortho PT Residency
5
Settled Stage / Mild Condition
Goals: Maintain or return to functional activities of the wrist and hand
•
•
Correct any biomechanical deficits that may occur during functional activity
Therapeutic Exercise:
Increase progressive resistive exercises and functional strengthening exercises as tolerated
Intervention for High Performance / High Demand Functioning in Workers or Athletes
Goals: Return to optimum level of function for work and leisure time activities, and reduce
likelihood of re-injury while attaining previous level of function. (usually within 1
month)
Approaches / Strategies listed above
•
•
Work on endurance training and work hardening for specific occupation or sport activity
Gripping activities should be painless
Cuong Pho DPT, Joe Godges DPT
Loma Linda U DPT Program
KPSoCal Ortho PT Residency
6
Selected References
Alberton G, et al. Extensor Triggering in de Quervain’s Stenosing Tenosynovitis. J Hand Surg.
1999;24A(6)1311-1314.
Anderson B, et al. Treatment of De Quervain’s Tenosynovitis With Corticosteroids. Arthritis
and Rheumatism. 1991;34(7)793-798.
Anderson M, et al. A Patient With De Quervain’s Tenosynovitis: A Case Report Using an
Australian Approach to Manual Therapy. Phys Ther. 1994;74(4):314-326.
Apple DF, at. al. Overuse Syndrome of the Upper Limb in People with Spinal Cord Injury.
Department of Veterans Affairs. 1996;5:97-107.
Backstrom K. Mobilization With Movement as an Adjunct Intervention in a Patient With
Complicated De Quervain'’ Tenosynovitis: A Case Report. J Ortho Sports Phys Ther.
2002;32(3):86-94.
Cooney WP. The Wrist Diagnosis, and Operative Treatment. vol. 2 Mosby, St. Louis, 1998.
Johnson CA. Occurrence of de Quervain’s Disease in Postpartum Women. J Family Practice.
1991;32(3):325-327.
Kent T, et al. Patient Satisfaction and Outcomes of Surgery for de Quervain’s Tenosynovitis. J
Hand Surg. 1999;24A(5):1071-1077.
Lichtman DM. The Wrist and Its Disorders. W.B. Saunders Company, Philadelphia, 1988.
More S. De Quervain’s Tenosynovitis. American College of Occupational and Environmental
Medicine. 1997;39(10):990-1002.
Piligian G, et all. Evaluation and Management of Chronic Work-Related Musculoskeletal
Disorders of the Distal Upper Extremity. American Journal of Industrial Medicine. 2000;37:7593.
Schned E. DeQuervain Tenosynovitis in Pregnant and Postpartum Women. Obstetrics &
Gynecology. 1986;68(3):411-114.
Sinan A, et al. Comparison of Nonsurgical Treatment Measures for de Quervain’s Disease of
Pregnancy and Lactation. J Hand Surg. 2002;27(2):322-324.
Zingas C, et al. Injectin Accuracy and Clinical Relief of De Quervain’s Tendinitis. J Hand
Surg. 1998;23A(1):89-96.
Cuong Pho DPT, Joe Godges DPT
Loma Linda U DPT Program
KPSoCal Ortho PT Residency