Wrist pain

Wrist fracture/Hand fracture

How do I know if I fractured my wrist?

The top five physical findings which are most useful in screening for wrist fracture.

  • Localized tenderness (Sensitivity [Sn] 94%)
  • Pain on active motion (Sn 97%)
  • Pain on passive motion (Sn 94%)
  • Pain on grip (Sn 71%)
  • Pain on supination (Sn 68%) Supination is turning the palm up
  • Bottom line: Any one of the above findings associated with a history of trauma should be sent for radiographs at the Doctor office or ER
  • Sensitivity of a test means if the test is negative then how likely you can rule out a diagnosis http://www.physio-pedia.com Cevik AA, Gunal I, Manisali M, et al. Evaluation of physical findings in acute wrist trauma in the emergency department. Ulus Travma Acil Cerrahi Derg. 2003;9(4):257-261.

Another major factor that one could help determine if there was a wrist fracture if there was a fall on a wrist (distal radial fracture common with this type of injury), car wreck, high impact collision with the hand or wrist like a punch to a jaw or wall (4th or 5th metacarpal fractures)

So to explain in more simple terms if suspect you have a fracture in your wrist AND you don’t have localized tenderness ,  don’t have pain with moving it on your own, don’t have pain with passively moving it with your other hand, no pain on gripping, no pain with turning your palm up you almost certainly DO NOT have a fracture.

If you don’t have pain with actively moving your hand there is a 97% chance you likely don’t have a hand fracture, if you don’t have local tenderness there is a 94% chance you likely don’t have a fracture and so forth according to the statistics above.



Scheuremann’s Disease and Hunter Pence

Image result for Hunter Pence baseball picture

Hunter Pence has Scheuremann’s disease. If you look at the picture that is his first picture as an Astro’s player above, he is almost side arming his throw.  (That picture is from the hardball times).  His condition causes stiffness of the mid and upper back and kyphosis. The condition cannot be corrected if the patient tries to use their own muscles.  The back of the spine grows faster than the front and thus the bones grow like a wedge.  This is why he throws so strangely.

Image result for image Scheuermann's disease

He short arms his throws. It is amazing that he is able to throw with such strength, velocity, and accuracy with a short arm throw.  If the spine does not bend as it should it makes throwing significantly more difficult.

In order to throw well from the outfield one must have good throwing mechanics most of the time.  That includes full thoracic extension and he does not have that. His thoracic extension is likely limited by about 20 degrees of normal.  Also his scapula (shoulder blade) and humerus must move in unison well.  His shoulder blade on his ribs is likely stiff as well. The muscles called the middle trapezius , lower trapezius, serratus anterior must help the shoulder blade to rotate upwardly to have excellent throwing motion.  His therapist/trainers in the past asked him to do physical therapy and strengthening exercises on his shoulder and it just hurt too much so they said back off and he has managed just fine.


Image result for image of scapula upward rotators

The muscles above help the scapula rotate well to help in the throwing mechanics of an outfielder.

The lattisumus dorsi helps you pull your shoulder back , the deltoids help you reach your arm up in part, and the triceps help to fling the ball, the biceps help to decelerate the arm.  These are just very basic observations.

Watch next time when he throws. It is amazing that somehow he has overcome a major physical impairment to throw at a professional level.



Carpal tunnel revisited

Carpal tunnel treatment-evidence based

The picture above is from the website nervesurgery.wustl.edu. The red coloring region is the distribution of the median nerve. When the carpal tunnel area has swelling it compresses this nerve and causes numbness and sometimes even weakness in the area that is red above. If it is severe there can even be muscle wasting in the palm region of the thumb called the thenar eminence.

One of the best treatments for carpal tunnel is below.

Continue reading “Carpal tunnel revisited”

Ulnar nerve dysfunction (forearm/pinky numbness)

Ulnar nerve physical therapy treatment

The above picture is from the website:  www.mdguidelines.com

The below image is from www.netterimages.com – This site has excellent images for anatomy. Netter the artist is really the gold standard artist for anatomy.

Above is a picture of the ulnar nerve and the distribution of numbness or tingling (the blue colored region) that can appear when there is an insult to the area.

The ulnar nerve can be injured in a variety of ways. The most common ways to injure it are:

  1. Keeping the elbow bent at night
  2. Keeping the elbow bent and elbow on a desk too often
  3. Keeping the elbow bent and placing head on hand and laying down watching TV
  4. Having consistent pressure on the outside of the wrist while riding a bicycle
  5. Pressure on outside of wrist using computer mouse

The problem of tingling or numbness into the 4th and 5th digit can originate from several sources (it usually is due to lack of oxygen/pressure/ or overstretch on the nerves)

  1. Cervical spine/neck C8 nerve root
  2. Cubital tunnel area- the funny bone region
  3. Guyan’s tunnel at the base of the wrist on the outside region


The best treatments from my personal experience with this injury, with patients that have had this injury, and according to the research article below is shown below: Continue reading “Ulnar nerve dysfunction (forearm/pinky numbness)”

Tennis Elbow/Lateral epicondylitis

Chronic Tennis Elbow physical therapy exercises

The picture above is from the website:  www.patienteducationcenter.org

As a physical therapist I have mentioned there are about 5 diagnoses that are just extremely difficult to get better in treatment.  Chronic tennis elbow is one of them.

It usually occurs with excess typing, using the computer mouse, pitching, playing tennis, and excess tool work as mechanic.

Some basic forms of treatment are:

  1. Tennis elbow strap- fairly effective
  2. Rest – good effectiveness
  3. Ice cup massage 5 minutes temporary relief excellent
  4. Cortisone injections fairly effective
  5. Your own blood injection fairly effective
  6. Friction massage deep-fairly effective
  7. Stretching fairly effective
  8. ****Eccentric strengthening 5/5 star excellence

For the injury that I had with lateral epicondylitis, my patients and with research – eccentric strengthening has worked the best. A picture of how to perform the exercise is below.

Continue reading “Tennis Elbow/Lateral epicondylitis”

Frozen shoulder

Frozen shoulder and Physical therapy

www.health.harvard.edu– The above pictures is from this website.

A few keys to determining if you have frozen shoulder are….

  1. Stiffness is your limiting factor of movement !!! Pain will also be a factor but stiffness is the leading limiting factor of movement
  2. The most limited movements will be usually in this order..external rotation (hand behind neck and elbow out)… then abduction (arm out to the side and up)…. then internal rotation (hand behind the back)
  3. It is more common in those that have diabetes and in women

According to the British Journal of Medicine…

It is more common if you have Diabetes, Dupuytren’s disease, fibromatosis, hyperthyroidism,hypothyroidism, hypoadrenalism, Parkinson’s disease, cardiac disease, pulmonary disease, and stroke.

Three phases of clinical presentation

Painful freezing phase Duration 10-36 weeks. Pain and stiffness around the shoulder with no history of injury. A nagging constant pain is worse at night, with little response to non-steroidal anti-inflammatory drugs

Adhesive phase Occurs at 4-12 months. The pain gradually subsides but stiffness remains. Pain is apparent only at the extremes of movement. Gross reduction of glenohumeral movements, with near total obliteration of external rotation

Resolution phase Takes 12-42 months. Follows the adhesive phase with spontaneous improvement in the range of movement. Mean duration from onset of frozen shoulder to the greatest resolution is over 30 months

Summary points

The three hallmarks of frozen shoulder are …shoulder stiffness; severe pain, even at night; and near complete loss of passive and active external rotation of the shoulder Lab tests are normal Frozen shoulder is rare under the age of 40; the peak age is 56 ,  Steroid injection is effective and best combined with physiotherapy. Refractory cases can be referred for manipulation under anaesthesia and, rarely, arthroscopic release

BMJ. 2005 Dec 17; 331(7530): 1453–1456.


There are 5 major exercises/concepts that may help at home.

Continue reading “Frozen shoulder”