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Old 08-09-2008, 04:38 PM   #1
Nick
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Default DeQuervain's

Long history of pain at the radial aspect of wrist and over the thumb. Not resolving. Any suggestions?
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Old 08-09-2008, 05:55 PM   #2
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Try the UL neural tension test moving very slowly. Sometimes you can catch "speed bumps" in the arcs of movement due to decreased flexibility. I keep a sharp eye on the wrist to prevent any ulnar deviation. A typical "speed bump" is at the end of elbow extension. The shoulder will want to rotate or roll the scapula. Another one is in the forearm. They often lack the last few degrees of supination and/or pronation.

Also look at thumb opposition. What is the orientation of the fingernails when they make a loop? Is it finget tip to finger tip or to side of finger?
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Old 08-09-2008, 11:02 PM   #3
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I always think radial nerve or C6 nerve root in these cases. I don't have much use for the DeQuervain's diagnosis.
I would be interested in ULNT radial, and I would probably treat the neck with mob/manip and simple contact and perhaps distally with neurodynamics. I would also try a repeated motion exam to see if you could centralize or abolish the symptoms with neck movements. I've had a couple people resolve with this alone.
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Old 08-09-2008, 11:04 PM   #4
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I think of lateral cutaneous nerve of the forearm, as it blends into superficial radial with actual anastomosis sometimes, but even if it doesn't, it's cutaneous field overlaps. So I would not leave out backtracking up musculocutaneous nerve, which might lead to some observation of intercostobrachial behaving badly.
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Old 08-09-2008, 11:23 PM   #5
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DeQuervain's is a rather outdated peripheral label.

ULNT 3 is definitely worth a go, mobilising softly at the point where pain slightly increases, plus or minus neck lateral flexion. I like supine lying for the movement.
Also musculocutaneous attention would be worthwhile.

What have you tried so far, Nick?

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Old 09-09-2008, 12:17 AM   #6
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Jason description above would be pretty much exactly how I have approached this thus far.
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Old 09-09-2008, 12:31 AM   #7
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Quote:
Originally Posted by Nick View Post
Jason description above would be pretty much exactly how I have approached this thus far.
Ooh, color me "no help", huh?

Any luck with manual or mechanical traction? If I'm unable to help, and the next step is something invasive (like surgery or ESI) I'll do a trial of this sometimes.

Tried some DNM as Diane suggests?

Got an MRI of the Cx spine by any chance? Is the patient considering more invasive care?
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Old 09-09-2008, 03:50 AM   #8
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I would like to know if it's the dominant arm, and if the patient wears a watch on it all the time (regardless which arm it is).

I treated my own uncle for a huge swollen and painful hand (non-dominant hand), secondary to him having wrestled a tractor steering wheel for several hours snowplowing out his farm yard the day prior - I learned he never took his watch off, hadn't for years, even at night. Just never bothered.

It went down by the next day with treatment (my kind, i.e. sophisticated hand holding/skin stretching), getting him to take the watch off and wear it on the other arm, and ice packs at intervals all evening. I think we steered clear of a Dx like that... just.
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Old 09-09-2008, 05:01 AM   #9
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Once, I had a patient with diagnosis of DeQuervain and after 3 sessions without a good result (using maitland techniques and neural mobilizations), I've decided to check her thoracic region.

I found a hypomobility region in T4-T6. I worked on this region and the symptons were better about 80%!

Who knows?!
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Old 09-09-2008, 06:39 AM   #10
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personally, i tend to watch for carpal fixation/instability, ULNT2R with finkelstein variation, and elbow fixation in a valgus position.
my 2 cents.
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Old 09-09-2008, 06:43 AM   #11
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Gustavo,

I think your post makes a very good point: there are more than two ways to treat a neurologically-based issue. Each of us has success with what each of us think is the optimum way to go, based on the criterion of a neural approach.
DNM, neurodynamics, thoracic/cervical mobilisations, ideomotion....
they all meet the criteria for intervention in their different ways. Acupuncture, I suspect, is in there too.
It's one of the good aspects of physiotherapy that we make sensible decisions based on logical reasoning.

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Old 09-09-2008, 01:05 PM   #12
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I have had excellant results with this label using the MFR approach/techniques. Cross hand releases over the forearm, arm pulls, treating the forward head postures, etc....not treating symptoms but looking elsewhere for the cause. As I journey down the river of my PT career, (27 years), the most effective techniques I use are the gentle fascial release techniques I have learned which are aimed at elongation of tissue and return of the client to a more optimum state of rest physiological posture. (Rocabado, Chaitow)
I occasionaly use mobs/manips on stubborn joint problems which have had far reachng effects. Frozen shoulder full functional return of ROM after T7-8 manipulation. Why????
We have all got results on a certain label using different techniques from our own personalized tool box. The most important thing , to me , is to keep learning and applying good clinical decisions. As the saying goes " If I don't know it, you can't have it" and "I can only color from my own box of crayons," so I keep looking at different colors which appeal to me and have a good effect .
Some times labels don't matter.
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Old 09-09-2008, 11:10 PM   #13
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Default Radial sided wrist pain

Hi Nick,

Radial sided wrist pain maybe caused by several reasons. Here are some of my screening suggestions: DSRN impingement as Diane stated from tight watch or impingement. It maybe 1st CMC/ basal joint OA more common in females. It also could be a SLAC wrist. A Scapoid fx would need recent hx of a FOOSH so thats out. I have heard of testing the radial artery pulse b/f and after the snuffbox (b/f next to FCR, after between the 1st & 2nd MCP base, but I think I would have a better chance of seeing a zebra walk down a NYC street. You can MMT EPL & EPB. EPB in 1st Dorsal compartment is #1 suspect for DeQ. (fibrocartilage metaplasia). Intersection syndrome- tenderness bet. ECRL/B & APL/EPB. Finally, I have seen alot of pt's with hand pain that also have scapular dysfunction. Co-incidence? If I were in Vegas, I would bet on Basal joint OA if the pt is a women in her early 40's.

Sincerely,

Mike
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Old 10-09-2008, 12:02 AM   #14
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Hmmmm There is a casino in Halifax.....

Besides that, Mike, could you expand your anacronyms, for those of us who are unfamiliar with them?

a SLAC wrist.
a FOOSH

You can MMT EPL & EPB.
ECRL/B & APL/EPB.
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Old 10-09-2008, 02:28 AM   #15
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Default acronyms

Hi Mary,

A SLAC wrist= Scaphoid lunate advanced collapse (degenerative process resulting from a long standing scaphoid-lunate ligament tear).

A FOOSH= fall on the outstretch hand.

MMT=manual muscle test. EPL=extensor policis longus & EPB= extensor policis brevis.
ECRL/B= extensor carpri radial longus & brevis.

APL/EPB= Abductor policis longus/ extensor policis brevis.

Sincerely,

Mike
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Old 10-09-2008, 02:29 AM   #16
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Thanks Mike
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