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#072: How To Know What Is Actually Causing Your Wrist Pain

***This is a podcast transcription and the grammar, spelling and slang may not be perfect 🙂

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Hey Desk Jockeys this is doctor Kevin Christie with another episode of the modern desk jockey I appreciate your time again this week today I’m actually going to be giving you a recording of a presentation I gave to a company that we do once a month for this particular company on different topics and this one is it really carpal tunnel syndrome and I really dive into carpal tunnel syndrome, de Quervain’s tenosynovitis other wrist pain, Pronator teres syndrome really how to differentiate it.


As you listen I’ll reference the slides obviously if you are listening to this podcast you’re not going to have the slides readily available to you but there are some stretches in there, there’s a couple diagrams I go over and a few other things that I’m going to put a video recording of this presentation on the show notes as well so when you have a chance to look it over and especially if you want to see the exercises and some of the things I reference in the audio you’ll have access to it. So when you’re listening to today’s recording understand that this was a webinar presentation so the people I was talking to you could see some of the slide presentations, you don’t have access to that through the podcast but you will for the show notes.


So make sure you do reference that and my challenge for you today is to take the self-assessment that I go over in this and make those changes, okay, and there’s about seven of the twenty that I go over. I do have a podcast episode on all of these questions, a twenty part question that you can also reference for a more in-depth ergonomic self-assessment. So check that episode out, but in this webinar presentation, I go over seven questions. So I challenge you to go through that and make those changes this week for you so it will be very helpful to help prevent any of these wrist, elbow, shoulder forearm conditions that we are seeing, so enjoy this presentation audio from the webinar that I gave and if you have any questions again you can always reach me and I will see you next week. Have a great week at work, have good happy holidays as well, here’s the presentation that I gave to a company called World fuel services.


Welcome and we’re going to discuss carpal tunnel syndrome or is it really ‘carpal tunnel syndrome’ and the reason why I phrase it that way is because too many times we actually are not dealing with carpal tunnel, we’re dealing with other conditions that will discuss or just frankly just elbow painfully, forearm pain, wrist pain and it has this blanket diagnosis as carpal tunnel syndrome and unfortunate a lot of people end up getting surgery, end up getting treated for something they actually do not have because it’s just kind of given a blanket diagnosis and so I really want to make sure we understand that just because you have wrist pain or just because you have forearm pain, elbow pain, thumb pain, hand pain doesn’t mean you have carpal tunnel. It could, and we’re going to try to differentiate that today in this presentation but you’re not going to get a diagnosis today, you’re not going to… I’m not going to rule in or rule out. I’m just going to give you some food for thought, some ideas that if you are dealing with this you know some of the questions to ask your provider and to give you some insights on what could potentially be happening from sitting at the computer typing, using the mouse and things like that.


So a lot of times when we’re dealing with wrist pain, carpal tunnel syndrome is a condition you could have. The other one you could have potentially is Pronator teres syndrome which I will break down for you as well. You could also potentially have de Quervain’s tenosynovitis just elbow pay maybe, forearm pain. It’s really trying to figure out some signs and symptoms that would really narrow down what you have going on and then from there maybe the physician would recommend some imaging to try to confirm that before anything more invasive is perform like surgery.

So too many times people are getting surgery for something they don’t have or getting injections or getting some type of treatment that’s not working because they’re not really targeting the correct area. So before I dive into those three main conditions the carpal tunnel syndrome.


Pronator teres syndrome and de Quervain’s I’m going to discuss a little bit the overuse injury cycle or the cumulative injury cycle, and this is how injuries occur, so many people come into our practice or when we’re inside recuperations, and they are very concerned and confused as to why they have a condition. They don’t remember any traumatic cause, nothing they can pinpoint, just really no reason why they would have this and carpal tunnel or wrist pain, hand pain things like that is one of those common things because it is usually, you know we think of typing as very easy but what ends up happening when you’re dealing with this cumulative of injury cycle is that when you have a situation where there are some overwork, okay and let’s first agree that typing for prolonged periods of time, sitting at a desk for prolonged periods of time, using a mouse a lot especially on the same arm. Those are all going to be forms of overwork, and that then leads to really this weakening or tightening of certain muscles. So every muscle in your body can either tend to become tight, or it can tend to become weak, and so it’s very common to have that situation occur and so the tightness in these forearm muscles carpal tunnel things like that are very common when we’re having these types of situations and it really ends up happening when we have weak and tight muscles, it leads to this friction pressure or tension onto the soft tissue.


So in the case of a carpal tunnel they’re going to get that pressure and tension in that area and the carpal tunnel is like it sounds like it’s a tunnel where a lot of your tendons and the median nerve, in particular, runs through, and that’s called carpal because there’s a bunch of carpal bones, and that’s the area of your wrist, and so if you get friction pressure and tension in that area, it ends up causing a decrease of blood flow to the area, a decreased circulation, and that’s going to cause a formation of adhesive fibers or scar tissue okay. I think we’ve all heard of scar tissue at this point and then when you get scar tissue in an area you’re going to cause then that area to be weaker or tighter, and that just perpetuates itself over and over again and this is the cumulative injury cycle that lays dormant without any symptoms for a long time and then finally the stroller broke the camel’s back you get the pain syndrome and now you have a condition and so this is the cumulative injury cycle and that’s how it’s occurring.


Starting with overwork leading to muscular imbalances and then causing the friction pressure and tension in the area which then leads to the scar tissue when it just keeps on going around and around, and then you end up with a potential pain.


The next slide that I want you to go over and I’ll discuss with you, and I’ll break it down is how injury occurs. I know if you see this it’s an equation I = (in*f)/ a*r


Okay the ‘I’ equals insult to the tissues, the ‘in’ is the number of repetitions, the ‘f’ is force, the ‘a’ is amplitude and the ‘r’ is relaxation, okay I’m not going to dive too much into that but let’s take typing which is a huge problem in this wrist, hand, forearm, thumb type of conditions. It’s got a high number of repetitions, it’s got a low force that’s a positive, and it’s got a low amplitude, which amplitude is like the distance of movement, so a keystroke is a low amplitude. It’s not much movement whereas a tennis serve is a high amplitude and then relaxation there’s not much relaxation in typing.


So when you look at this math equation and remember your math the top numbers being higher and the bottom numbers being lower could make the number equal higher. So the insult is higher and what happens within typing, when you have a high number of repetitions, the low amplitude and the low relaxation time those are three factors that are negative against you, and that’s why typing can be very injurious, and I wanted to just go over this so that you can understand.


We can apply this equation to all kinds of overuse injuries and give us a reasonable expectation of if something can cause injury, and a lot of people get confused as to why typing can cause such an issue, and this is why, because again the repetitions are high, the amplitude is low and the relaxation time is minimal, and those are problematic to cause issues.


So how can we address this right, how can we prevent some of these things from occurring by using this? And obviously to decrease the repetitions we want to increase the relaxation time and take micro-breaks. We want to decrease those repetitions and increase relaxation, and obviously, we want to prove the ergonomics as well which we will obviously discuss.


Okay moving on to our first condition that we’re going to discuss which is carpal tunnel syndrome, essentially carpal tunnel syndrome causes pain, tingling and numbness in your hand from pressure on that median nerve in your wrist okay. That median nerve comes all the way from your neck all the way down the shoulder, down the arm into the hand and when it gets compressed at the carpal tunnel that is technically carpal tunnel syndrome. Now one of the concerns, one of the problems is it can get compressed in other areas along that chain from the neck down, and if it’s getting compressed there then you don’t really have carpal tunnel and if someone goes in to try to release that carpal tunnel surgically it’s not going to fix the problem so you’ve got to really make sure that you understand that you know the carpal tunnel caused by this pressure on the median nerve and it really is causing a lot of different types of sensations just to reiterate pain, tingling and numbness in your hand okay and a lot of times swelling can be a cause of this which is why things like pregnancy and obesity can actually lead to carpal tunnel believe it or not. So make sure if you’re suffering from other conditions like hypothyroidism, rheumatoid arthritis, obesity or pregnancy that could be a cause of your symptoms as well and again carpal tunnel surgery or manual therapy for a carpal tunnel is not going to fix your issues. So repetitive motions are usually one of the biggest cause of true actual carpal tunnel syndrome.


Right moving on to the next one Pronator teres syndrome, this one is very, very often mistakenly missed and the person is diagnosed with carpal tunnel syndrome. Pronator teres is a muscle that runs up by your elbow, it’s it attaches from the inside of the elbow to the middle of the forearm, and it pronates the arm okay so if I am sitting at my computer and I go into the typing position that is considered pronation of your forearm and hands. If I was open them up and my palms we’re facing the sky that is supination okay so as this muscles name implies this is going to pronate the arms and when you’re typing and using the mouse you’re activating Pronator teres excessively. Well what ends up happening is the median nerve that we describe it also runs through and by the two heads of the Pronator teres and can get entrapped there so a condition where the Pronator teres muscle in the form becomes overused and that scar tissue lays down as we mentioned before in that cumulative injury cycle and so you get the adhesion in the scar tissue. It can entrap that medium nerve causing very similar symptoms in the forearm, wrist, and hand. The big differentiation and I’ll say this a couple of times between the two is if you have decreased sensation over the pad of your thumb.


So it’s called the [inaudible 12:54] but you know you get that fat pad there that where your thumb is, if you have decreased sensation over that pad that’s going to distinguish Pronator teres syndrome from carpal tunnel because that sensory branch of the median nerve that innervates that [inaudible 13:10] palm It does not pass through the carpal tunnel.


So to break that down in a layman’s term is your nerves have a motor branch and sensory branch. The motor is movement, and sensory is what you feel, so you touch something obviously you feel that. Well that sensory branch doesn’t even go through the carpal tunnel to that that fat pad of your thumb so if that’s a problem then obviously it’s going to be coming upstream at the Pronator teres and that along with some palpation that we do up in that muscle group is how we usually distinguish Pronator teres syndrome from actual carpal tunnel, okay so that is the big distinction between Pronator teres syndrome and carpal tunnel syndrome.


The third one I want to discuss was de Quervain’s tenosynovitis, and this affects the two tendons that control the movement of the thumb, there’s… if you look at your thumb on the outside of it on the top are you’ll see some tendons right there. Those are the two tendons that can end up in that tunnel there they can become inflamed which really causes a lot of pain in that area. So if you’re having pain on the outside of the thumb they can have a gradual or onset, sorry an onset of localized pain right there over that thumb part that’s going to be de Quervains and many times that happens from typing and using a mouse as well and it’s people again sometimes just automatically think because they have wrist pain they have carpal tunnel and this one is going to be different, where it’s going to be more on the side of the thumb side of the wrist and that is your de Quervains tenosynovitis.


So there are other things that occur, you can have arthritis of the hands, you can have just a trigger point in your forearm, you can have gopher zobo tennis elbow where you’re going to have pain more up in the elbow but the three that I really wanted to distinguish for you today in this presentation that is often confused, whether you’re searching doctor Google or you’re seeing your primary care or other providers, too often it is missed and so make sure that we are getting the right diagnosis so that way that the treatment is correct.


Alright so what you do about this, we mentioned earlier about ergonomics. So one of the biggest things we need to address is the keyboard and the mouse, you really want to make sure there should be no twisting in your shoulders or neck. So you want to really reposition the mouse as needed once the keyboard is in the correct position. You want that keyboard right in front of you and not reaching for it, your wrist should be flat and straight about your forearms when using your keyboard and mouse, you don’t want them turning in. If your wrists are deviated left, or right or and your middle finger is not in line with the bones of your forearm as you type you may need a different keyboard as well. There are different keyboards that are going to adjust to your hands and even have a split keyboard if that helps you out, it’s something that you’re dealing with you may have to take that recommendation. If you rush your palms on the desk while typing your wrist will be bent back to reach the keyboard, you should have a soft palm rest to level out the angle. There’s that wrist guard you can put at the keyboard, that will really help you out in preventing some of the issues there okay and then lastly there should be no twisting in your shoulders or neck that is commonly an issue.


The other thing you can do with your mouse you want to make sure that you have a mouse pad with the wrist guard as well and then you can also alternate your mouse from right to left, and I know it doesn’t seem impossible, but you can put the mouse on the left side and alternate that and try to alleviate some of the symptoms may be on your right. So that is very helpful for you, in this picture here you can see this person with their desks set up, the elbows bent in ninety shoulders relaxed, they are not reaching for the keyboard. One of the biggest mistakes that people make is they prop up that keyboard with the stands, you know you can flip the back of the keyboard stand and have it inclined and then when you’re typing like that your wrists area an extension which is actually going to cause a lot of stress in that area.


You actually want to have a negative tilt downward; it’s very hard for a lot of people to do that unless you have a keyboard tray that allows for that. I have seen that frequently enough but not everybody does, so if you don’t have that the next best is to just lower down the razor, so don’t have those ups so the keyboard is flat and then having that wrist guard, that will keep your wrist in neutral when you type and will put a lot less stress on the keyboard.


So that’s going to lead me to the next thing, I’m actually going to go over a quick little workstation self-assessment that is very specific to these things that I just mentioned and how it relates to the forearm. This is not the complete twenty part questionnaire that we do, there’s access to that, and other women have actually done but this here and go through with you, if you answer no to any of these next seven questions that is something you need to fix okay.


So this is kind of your take-home moment and if you’re at the desk, you can kind of check yes or no to these and make some reference obviously you have access to the presentation as well to review, so I highly recommend that.


Okay, so number one is can you easily reach your work without interference from the arms of your chair? Again if you answer no, you need to fix that okay, so that’s number one.

Number two is your arms, and your shoulders relaxed without interference from the arms of your chair? Again yes or no if you answer no you need to fix that.

Number three are your shoulders relaxed and not elevated when you work on your keyboard.

Number four is your arms rested at your sides rather than stretched out in front of you? You do not want your arm stretched out in front of you.

Number five can you reach your mouse without rotating your arm outward or reaching to the side? That mouse is too far to the side or too far from your reaching for that’s going to cause problems.

Number six is your keyboard at the approximate elbow level with your forearms level and flat? I’ll reiterate that one, is your keyboard at approximately elbow level with your forearms level and flat and lastly number seven when typing or your wrists in line with your forearms and not bent upward or to the sides? So when typing is your wrists in line with your forearms and not bent upwards or to the sides that’s going to cause many issues with the wrist okay so that’s the little self-assessment I wanted you to take the keyboard mouse and basically the hand all the way up to the shoulder which is causing a lot of these types of conditions.


Alright moving on and we’re going to go over some wrist stretches for you, this slide here is just the basics, so I want you to try to perform these two to three times per day. I want you to stretch lightly and don’t force it, three sets of each stretch for fifteen to twenty-second hold and perform on both arms okay, so that’s the basics of the stretch.


This slide here is the carpal tunnel prevention card that we have, and as a member of this presentation you have access to that card, and then I’m going to go over the next slide which is an image of a close up image of how to do the stretch, so you can see that again apply those wrist stretch basics as far as the sets and reps and times per day to this one. So that is stretched number one, and as you can see there this is stretch number two that’s going to help out with the thumb and that thinner pad, and this is number three. So just to reiterate that is trying to differentiate what type of hand, elbow, wrist forearm pain even shoulder pain that you’re having give you a better understanding that it’s not always carpal tunnel there’s more to it. Have proper ergonomics implement those tips that we gave you, try to take micro-breaks that prevent that overuse injury cycle and you should be okay and help to prevent or manage these symptoms from happening.