05 Feb A strange case of the creaks!
Got creaking thumbs – read on?
I had a patient who came in this week with a strange case of ‘The creaks’. Mr ‘x’ – not a criminal master mind but a sports enthusiast – honest – had been kayaking for three days, which for him was much more than he had ever done before, over 2 weeks ago. He started to notice a strange yet painful creaking in his wrists which also gave rise to lumps or swelling forming along the thumb side edge of his wrists and forearms.
He wasn’t able to move his hands at all without the onset of creaking and pain so he came in to see what I thought. I have to say I have never felt creaking like it as it would reverberate as far up the up as the shoulders. We were able to isolate the muscle group which caused most creaking and pain and identified these to be the ‘extensor pollicis muscle groups’ on both wrists.
Now – looking at the mechanism of injury (kayaking for 3 days straight) – The hands would have been gripping the paddle fairly hard whilst the elbows and shoulders would have been rolling to provide the necessary leverage and power to glide through the water. Having the hands and thumbs gripping the paddle for so long requires that the musculature throughout the arm and wrists to contract and relax continuously for hours at a time. This constant gripping and slight movement of the wrist may have caused tiny microtears to form which get more numerous as the days go on. The severity, intensity and nature of the pain (high levels of pain, constant and sharp) and the aggravating factors which cause the pain it is highly likely that the musculature, tendons and fascia have been thoroughly irritated to the point that swelling / inflammation is present. Swelling within the tendon sheaths themselves – a condition called ‘Tenosynovitis’.
This is the back of the hand and forearm with a in detail view of the ‘extensor pollicis muscle group’ and their attachments. You can see that the tendons run from the thumb, along the edge of the forearm (radius) to form the muscle bellies which in turn attach to the bones in the forearm. These muscles let us give the ‘thumbs up’ sign and allows us to open the grip of our thumbs.
SO WHY THE CREAKING?
Our tendons are strong lengths of tissue which need protecting from other structures in the wrist as they often bend around bones to form pulleys – see the picture above and note how the tendons run along bone. Soft tissue gliding over bone leads to tethering and breakdown of that tissue unless protected in some way. Tendons are protected by a ‘ tendon sheath’ which encloses the tendon itself and allows for friction-less movement of the tendon within the sheath. With regard Mr X’s creaking it is very likely that this is is happening WITHIN the tendon sheath itself. This is caused by inflammation between the tendon and its sheath, which if severe enough can fill the space between the tendon and sheath so much that the swelling pushes out into the lining of the sheath and forms lumps along the length of the tendon.
WHAT CAN BE DONE WITH THIS?
My plan for treatment was simple. We needed to prevent the swelling from occurring in the future, reduce the inflammation currently present, decrease pain and restore normal function of the wrist and thumb through rest and rehabilitation. Limiting the use of the hand with a splint or tape is a good first step as this reminds Mr X to be careful with the wrist. It also restricts too much movement so the sheath isn’t irritated any further.
Ice, non-steroidal anti-inflammatories (NSAIDs) and rest will act to lessen the amount of inflammation currently in the wrist and then when this recedes and the swelling is gone we can then start rehabilitation which includes retsoring range of movement, power and confidence when using the wrists.
As I said at the beginning – this is a severe case so it is likely that physiotherapy itself will cure the issue. Given the fact that all movements hurt, its a constant pain and the swelling is so much so that it is forming visible lumps then I thought it best to get the area looked at through ultrasound sonography – a type of imaging technology which is quick, non invasive and can give excellent images to work from – via an Orthopaedic surgeon. If he finds that there is a large amount of inflammation then he may decide to inject with cortico-steroid to reduce it and possibly – if severe enough – drain the inflammation.
We have agreed to a re-assessment in 1 week following basic physiotherapy, stretches, taping and rest to see if issue has improved itself and in the meantime a referral has been made to get the wrist examined thoroughly via Ultrasound sonography.
I will keep you posted!
If you have any issues with creaking or anything similar then come and see us – Rosier Physio & Movement Studio, Newtown Road, Newbury, RG14 7EB or call us on 01635 569329