Amanda A Grant PT, DPT, FAAOMPT, MTC, CLT,OCS

and

Matthew L. Daugherty, PT, DPT, MOT, OTR/L,FAAOMPT, MTC, OCS

Manual Therapy Interventions for Wrist Pain

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Disclosure

Both speakers are employed by the University of St. Augustine for Health Sciences (USAHS).Some manual treatment techniques are taught at USAHS.No relevant financial relationship exists.

Objectives

1) Describe the influence of biomechanical and anatomical structures on wrist pain.

2) Identify, through differential diagnosis, impairments at the wrist, radiohumeraljoint, distal radioulnar joint, and TFCC.

3) Demonstrate and integrate manual therapy intervention techniques in the management of wrist pain.

Wrist Anatomy - Review

Distal Radioulnar

Radiocarpal

Midcarpal

Carpal metacarpal

Wrist Pain Differential Diagnosis

Big things to look for….HistoryMOINature/location of Pain

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Compensatory Movements with Limited Pronation or Supination

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Limited Pronation with Shoulder Compensation

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Limited Supination with Shoulder Compensation

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Radiohumeral and RadioulnarJointRelationship

CompensationsLacking pronation results in increased GH abduction and CMC flexion or opposition

Irritation of APL and EPB

Lacking supination results in increased GH adduction and ER, and wrist ulnar deviation

Strain to TFCC

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CMC Joint AROM Assessment of Opposition

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Adductor PollicisAttachments:Transverse head:

anterior body of the third metacarpal

Oblique head:bases of the second and the third metacarpals and the adjacent trapezoid and capitate bones medial side of the base of the proximal phalanx of the thumb and the ulnar sesamoid

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Adductor Pollicis Length Assessment

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Radio-humeral and RadioulnarJoint Relationship

Kinetic chainThe body will compensate in the presence of dysfunction

“There is no prediction for a normal compensation BUT there are some common occurrences.”Patla, C. JOSPT 2000

Examination for Joint Mobility for Supination/Pronation Impairments

Ulna-meniscal triquetral joint

Distal radius-ulna joint (DRUJ)

Proximal radio-humeral joint

Must check alignment prior to assessment and manipulation

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DRUJ Assessment

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DRUJ Assessment

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Proximal Radio-Humeral Joint

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Proximal Radio-Humeral Joint Assessment and Treatment

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Proximal Radio-Humeral Joint-Assessment and Treatment

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Ulna-Meniscal-Triquetral Joint(UMT Volar Glide)

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UMT Volar glide

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UMT Volar glide

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Wrist Case #125 y.o. female c/o sx beginning after 2 day bike ride (totaling >150 miles)

Paresthesia in ulnar nerve distribution (digits IV ulnar half and V) volarly only.Sensory changesDifficulty in separating fingers/ Wartenberg signHand clumsinessHand weakness and loss of grip power and dexterity

MOI: Prolonged wrist extension with elbow locked in extension, and pressure through ulnar border of the hand/wrist

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Ulnar Tunnel Syndrome

3 potential sites of entrapment

Just proximal to or within Guyon’s Canal (sensory and motor involvement)

Between abductor digiti minimiand flexor digiti minimi (motor only)

Distal end of Guyon’s canal (sensory only)

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Unique interventions to Case #1

UMTVDistal RadioulnarjointProximal Radioulnar joint

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UMT Volar Glide

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Wrist Case #2

45 y.o. male chief c/o chronic proximal wrist pain

Located centrally and points to dorsal, distal forearm surface.Avid mountain bikerNo recent MOI

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Wrist Case #2

Long history of going ‘over the bars’, Fall on outstretch hand (FOOSH) injuries.

Pain worsens with wrist extension, particularly when loaded-closed chain and in pronation or supination.

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Unique interventions to Case #2

Distal Radioulnar joint

Lateral Carpal Glide

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DRUJ Instability

Physical ExamAROM

PROM (Classical)

Joint Mobility

Special TestsDRUJ instability test

Reprinted from Rehabilitation of the Hand and Upper Extremity, 201113

Distal Radio-Ulnar Joint

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DRUJ Treatment

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DRUJ Treatment

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DRUJ Instability Management

Minimize mal-alignmentExternal Stabilization

TapingExternal bracing

Internal Stabilization Must be initially done with alignment or bracingStrengtheningProprioception/stabilization therex

Lateral Carpal Glide-Option #2

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Lateral Carpal Glide-Option

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Lateral Carpal Glide-Gripping

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Lateral Carpal Glide-Open Chain Flexion and Extension

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Lateral Carpal Glide-Closed Chain

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No success distally????

Assess proximally

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Wrist Case #3

27 y.o. female with chief c/o sudden onset wrist pain.

Located on ulnar side of wrist .Recreational tennis player and works out at gym 3+ days/week.Recent MOI-recent pain after gym workout 1 week ago.Getting better but still has 3/10 pain with gripping activities and lack of full grip strength.

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Wrist Case #3

Joint and TendonopathyImpairments???

Unsatisfactory response to distal (wrist) treatment

Distal Radioulnar Joint GlidesLateral Carpal Glide

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Unique interventions to Case #3

Proximal Radio-Humeral Joint Glides

Lateral Glide of Ulna

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Proximal Radio-Humeral Joint-Treatment

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Lateral Glide of Ulna

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Lateral Glide of Ulna

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Lateral Glide of Ulna

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Lateral Glide of Ulna-Treatment

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Lateral Glide of Ulna –Supportive Treatment

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Lateral Glide of Ulna –Supportive Treatment

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Closing Remarks

Kinetic chainThe body will compensate in the presence of dysfunction

“There is no prediction for a normal compensation BUT there are some common occurrences.”Patla, C. JOSPT 2000

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Closing RemarksDon’t give up!

Assess the kinetic chain proximally and distally.

“Foot/ankle” of the UE.

PT’s need to be treating the entire UE, including hand and wrist.

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Thank you for the opportunity to share our clinical pearls with you.

Special Thanks to Megan Dawson and Morgan O’Clair

Questions???

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