Muscle Medicine: The Revolutionary Approach to Maintaining, Strengthening, and Repairing Your Muscles and Joints (24 page)

Two forearm muscles that control the thumb, the abductor pollicis longus and extensor pollicis brevis, can fatigue and shorten, irritating and inflaming their common tendon and tendon sheath, causing pain on the thumb side of the wrist. This overuse condition, De Quervain’s syndrome, often afflicts people who take up potentially thumbstressing activities such as knitting or prolonged computer use, or new mothers who are constantly picking up their infants.

The most frequently diagnosed nerve disorder in the arm is carpal tunnel syndrome. The median nerve passes through the carpal tunnel, where it can be compressed. This compression can cause numbness, tingling, and weakness in the thumb, index, or middle fingers, as well as the palm and forearm. Space in the tunnel gets tight when, for example, repetitive stress causes the neighboring tendons to become inflamed or the transverse carpal ligament thickens. But tight muscles, typically the pronator teres, which helps rotate the forearm, often compress the nerve and create the exact same symptoms. The ulnar nerve, which passes through a groove on the inside of the elbow (at the medial epicondyle), can also become compressed, causing tingling and numbness in the fourth and fifth fingers—a sister syndrome to CTS known as cubital tunnel syndrome. Like the median nerve, the ulnar nerve can be compressed by tight muscles at a number of spots up and down the arm. The radial nerve can suffer the same fate, getting trapped at several sites in the arm, causing numbness and tingling on the back of the hand.

WHAT GOES WRONG, AND HOW TO FIX IT

Mostly Muscular

Tennis Elbow (Lateral Epicondylitis)

Bob is a fifty-seven-year-old teaching tennis pro in northern New Jersey who has been treated for tennis elbow off and on for over a decade. He’s received corticosteroid injections for the trouble spot, which helped for a little while, until the next flareup, when the outer side of the elbow would again become painfully tender. Bob has a classic overuse injury. The forearm muscles that constantly work to straighten out the elbow (for instance, hitting backhand shots over and over) get irritated, along with the tendon on the outside of the elbow to which they are attached. The muscle medicine approach is to manually work to relax the muscles of the forearm that are tugging on that tendon and, in Bob’s case, to work on the tight shoulder that was contributing to the problem. He was out of trouble after six visits. Then he was able to begin physical therapy to strengthen the muscles that supported his newfound normal range of motion in the shoulder. He’s been pain-free for the past two years.

We actually don’t like the label
tennis elbow
. Therapists and physicians see lots of lateral epicondylitis patients who play tennis and lots who don’t. What they all tend to have in common is poor form doing their chosen activity. Often the problem begins at the shoulder—think of it as the first domino to fall. If the shoulder muscles are tight and the shoulder joint is not able to rotate normally, the elbow and wrist will have to make up the difference with extra motion, in this case overextension. That’s true whether you’re hitting a backhand or taking care of home repairs with a screwdriver. Muscle imbalance can be another contributing factor. If the biceps is tight or overdeveloped, the antagonist muscle, the triceps will have to overwork to straighten out the elbow, stressing that same outer-elbow area.

Golfer’s elbow, or medial epicondylitis, is a similar story, except this time it’s the flexor muscles and tendons on the front of the forearm that attach to the inner knob of the elbow, the medial epicondyle, that get overstressed. Golfers, bowlers, and baseball pitchers, who flex or snap their wrists, are vulnerable, as are people who put in long hours working with hand tools.

The textbook explanation of what happens in these tendinitis cases is that over-stressed
tendons and muscles suffer repeated microscopic tears that lead to inflammation. It’s inflammation that the
itis
in
lateral epicondylitis
or
Achilles tendinitis
refers to. As we mentioned in
chapter 3
, researchers now understand that tendons, unlike muscles, have only a limited capacity to become inflamed. With chronic tendinitis, the initial swelling goes away. It is more likely that the pain is caused by the repeated scarring of the tendon or irritating chemicals produced by that scarring. Both of these reduce the blood supply and make the tissue brittle and more susceptible to further injury. (
Tendonosis
is a better term for this degeneration of the tendon’s collagen fibers, but the medical profession has been slow to update its vocabulary.) Manual therapy works because it reduces the muscle’s pull on the tendon, allowing the tendon some relief from tension so it can heal. Meanwhile, leading doctors in academic medicine have been rethinking the medical treatment of damaged tendons (see the box below). For those uncommon cases of tennis elbow and golfer’s elbow that resist all forms of conservative treatment, surgical procedures can remove the damaged section of the tendon and stitch it back together.

PRP THERAPY

Dr. Jennifer Solomon, physiatrist, Hospital for Special Surgery: “Lots of doctors try to treat chronic tendon pain with corticosteroid injections to reduce inflammation, but patients may not necessarily respond. Most of the pain associated with tendonosis probably comes not from inflammation but from other irritating biochemical substances associated with the injury. It’s more important to address the underlying issue. For a majority of cases, doing manual muscle therapy and then physical therapy is highly effective. But there are patients for whom nothing seems to work. With this group, we are having a lot of success with PRP or plasma-enriched protein injections. We take some of the person’s blood, thin it down to obtain nutrient-rich plasma, and inject it back into the area. It gets nutrients into the tendon tissue and promotes healing. I think in the next ten years you’re going to see it being used to treat arthritis, spinal disks, a lot of musculoskeletal areas where we hadn’t had much progress before.”

De Quervain’s Tenosynovitis

Ruth, in her fifties, worked at an assembly-line job in a New Jersey factory, where she performed the same movement over and over, hooking a metal plate with a device and flipping it over. After years of that, she had developed a persistent dull ache on the thumb side of her wrist. This was De Quervain’s tenosynovitis, an inflammation and irritation of the tendon sheath that houses several small muscles that control the thumb. Her doctor put her in a wrist brace, which offered no relief. He gave her a corticosteroid injection, which did relieve her symptoms, but only for a few months, because the tight, shortened muscles weren’t addressed. Finally, manual therapy broke up the tightness in the muscles that were pulling on the tendon, and this relieved the pain. Once the muscles could move normally, Ruth was given conditioning exercises to develop the strength and flexibility of the muscles and tendons. On her own time, she was able to build up the resilience of the forearm so she could return to her job without crossing the line into repetitive stress injury.

Painstaking manual work such as sewing or woodworking or, in Ruth’s case, assembly-line labor requires twisting and grasping movements that can overstress the thumb tendons, especially when the wrist is held in an extended position (knuckle side pulled back).

With any new activity, the muscles and tendons may not have a chance to adjust to the sudden extra demand. Baby-holding isn’t exactly a sport, but good form is just as important as it is in tennis. When De Quervain’s is caught early enough, inflammation is part of the injury package; Dr. Solomon has had good success treating it with one or two corticosteroid injections. But the best plan of attack is the same as with the other repetitive stress arm injuries: correct your form, relax the muscles manually, and condition them with physical therapy exercises.

Muscle or Joint?

Carpal Tunnel Syndrome

Julie is a twenty-five-year-old grad student at Rutgers, anxiously typing through the day, trying to finish her dissertation on deadline. As she neared her goal, her hands began to give out on her. She’s had numbness and tingling in the thumb and first two fingers of her left hand. A diagnostic test revealed she had a mild case of carpal tunnel syndrome. Her doctor recommended surgery, but she was willing to try the

PROTECT YOUR WRISTS

When you’re typing, you should be able to keep your wrists straight and your elbows bent at about ninety degrees. A sliding keyboard tray can help you find the right distance between the keyboard and your body. Try to keep your forearms in a neutral position and not slightly turned out to either side.

When you’re typing or doing housework or home repairs that involve a lot of wrist movement, take breaks as often as possible, for instance, every fifteen minutes or half an hour.

Whether you’re picking up a baby or working a screwdriver, keep your arms in as close to the body as you can. The more you extend the arms, the more stress you’re putting on the elbow and wrist.

If you have any hand/wrist nerve issues, try wearing a wrist splint or brace to bed. People often sleep in a stressful, wrist-flexed position.

Tennis players and golfers should get regular tune-ups from a teaching pro, especially if they’re having elbow or wrist pain. Tennis players with tennis elbow should take a look at their racquet. A racquet that is too heavy, too tightly strung, or has too small a grip may be causing or contributing to the problem.

Don’t lean on your elbows.

Weight lifters who pump up their biceps need to make sure to develop balance by working the antagonist muscle, the triceps, as well.

muscle medicine approach first. Dr. DeStefano worked to loosen all the muscles in the shoulder and the forearm, but as he suspected, it was a small forearm muscle, the pronator teres, that was the primary problem. The tight, inflamed muscle had been pressing against the median nerve. After five visits, Dr. DeStefano had restored normal movement to the muscle and the symptoms disappeared. Julie went home with a program of stretching and strengthening exercises to keep her out of trouble as she plowed through the last chapters of her dissertation.

In her fifties, Martha had kept up a heavy daily typing schedule for two decades working as a secretary for a northern New Jersey manufacturing company. She’d had intermittent pain and numbness in the hands for years, but she’d managed to get by, dulling the symptoms with Advil. Finally, it became too much. She was
manually treated for the muscles of her arm, wrist, and hand, including the pronator teres, but she improved only slightly. The nerve damage was so severe that the muscles in the hand that are activated by the median nerve had already started to weaken, or atrophy. She couldn’t open a jar and could barely button her shirt. Dr. DeStefano sent her to a hand specialist who cut the transverse carpal ligament and opened up badly needed space for the nerve. The operation was a success, but she still had some localized hand pain caused by surgical scarring. Manual work on the scarred muscle tissue brought her completely out of pain.

Two stories, two different strategies. Overuse injuries often come about from a combination of different factors. In the case of carpal tunnel syndrome, the main issue is the pressure on the median nerve within the carpal tunnel. But the median nerve can be entrapped by the transverse carpal ligament directly, by the swelling of structures within the tunnel, or by an accumulation of scar tissue or foreign bodies.

Again, it comes down to that combination of bone, joint, and muscle that is specific to every person’s injury. Both Julie and Martha were women with narrow wrist bones, which made them even more susceptible. (Pregnancy, and the fluid retention that comes with it, is another risk factor; genetics and trauma, which don’t discriminate by gender, can also bring the syndrome on.) Julie is young. Her con-