Mechanics and Reduction of Wrist and Arm Musculoskeletal Disorders (MSKD) - USA

Congratulations! You have completed the Mechanics and Reduction of Wrist and Arm Musckuloskeletal Disorders course. Listed below are the key points presented in this course. Take time to review the material before you try the assessment. Download and print a copy of the detailed Course Review In this course you have learned to:        Identify commonly injured structures in the shoulder, wrist and hand      Explain signs and symptoms of rotator cuff tears, CTS, de Quervian’s syndrome, and stenosing tenosynovitis      Relate stretching maneuvers to exercised muscle groups.   We all use our upper extremities during our work and personal activities. Rotator cuff injuries result in shoulder pain which may transition to pain in the upper arm and elbow. Epicondylitis, inflammation of the tendons surrounding the medial and lateral epicondyles of the elbow, also result from overuse. Additionally, tunnel syndromes, both carpal, radial and ulnar, may decrease hand function.   Whether due to transient conditions, such as pregnancy,1, 2 or medications we take for cholesterol3 or infections,4, 5 we must counteract daily stresses accumulated in our musculoskeletal (MSK) system. Relaxation and release of tension can be accomplished through simple, yet effective, exercises performed during the day.6 View these instructions for information on navigating through the self-evaluation tools we call ‘Your Turns’. Click the icon below to start the self-evaluation exercise. Note: This is not part of the final Assessment.   Learn How to Navigate the Your Turns Learn how to navigate the Your Turns. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/navig-instr/index.htmlPDF File: Upon completion of this course, you will be able to:      Identify commonly injured structures in the shoulder, wrist and hand      Explain signs and symptoms of rotator cuff tears, carpal tunnel syndrome, de Quervian’s syndrome, and stenosing             tenosynovitis      Relate stretching maneuvers to exercised muscle groups   The study of human movement, kinesiology, encompasses both the structure and motion of our musculoskeletal system. Later in this course you will see how exercises stretch specific muscle groups releasing tension due to stress or daily life. To help you understand the importance of these activities, we begin with a review of anatomy and pathology seen in the shoulder, wrist, and hand.      Stretching of our shoulders and wrist help maintain, and may even increase, our range of motion in the joints. The shoulder, like any joint, has bursae, tendons, ligaments and muscles. This section focuses on the structures which maintain the position of the humeral head within the glenoid fossa of the scapula called the rotator cuff. This group of tendons and muscles help us raise and rotate the arm.7 The most common shoulder problem, rotator cuff tears, whether symptomatic or asymptomatic, increase with age.8  Click on the link below to learn more about rotator cuff muscles.  Learn More about Rotator Cuff Muscles Learn more about rotator cuff muscles.7, 9 Supraspinatus – maintains humeral position, abducts the arm.   Subscapularis – helps maintain the humeral position within the glenoid fossa, medial rotation of the humerus.   Infraspinatus – connects the scapula to the humerus, external shoulder rotation, arm extension and abduction. Teres minor – stabilizes the humerus in the glenoid fossa; external rotation of the shoulder.   Each of the rotator cuff muscles have a corresponding tendon. The biceps tendon courses through the biceps groove located in the head of the humerus.  The wrist lies between the forearm and digits of the upper extremity. Four small carpal bones lie adjacent to the radius and ulna with the remaining four articulating with the digits.   Multiple musculoskeletal structures traverse the wrist bones to include the median nerve, tendons, the abductor pollicis longus (APL), and extensor pollicis brevis (EPB). All pass through a tendon sheath inserting onto the base of the first metacarpal of the thumb.   Carpal tunnel syndrome (CTS) and de Quervian’s syndrome may result from overuse of the wrist and thumbs, however, both may be due extremity swelling during pregnancy.1, 10   Click on the links below to learn more about wrist anatomy and methods to minimize or prevent repetitive injuries to the wrist structures. Learn More about Carpal Tunnel Learn more about carpal tunnel. Tab TitleTextStructures9, 11  The carpal tunnel lies anterior to the wrist bones containing the flexor pollicis longus tendon (FPL), the median nerve (middle; yellow), four flexor digitorum superficialis tendons (FDS), and the flour flexor digitorum profundus tendons (FDP). Overlying the carpal tunnel is the flexor retinaculum. The flexor carpi radials (FCR) lies lateral to the carpal tunnel covered with a separate reticulum covering.CTS Symptoms12, 13  Carpal tunnel syndrome is the result of compression of the medial nerve. Possible signs of CTS Burning, tingling or numbness in the hand Hand weakness ​Pain in the forearm ​Performing exercises, such as the wrist stretch or towel shake (discussed later) help manage median nerve compression. Pain, tingling and numbness on the lateral side of the hand (light) raises concern for compression of the median nerve. The same symptoms on the medial side (dark) indicate compression of the ulnar nerve.   Risk Factors1, 14, 15Any time the median nerve becomes compressed the risk of developing CTS increases. This may be the result of swelling of the hand due to pregnancy-induced edema, chronic compression due to work tasks, or inflammation due to arthritis. Women tend to have a higher incidence and increasing age increases our risk of developing CTS.   Medical conditions Diabetes High blood pressure / Hypertension Arthritis Medications Thyroid disorders Personal habits Smoking High salt intake Sedentary lifestyle Obesity Work tasks Keyboard and mouse use Gripping (i.e., transducer, radiography exposure control) ​Vibrating tools / equipment (i.e., portable exams) Wrist Ergonomics6, 13  CTS, simplified, is caused by pressure on the median nerve. This can be due to physiologic processes such as swelling due to inflammation or edema. External contributors include improper ergonomics of the wrist.   Suggestions to reduce external compression of the median nerve. Decrease the force needed to perform tasks (i.e. gripping objects, amount of pressure). Relax, take breaks, and stretch. Maintain a neutral wrist position. This includes maintaining good posture while performing our tasks. Stay warm. Massage your hands.   This technologist demonstrates a neutral position with the wrists parallel to the forearms. Bend the elbows at a 90-degree angle, keeping the arm close to the body.  Learn More about de Quervian’s Syndrome Learn more about de Quervian’s Syndrome.9, 16 Tab TitleTextInvolved Structures  De Quervian’s syndrome (tenosynovitis) is the inflammation and swelling of the abductor pollicis longus (APL), extensor pollicis brevis (EPB), and the overlying tendon sheath. Actions such as gripping, clenching, pinching or wringing requires movement of the thumb tendons through their sheath.  The APL originates at the posterior, proximal radius and inserts at the base of the first metacarpal bone. The EPB originates in the middle third of the ulna and inserts into the base of the proximal phalanx of the thumb. Extensor retinaculum – teal; Tendon sheath – purple. Symptoms De Quervian’s results in pain located at the base of the thumb within the anatomic snuffbox. Inflammation of the tendons, extensor retinaculum and tendon sheaths hinder movement of the thumb when coapting with the index finger.   Symptoms include the following: Pain at the anatomic snuffbox Swelling Numbness on the back of the thumb and index finger due to nerve compression Crepitus or snapping with thumb movement Discomfort when performing the Finkelstein’s test Performing wrist exercises, such as the tennis ball squeeze and weighted pinch grip (discussed later) help exercise the APL and EPB.   Pain in the anatomic snuffbox (black triangle; left hand) occurs when moving the thumb and index finger together.    Risk FactorsInjuries, such as a sprain or hyperextending the thumb, may be the start of de Quervian’s. However, chronic injury in the form of a repetitive motion results in long standing pain.   Individual  Activities Female 40 or older Ethnicity (African descent increases risk) Pregnancy Previous injury Inflammatory arthritis Lifting heavy objects Hobby that uses wrist (i.e., playing piano, golfing, musicians, hand sewing) Maternal lifting of the neonate with thumbs radially extended. Thumb use with smart phones or the space bar on a keyboard. Abduction of the thumb while playing the trumpet combined with the pinching motion with the index finger increases the chance of developing de Quervian’s syndrome. The hand is a mechanical marvel containing five digits, four fingers and the thumb. The latter, our opposable thumbs, allow us to hold and pick up objects. Touching of the thumb to the digits provide the basis for counting, communication while signing, or as part of our body language.   Digits of the hand Thumb (T) located on the radial side of the forearm Index finger (I) – second digit Middle finger (M) – third digit – usually the longest Ring finger (R) – forth digit Little finger (L) – located on the ulnar side of the forearm Click on the link below to learn more the pulley system of the digits and the result when tendon sheath inflammation or scaring hinder movement. Learn More about Stenosing Tenosynovitis Learn more about stenosing tenosynovitis.9 Tab TitleTextInvolved Structures Muscles that allow us to move our fingers originate in the palm of the hand or forearm. The dorsal and palmer areas of the hand have innervation from branches originating in the brachial plexus.   The tendons that course through the carpal tunnel to the digits glide through sheaths (purple). Each sheath has an overlying fibrous layer – called a pulley - holding the apparatus in place (teal). When we curl the digits, the muscles contract, tendons glide through their sheaths, and our fingers flex. Trigger FingerStenosing tenosynovitis or trigger finger / thumb occurs when the pulley mechanism becomes inflamed. The result is a digit locking in the flexed position. The finger or thumb cannot extend due to catching within the tendon pulley system or a stenosing tenosynovitis.   As with other MSKD, medical conditions, such as inflammatory arthritis increase the risk of developing trigger finger. Repetitive, forceful grasping of an object, such as a pencil, gardening tools or a baseball bat.   The left image shows forceful gripping of an ultrasound transducer as evidenced by the white knuckles. In radiography, forceful grasping of the exposure button contributes to inflammation of the digit pulley system.   Your Turn Your Turn. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/fw-arm-your-turn-001/index.htmlPDF File: In this section we will focus on wrist and arm movements which may help decrease our risk of developing pain or numbness due to repetitive motion. This type of injury makes tasks, such as answering email, preparing meals, or performing work assignments difficult.   The following section illustrates a sample of beginner stretching exercises. Though examples may show only one joint, there are multiple benefits throughout the upper arm.   Remember, we are training the movement not just the muscles. Strengthening and stretching improves the stability of our joints. The palmer wrist contains two passages for nerves and tendons, the ulnar and carpal tunnel.9 Repeated damage results in numbness in the hand with the location indicating the affected nerve. Ulnar nerve damage results in numbness, and weakness in the ring and little fingers. Injury to the median nerve, which courses through the carpal tunnel, results in symptoms in the first three digits on the radial side of the wrist.9, 13   Carpal tunnel syndrome (CTS) has a higher incidence than ulnar tunnel syndrome (UTS), however, exercising wrist structures aids in restoring the range of motion through stretching the wrists, hands, and fingers.13, 17 These movements, though focusing on the wrist flexors and extensors, also exercise the forearm.   Computer mouse and keyboard use compresses structures located on the palmar side of the wrist and hand. Download and print a copy of the Wrist Stretch step-by-step guide.  Wrist Stretch Wrist stretch. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/25wrist-stretch-2.mp4PDF File: One method to strengthen and exercise the hand muscles is to squeeze and release an object that fits into the palm of your hand (i.e., tennis, stress or physio ball, therapy putty).18 This activity helps improve your grip strength, ability to hold onto your dog’s leash, or hold a tea cup. This squeeze – release cycle contracts and relaxes the hand and forearm muscles. Muscles involved9   Wrist flexion and grip release  Wrist extension and grip force muscles  Deep muscles used to flex and extend the fingers and thumb Extensor digitorum comminis Flexor digitorum profundus  Flexor pollicis longus Lumbricals Interossei Adductor pollicis Download and print a copy of the Tennis Ball Squeeze step-by-step guide.   Tennis Ball Squeeze Exercise Learn more about the tennis ball squeeze exercise. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/ball-squeeze.mp4PDF File: Another method to exercise the fingers, wrists, and forearms is to perform finger press exercises. Also called the spider stretch, this movement exercises from the fingertips to the elbow. When performing this maneuver round your fingers in a claw-like position, and spread the fingers. Benefits Begin this stretch with the fingertips together. Exercises Stretches Hand extensors Tendons Palmar fascia Carpal tunnel structures Median nerve Download and print a copy of the Spider Stretch step-by-step guide. Learn More about Spider Stretches Learn more about spider stretches. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/spider-stretch.mp4PDF File: A different movement that improves your wrist and grip strength is the fingertip wall push up. There is an additional benefit of exercising the remaining forearm and triceps. Muscles involved9 Pectoralis Anterior deltoid Triceps Biceps Finger extensors Download and print a copy of the Fingertip Wall Push Ups step-by-step guide. Modifying the hand position during the push up changes muscle groups. . Fingertip Wall Push Ups. Learn more about fingertip wall push ups. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/fingertip-wall-pu.mp4PDF File: Your Turn Your Turn. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/fw-arm-your-turn-02/index.htmlPDF File: You are doing a great job starting your stretching routine with these exercises! If you have become comfortable with these maneuvers, take a moment to think about how you can increase the exercise intensity by adding pressure or resistance.   The following sections show progression of exercises using easy to find objects such as books, chairs, or balls.   Grasping of on object with the thumb on one side and the fingers on the opposite side describes a grip pinch (aka lateral pinch). This maneuver uses muscles that originate in the forearm but insert or attach in the hand.    Extrinsic muscles of the hand: Flexor digitorum superficialis Flexor digitorum profundus Palmaris longis Flexor pollicus longus Nerves used with grip pinch Interosseous branches of the Ulnar nerve Median nerve This is a demonstration of the two-point pinch where the thumb and first finger touch, similar to when using a ‘pinch of salt’ in a recipe. Download and print a copy of the Weighted Grip Pinch step-by-step guide. Weighted Grip Pinch Learn more about the weighted grip pinch. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/weight-grip-pinch20.mp4PDF File: The triceps brachii is the large muscle located on the posterior upper arm which helps us to straighten the arm at the elbow. This muscle, coupled with the latissimus dorsi, aids in movement of the arm towards the body. This three-headed muscle originates at the scapula, and the upper humerus and inserts into the posterior elbow.    The bicep muscle contraction counteracts the triceps movement. Consider doing exercises for both muscles. Download and print a copy of the Chair / Bench Dip step-by-step guide. Learn More about Chair / Bench Dips Learn more about chair / bench dips. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/chair-dip.mp4PDF File: The use of a ball during the push up maneuver uses your body weight to exercise the arms, shoulder, and chest. The ball requires the use of core muscles (i.e., abdominal, back) to keep a stable position. Since the ball moves you away from the wall, you must move further (increase the range of motion) to complete the exercise.   Download and print a copy of the Mini-ball Wall Push up step-by-step guide. Mini-ball Wall Push Up Learn more about the mini-ball wall push up. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/mini-wall-pu.mp4PDF File: The grasping of a rolled-up towel helps strengthen your hand. The movement or shaking of the towel can help relieve pressure on wrist nerves, vessels, and increase your wrist range of motion.   Download and print a copy of the Multi-directional Towel Shake step-by-step guide. Multi-directional Towel Shake Learn more about the multi-directional towel shake. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/towel-shake.mp4PDF File: Your Turn Your Turn. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/fw-arm-your-turn-03/index.htmlPDF File: You are doing a fantastic job! As you progress through these exercises, be aware of what your body says. Remain positive even on days when doing easier exercises, remember, action is the key!    Discontinue if you experience the following: Pain Numbness Resistance bands increase the intensity of many exercises. You can find these bands with or without handles, this tool allows you to increase the work your muscles perform. We know that we exert our muscles when stretching the band; however, a slow release of the band stress provides exercise. Resistance bands pack easily allowing us to continue our routine when traveling. Download and print a copy of the following step-by-step guides. Resistance Band Curls Resistance Band Overhead Triceps Press Band Overhead Triceps Press Learn more about band overhead triceps press. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/overhead-tricep-press.mp4PDF File: Resistance Band Curls Learn more about resistance band curls. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/band-curls.mp4PDF File: A stability ball is a large flexible ball ranging in size from 35 to 85 centimeters / 14 to 34 inches. The size of ball used depends on your height. To determine the correct circumference, when sitting on the ball your thighs should be parallel to the floor.19 An exercise ball is also called a Swiss, gym, yoga, or pregnancy ball. Our first exercise, a stability ball wall-out, uses the following muscle groups20 Lower back Deltoids Rectus abdominus Obliques Triceps Pectoralis major Trapezius Hamstring tendons Gluteal muscles   Download and print a copy of the Stability Ball Walkout step-by-step guide. Stability Ball Walkout Exercises Learn more about stability ball walkout exercises. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/sb-walk-outs.mp4PDF File: Two helpful isometric movements, straight arm and forearm plank, exercise muscles in our cores, chest, arms, and back. Using a stability ball increases the difficulty of these exercises and the intensity of our workout.   Isometric describes an exercise which muscle contraction occurs without joint movement. Muscles used in this exercise20     Abdominal Spinal erectors Deltoids Triceps Trapezius Rhomboids Rotator cuff Gluteal Quadriceps Gastrocnemius Pectorals Serratus Download and print a copy of the Stability Ball Up and Down Planks step-by-step guide. Up and Down Planks Learn more about up and down planks. Instructions:Flash File:HTML5 File:/content/generator/Course_90024587/sb-up-down-planks.mp4PDF File: Explore the links below for the Glossary, References, and Further Reading opportunities. Glossary. Glossary Tab TitleTextA - FAbduct (arm) – Movement of the upper extremity away from the midline.   Abduct (thumb) – Movement of the thumb away from the index finger.   Brachial plexus – Network of nerves located in the axilla posterior to the clavicle.   Bursae – Sac or pouch-like structure surrounding a joint filled with fluid to reduce friction occurring with movement.   Ergonomics – The study of a person’s efficiency in either a personal or work environment.   Extension – The movement of a limb from a bent to straight position.   External rotation (arm) – Movement of the humerus when the arm rotates laterally.   Finkelstein’s test – A test used to help diagnose the origin of radial wrist pain. The thumb is moved towards the ulnar side of the hand with the remaining digits curled around the thumb. The examiner moves the hand towards the ulnar wrist resulting in radial side pain with de Quervain’s Syndrome.I -UInternal rotation (arm) - Movement of the humerus when the arm rotates medially. Ligament – Connect bone to bone or cartilage to joints.   Median nerve – Nerve arising from the brachial plexus, passing on the radial, anterior portion of the arm through the carpal tunnel to supply the lateral three fingers (thumb, index, middle).    Muscle – Specialized structures which contract to move or maintain position of the body or limb.   Nerve – A fiber bundle that transmits signals between the body, spine, and brain.   Tendon – Structure connecting muscle to bone.   Tenosynovitis – Swelling of a tendon due to inflammation due to repetitive movement.   Ulnar nerve - Nerve arising from the brachial plexus, passing on the ulnar, anterior portion of the arm and passing through Guyon’s canal to supply the medial two fingers. References / Further Reading References / Further Reading. Tab TitleText1 - 81. Almeida, H.A., Ascenso, R.M.T., and Oliveira, E. (2018). Anthropometrics and Ergonomics in Pregnant Women. In Brandão, S., Da Roza, T., Ramos, I., et al., (Eds.), Women's health and biomechanics: where medicine and engineering meet (pp. 97-108). Cham: Springer International Publishing.   2. Thabah, M. and Ravindran, V. (2015). Musculoskeletal problems in pregnancy. Rheumatology International. 35(4): 581-587.   3. Auer, J., Sinzinger, H., Franklin, B., and Berent, R. (2016). Muscle- and skeletal-related side-effects of statins: tip of the iceberg? European Journal of Preventive Cardiology. 23(1): 88-110.   4. Shimatsu, K., Subramaniam, S., Sim, H., and Aronowitz, P. (2014). Ciprofloxacin-induced tendinopathy of the gluteal tendons. Journal of general internal medicine. 29(11): 1559-1562.   5. Stinner, D.J., Orr, J.D., and Hsu, J.R. (2010). Fluoroquinolone-associated bilateral patellar tendon rupture: A case report and review of the literature. Military Medicine. 175(6): 457-459. 6. Industry standards for the prevention of work related musculoskeletal disorders in sonography. (2017). Journal of Diagnostic Medical Sonography. 33(5): 370-391.   7. Maruvada, S., Madrazo-Ibarra, A., and Varacallo, M. (2020). Anatomy, rotator cuff. StatPearls [Internet]. 2020; Available from: https://www.ncbi.nlm.nih.gov/books/NBK441844/.   8. Minagawa, H., Yamamoto, N., Abe, H., Fukuda, M., Seki, N., Kikuchi, K., . . . Itoi, E. (2013). Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. Journal of orthopaedics. 10(1): 8-12.  9 - 179. Moore, K.L., Dalley, A.F., and Agur, A.M.R. (2015). Arto superiore. In Moore, K.L., Dalley, A.F., and Agur, A.M.R., (Eds.), Anatomia umana: A orientamento clinico (pp. 709-864). Philadelphia: Casa Editrice Ambrosiana.   10. OHCOW. (2020). Ergonomics & pregnancy, Occupational Health Clinics for Ontario Workers Inc.: Ontario.   11. Presazzi, A., Bortolotto, C., Zacchino, M., Madonia, L., and Draghi, F. (2011). Carpal tunnel: Normal anatomy, anatomical variants and ultrasound technique. Journal of Ultrasound. 14: 40-6.   12. CCOHS. (2019). Work-related musculoskeletal disorders (WMSDs). 2019 2019 [cited 2019 13 November]; Available from: https://www.ccohs.ca/oshanswers/diseases/rmirsi.html.   13. Yoo, W.-G. (2015). Effect of the release exercise and exercise position in a patient with carpal tunnel syndrome. Journal of Physical Therapy Science. 27(10): 3345-3346.   14. Harrison, G., Harris, A., and Flinton, D. (2018). Can teaching ultrasound ergonomics to ultrasound practitioners reduce white knuckles and transducer grip force? Journal of Diagnostic Medical Sonography. 34(5): 321-327. 15. Khaliq, Y. and Zhanel, G.G. (2005). Musculoskeletal injury associated with fluoroquinolone antibiotics. Clinics in Plastic Surgery. 32(4): 495-502.   16. van Holsbeeck, M., Ditmars, D., and Introcaso, J. (2016). Sonography of the wrist and hand. In van Holsbeeck, M. and Introcaso, J.H., (Eds.), Musculoskeletal Ultrasound (pp. 870-945). Philadelphia: Jaypee.   17. Garfinkel, M.S., Singhal, A., Katz, W.A., Allan, D.A., Reshetar, R., and Schumacher, J., H. (1998). Yoga-based intervention for carpal tunnel syndrome; A randomized trial. JAMA. 280(18): 1601-1603.18 - 2018. Stoffer-Marx, M., Klinger, M., Luschin, S., Meriaux-Kratochvila, S., Zettel-Tomenendal, M., Nell-Duxneuner, V., . . . Stamm, T. (2018). Functional consultation and exercises improve grip strength in osteoarthritis of the hand - A randomized controlled trial. Arthritis Research & Therapy. 20.   19. ACE. (2001). Strengthen your abdominals with stability balls. 2001 [cited 2020 April 28]; Available from: https://acewebcontent.azureedge.net/assets/education-resources/lifestyle/fitfacts/pdfs/fitfacts/itemid_129.pdf.   20. Ferke, Z. (2016). Calisthenics mastery. 2016 [cited 2020 April 29]; Available from: http://calisthenicsmastery.com/. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages.   All names and data of patients, parameters and configuration dependent designations are fictional and examples only.   All rights, including rights created by patent grant or registration of a utility model or design, are reserved.   Please note that the learning material is for training purposes only!   For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. 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