Is your Wrist Pain a Tendonitis? All about Diagnosis, Treatment and Recovery — Transcript

Full transcript

1. 0:00In this video I’m going to explore the  different types of tendinitis that can
2. 0:04affect the wrist. Im going to look at which are  the most common tendons that can be affected,
3. 0:10what the causes are, and how you can  get it better. Im Stephen Bunting,
4. 0:14I’m a specialist MSK physiotherapist working in  the UK. Welcome to the channel where I explore the
5. 0:21common MSK problems that affect everyday people  and the evidence based treatments that can help.
6. 0:42Well tendons are the rope like structures that  most muscles use to connect to bones. ‘itis’
7. 0:48means inflammation, so tendonitis basically means  an inflamed tendon. Now some tendons like for
8. 0:55example the Achilles tendon, the hamstring  tendons, the biceps or triceps tendons, are
9. 1:02single tendons which act alone or as part of small  group, to move a particular joint. But the tendons
10. 1:09around the wrist and also the ankle and foot are  bit different. There are lots of them bunched
11. 1:15together. In the wrist, there are 12 tendons which  cross over the back of the wrist and another 11 on
12. 1:22the front of the wrist, and between them they  move the wrist in all different directions
13. 1:27and also each individual finger and thumb. And in  order to stop them all rubbing against each other,
14. 1:34and the underlying wrist bones, they each have a  tendon sheath which surrounds them, a bit like the
15. 1:41insulating layer around an electrical cable. And  within each tendon sheath is a layer of synovial
16. 1:47fluid, which is an oily slippy fluid, which  bathes the tendon fibres and allows them to
17. 1:53move freely within the sheath. In this way, lots  of tightly packed tendons can move freely in a
18. 2:00confined space without friction. At least thats  what happens when things are working normally. But
19. 2:07like any system, it’s only as good as the person  using it. If you overload the wrist tendons,
20. 2:13then they can become inflamed and the inflammation  in tendons with sheaths gets contained within the
21. 2:20tendon sheaths causing a Tenosynovitis, which  is an inflammation of the tendon sheath. So
22. 2:28to be accurate we don’t get a tendonitis  around the wrist, we get a tenosynovitis
23. 2:35because it’s the wrist tendon sheaths that  get inflamed, not the tendons themselves.
24. 2:44In the vast majority of cases a wrist  tenosynovitis is caused by overuse. It can
25. 2:51be a single instance of heavy lifting but more  commonly it’s caused by lower level repetitive
26. 2:57activities over a longer period, usually a few  weeks or months. The usual activity culprits
27. 3:04are excessive use of a keyboard, mouse, tablet  or gaming controller. Also things like writing,
28. 3:12needle crafts, racket or throwing sports and also  using weights in the gym with poor wrist form.
29. 3:19And anyone can get it, and at any age. It’s more  common in the younger age groups up to middle age
30. 3:26because these age groups are more likely to be  involved with repetitive strenuous activities.
31. 3:32The other group of people who are at risk of  tenosynovitis are poorly controlled diabetics,
32. 3:38because of poor tissue healing, and also gout  and rheumatoid arthritis. So if you have a
33. 3:44persistent tenosynovitis and you can’t think of  an obvious overuse cause then do get medically
34. 3:50checked out. A simple blood test is usually all  that’s needed to check for these conditions.
35. 4:01Well pain directly over the affected tendon is  the most common symptom. It’s usually a dull
36. 4:07ache but with intermittent sharp stabs of pain  when moving the wrist. The tendon might also be
37. 4:14swollen and because any swelling is contained  with the tendon sheath, it tends to be very
38. 4:20localised,
39. 4:21rather than spreading out around  the whole wrist like a joint swelling might do.
40. 4:26And when tendon sheath swelling has been present  for a while, it tends to get a bit sticky and it
41. 4:32can cause a creaking or popping sensation when  the tendon moves. We call this tendon crepitus
42. 4:39and it’s a common sign of chronic tenosynovitis.  The other common symptom is local tenderness. So
43. 4:47if you poke the affected tendon with a finger,  it’s usually going to be painful. And because it’s
44. 4:53an overuse problem, any movement of the affected  tendon is likely to be painful. So that might be
45. 4:59a wrist movement, or the movement of a  finger or thumb. And if these symptoms
46. 5:04persist then you’re likely to get weakness and  stiffness of the wrist and the fingers or thumb.
47. 5:15Well thankfully this is usually fairly  straightforward because the wrist tendons
48. 5:19are quite easy to feel and they tend to get very  tender when inflamed. So basically a patient
49. 5:26with a wrist tenosynovitis is usually going to  point to the exact tendon which is affected.
50. 5:33So you can divide the wrist up into 6  sections. On the back of the wrist the
51. 5:38patient might point to the thumb side of  the wrist, the middle area or the little
52. 5:43finger side. And similarly on the palm side of  the wrist they might point to the thumb side,
53. 5:50the middle part or the little finger side. And  each of these 6 areas corresponds to a particular
54. 5:58tendon or group of tendons. Now buckle up because  in the next section I’m going to go through these
55. 6:05tendons and they all have long latin names.  But don’t let that put you off. Being able to
56. 6:10name the particular tendon affected is nice  to know, but it’s not really necessary. Just
57. 6:16knowing which of those 6 areas is your problem  area is enough to follow the treatment regime.
58. 6:23So if your pain is over the back of the wrist on  the thumb side right here then the tendons usually
59. 6:28involved are Abductor Pollicis Longus and Extensor  Pollicis Brevis, and indeed these are by far the
60. 6:35most common tendons affected by tenosynovitis  of the wrist. So much so that is gets its own
61. 6:41name - De Quervain’s tenosynovitis, otherwise  known as mommy thumb because mothers of babies
62. 6:49and young toddlers are the most common group of  people affected by this. Now because De Quervains
63. 6:55is the most common wrist tenosynovitis, Ive dealt  with it separately in another video which I’ll
64. 7:01link to up here and in the description. So if you  think you have De Quervains then go and check that
65. 7:09out. For the rest of you, stick around and we will  go through the other tendons that can be affected
66. 7:15around the wrist. So let’s move into the middle  section on the back of the wrist, and the tendons
67. 7:21which live here are Extensor Carpi Radialis Longus  and Brevis, which both extend the wrist, Extensor
68. 7:30Pollicis Longus, which straightens the thumb,  Extensor Indices, which straightens the index
69. 7:36finger, Extensor Digitorum which extends the wrist  and straightens all of the fingers, and Extensor
70. 7:43Digiti Minimi which straightens the little finger.  Still on the back of wrist but now over the little
71. 7:50finger side, we have Extensor Carpi Ulnaris, which  is a large tendon that extends and also side bends
72. 7:57the wrist like this. ECU is the second most  common wrist tendon affected by tenosynovitis.
73. 8:06Now onto the palm side of the wrist and over  the little finger side we have Flexor Carpi
74. 8:12Ulnaris which helps flex the wrist and this  is the 3rd most common wrist tendon affected
75. 8:17by tenosynovitis. In the central portion of  the palm we have 8 Flexor Digitorum tendons
76. 8:24which bend the fingers and the Flexor Pollicis  Longus tendon which bends the thumb, and then
77. 8:31finally over the thumb side we have Flexor  Carpi Radialis which is another wrist flexor.
78. 8:38This diagram can be really useful in helping  to determine which tendon it might be. So to
79. 8:46work out which tendon might be affected, you  first look at which of the 6 sections of the
80. 8:52wrist is most painful and then if there are  a few different tendons within that section,
81. 8:57you would then look at which movement is most  painful, either a wrist movement or a finger
82. 9:03or thumb movement, and then see which  tendon is responsible for that movement.
83. 9:09Of course if you then go and see a hand specialist
84. 9:12then they could image the wrist using  MRI, or preferably ultrasound which can
85. 9:17show the wrist tendons beautifully  and see them moving in real time.
86. 9:23In tenosynovitis, on an ultrasound scan, the  tendon will be surrounded by a halo of fluid.
87. 9:29This sometimes gets called a bullseye  sign because you get a white central
88. 9:34tendon surrounded by a black ring  of fluid, resembling a bulls eye.
89. 9:43Before we get started on the treatments let  me just say that a single first episode of
90. 9:49tenosynovitis will almost always gets better  with the following treatments but if you don’t
91. 9:55address the reason why it occurred in the first  place, then it’s highly likely to come back. So
92. 10:01make sure to stick around until the end of  the video because I’m going to talk about
93. 10:05the things you can do to mitigate against this  becoming a repetitive problem in the future.
94. 10:11Ok so onto the treatments, and once  you’ve identified which tendon,
95. 10:16or at least which of the 6 areas of the wrist,  is the one most likely effected in your case,
96. 10:21you must now rest it, or at least reduce  whatever activity you’ve been doing that
97. 10:27has aggravated it. This is paramount or you’re  going to fighting an uphill battle. So it might
98. 10:34be reducing your gaming time, mouse use, a  particular sport or whatever it is in your
99. 10:41case. Some form of immobilisation splint can  also be really helpful. A general wrist splint
100. 10:48like this one can be a godsend in most  cases of tenosynovitis. Just make sure
101. 10:53you use it pretty much all the time to start  with and then slowly wean off as the symptoms
102. 10:59settle. You can even wear it at night if  your pain is severe and disturbing sleep.
103. 11:05The other thing you can do to help yourself is  some form of antinflammatory treatment. If you
104. 11:11can take oral anti-inflammatory tablets then  thats usually the most effective option. Just
105. 11:17make sure that you check with a prescriber or  pharmacist first as not everyone can take them.
106. 11:23If you can’t take the tablets then you might able  to use the gel which can also be very effective
107. 11:29as these tendons are very superficial  and the gel can usually penetrate to an
108. 11:34effective depth. Just make sure you use the  tablets or gel as instructed on the packet.
109. 11:40They won’t work if you use them sporadically.  They must be used regularly at maximum dose
110. 11:47and usually for a few weeks. If you can’t  use the anti-inflammatory tablets or gel
111. 11:52then you could use an ice pack, applied  for about 20 mins 3 or 4 times daily.
112. 11:59In most cases, if you follow this advice then  your tenosynovitis should settle down usually
113. 12:05within about 6 weeks. If yours does’nt then ask  yourself if you’ve given your wrist enough rest,
114. 12:12as continued overuse is the main reason  why most tenosynovitis doest get better.
115. 12:19But If you feel that done everything you can  and it’s still painful and maybe swollen,
116. 12:25then go and get professional advice. A  simple blood tests can check for diabetes,
117. 12:30gout or Rheumatoid Arthritis. Like I mentioned  earlier, if you have one of these conditions
118. 12:37then it’s important to treat that first as your  tenosynovitis might not improve until you do so.
119. 12:44But if these conditions have been excluded and  your tenosynovitis is not responding to the
120. 12:50self help treatments then the next step would  usually be a cortisone injection. These can be
121. 12:56done in general practice by basically  injecting the painful tendon by feel,
122. 13:02but my preference is to inject under  ultrasound guidance as the needle can
123. 13:07be placed precisely into the swollen tendon  sheath and therefore the drug is delivered
124. 13:12exactly where it is needed. A tendon sheath  injection is usually a curative treatment in
125. 13:19the majority of cases. Sometimes it might need  repeating a 2nd time but once is usually enough.
126. 13:26And finally for those rare cases of persistent  tenosynovitis that have been resistant to all
127. 13:33the treatments we’ve talked about so  far, then surgery is the last resort
128. 13:37option. De Quervains tenosynovitis is the  one exception where surgery is a fairly
129. 13:44common treatment but for the other wrist  tendons, surgery is much less common and
130. 13:49indeed I can count the number of patients I’ve  sent to a surgeon on one hand as it’s rarely
131. 13:55needed. The surgery involves removing inflamed  tissue and scar tissue in a procedure called
132. 14:02a debridement and then sometimes rerouting  the tendon into another part of the wrist.
133. 14:13Ok so this might be a single episode of  tenosynovitis that you’ve had due to one
134. 14:18off period of time where you were overloading  your wrist and now that you’re all better,
135. 14:23you might not expect it to ever come back again.  And thats great, but as I mentioned earlier,
136. 14:29in some people tenosynovitis can be a problem  which recurs time and time again IF you continue
137. 14:37to do the activity which is annoying the wrist  tendons. So this next section is aimed at the
138. 14:43person who is overloading their wrist frequently,  maybe it’s due to their job or a sport they love
139. 14:50to do. But they just can’t stop doing the problem  activity for the long term. And so if that person
140. 14:57is you then you basically have 2 choices if  you want to stop this from becoming a recurring
141. 15:02problem. You can either reduce or modify the  activity which is causing the problem, or you can
142. 15:10increase your wrist strength so it can cope with  that activity. And it’s that simple. 2 choices.
143. 15:23So option 1, the reduced activity option, might  mean just simply reducing the offending wrist
144. 15:30activity for the long term. That might be easy to  do if it’s a pastime like gaming, or a sport. But
145. 15:37it’s a harder option when that activity might be  related to your job. So the first thing to do is
146. 15:43discuss it with your employer and see if you  can get an ergonomic assessment. Because there
147. 15:48might a solution to help reduce the strain on your  wrists, as the chances are that other people will
148. 15:54also have had this problem, and found a solution.  It might involve using a certain tool or piece of
149. 16:01equipment to help make a repetitive job a bit  easier. If you work in an office then the usual
150. 16:08culprits are the mouse and keyboard, especially  the mouse. A conventional mouse like this one
151. 16:15can easily overload the wrist extensor tendons  over the back of the wrist. So changing to an
152. 16:21ergonomic mouse like this one might be a really  simple solution. This type of mouse puts your
153. 16:27wrist in a much better ergonomic position and can  make a huge difference in reducing wrist extensor
154. 16:34tendon pain. Il put a link to this particular  mouse in the description below because it’s
155. 16:40one that I can personally recommend. Ergonomic  keyboards like this one can also set your wrists
156. 16:46in a better position and can also help offload  those wrist extensor tendons. And there are many
157. 16:53different products on the market aimed at making  certain jobs easier and with less strain on the
158. 16:59joints. So do a bit of research if your  wrist pain is being caused by your job. If
159. 17:05it’s a sport then the best option is talk to  professional coach. Changing your technique,
160. 17:12using a different bit of kit, or starting a  specific training regime might be the solution.
161. 17:22Now the other option, option 2, is to try and  increase your wrist strength and resilience
162. 17:29so that it can hopefully cope with the activity  that you’re asking it to do. So this option
163. 17:34might be suitable for the person who just can’t  reduce their wrist activities for the long term.
164. 17:40You might be worried about losing your job or  having to stop a particular sport permanently.
165. 17:46In this case, strengthening the wrist might be  your only remaining option. Before starting an
166. 17:52exercise programme though, you’re going to need  to settle the pain down as much as possible by
167. 17:58doing the treatments that we’ve talked about  earlier in the video. If you start trying to
168. 18:03strengthen the wrist while the tenosynovitis  is still active then you’re just going to make
169. 18:08it worse. There are no short cuts with this.  You can only start the exercises once it’s
170. 18:15settled right down. Now I’ve done a separate  video which go’s through a detailed programme
171. 18:21of strengthening exercises for the wrist and i’ll  link to that up here and in the description below.
172. 18:30Just make sure you take your time, start  really really gently and progress really
173. 18:36really slowly as the last thing you want to do  is cause another episode of your tenosynovitis
174. 18:43because you’ve overcooked the exercises. You  must respect pain and be prepared to back off
175. 18:49if needed. Give yourself at leat 3 months to  go through a wrist strengthening programme.
176. 18:56Ok well about wraps up tenosynovitis  of the wrist. I hope the video has
177. 19:00been helpful for you. If not, and you think  your wrist pain is due to something else,
178. 19:05then Ive got quite a collection of videos on  the channel now, covering all of the common
179. 19:10and many of the uncommon wrist conditions  so do go and have a look. Chances are that
180. 19:16I’ve covered it. Well, thats it. Thanks very  much for watching. Take care and bye for now.