Understanding Hand Pain: A Four-Part Series on Evaluation, Causes, and Treatment

A few years back, I took care of a middle-aged woman with burning pain in her hands. It was worse in her right hand compared with her left. In addition, she was very weak in both of her hands. She had been given various diagnoses such as carpal tunnel syndrome, complex regional pain syndrome, and peripheral neuropathy and a few doctors simply did not know what was going on. She was of professional woman with a very active lifestyle and had been going through a transition in her career. She had been flying back and forth across the country and carrying her computer in her backpack. Her job involved a tremendous amount of driving and she was not using proper ergonomic posture while driving. In light of her busy career, she was not able to maintain good strength in her upper body and overall she was weak. She already had MRIs of her upper back, neck and shoulder as well as x-rays of her hands. All of which were negative. Lastly, she underwent nerve conduction studies and EMG of her upper extremities which was negative. In this 4 part series, we will discuss the evaluation of such symptoms possible causes and treatment.

In evaluating a person with this problem, holding a steering wheel for long hours, a weak upper body, hypermobility, as well as carrying a heavy backpack for long periods all may contribute to her situation. Frequently there can be burning in the hands as well. Once the diagnosis of carpal tunnel syndrome has been ruled out, these patients frequently come to my office to understand what is going on. Occasionally they carry a diagnosis of CRPS. Other times they simply have hand pain. This pain syndrome is extremely common in my hypermobile patients, even if they are not aware that they have hypermobility both in the front and on the back.

I begin by looking at the thoracic spine and upper ribs. In the area where the neck (cervical spine) attaches to the upper back (thoracic spine), the 1st rib also attaches. This is called the transition zone because proper alignment of the neck is always in slight extension (lordosis) and proper alignment of the thoracic spine is always in slight flexion (kyphosis) so there is a tremendous amount of wear and tear at C7 and T1, the lowest part of the neck and the highest part of the upper back. This happens to be with the first rib attached. As a result, with the wear and tear of ageing, overuse, or simply carrying excessive weight in these areas i.e., heavy backpacks, all three structures can move out of place. This is particularly concerning when it is the upper ribs, especially the first rib. When the first rib or even the first few ribs, (because frequently they move in a group) move out of place, there can be pressure on the brachial plexus. Since the brachial plexus involves the nerves supplying the entire arm, there can be strange and concerning sensations of nerves in the arm and the hands, like pain, particularly burning pain. One might can have burning, numbness, lack of sensation prickling and many other sensations that don’t follow classic dermatomal pain distribution. Again this is simply due to instability. Interestingly, in our patient, although she did not initially report pain in the ribs and upper back and lower neck, she was absolutely tender there and out of alignment. Once we had her properly aligned, she felt better , but her symptoms returned. After another examination it was clear that she was out of alignment again. In this case, it was clear that what she needed was regenerative medicine in and around her upper back, rib attachments and sometimes even the neck.

The Hidden Link: Shoulder Capsule Instability and Hand Nerve Symptoms

In evaluating someone with pain and possible overuse of the hand, I like to examine the shoulder. What I find so frequently (that it is almost predictable), is that there is instability of the anterior and posterior capsules of the shoulders. This means that the ball part of the ball and socket joint of the shoulder moves around excessively. This results in pain when pulling the seatbelt across the body. Otherwise, this is known as external rotation of the shoulder. These capsules help hold the humerus in place. We know that the shoulder joint is a very shallow ball-and-socket joint and it is very easy to move the bone of the arm out of place in the shoulder. Sometimes, when the humerus bone is out of place, it puts pressure on the brachial plexus. The brachial plexus is a group of nerves coming from the neck supplying the arm. This can result in nerve symptoms in the hand or arm. It can be confused with pain coming from the neck. When the MRI of the neck is normal, we need to consider the instability of the shoulder. One tip-off to this situation is they tell me that if they lie on their back, the symptoms recur. Also, the pectoralis and latissimus muscles will try to tighten up to help hold the arm in place. We can treat the tendons of these muscles with PRP as well as strengthen the capsules at the same time. If the problem is instability of the capsules putting pressure on the brachial plexus, the nerve symptoms will resolve. In the case of our intrepid traveler, she was unstable and in pain around her shoulder joint.

Also, although this was not the case in our patient, the most common torn tendon in the body is the supraspinatus tendon located at the top of the shoulder. This is responsible for bringing the arm straight out to the side. This can be torn when someone is someone goes to lift more than their arm can hold. If it is a small tear or an incomplete tear or tear with no retraction, PRP will help heal this. But if it is retracted, then surgery is the answer.

Exploring the Hidden Causes Beyond Carpal Tunnel Syndrome

Now that we have looked at the upper back, neck, ribs and shoulder, let us consider the elbow. Often, patients are so drawn to the hand pain and possible dysfunction at the base of the thumb, that they have not focused on the pain in the elbow. Frequently there is an overuse syndrome of the common flexor, extensor, pronator teres, or supinator tendons. Often the annular ligament has become degenerative or stretched and the anconeus tendon and biceps tendon are often very tender. As a result of this, the patient will bypass the use of her forearm muscles and take the load in her hands. Guess what? When I pressed on these structures, she pulled away from me due to the pain. She responded well to PRP however it took multiple treatments because it is very hard to rest the elbow (to let the overuse settle down)

Next, I always examine the wrist to see if there is swelling in the wrist joint itself from overuse. In addition, the joint between the radius and ulna, the distal radial ulnar joint (called the DRUJ), is frequently loose. We can move the ulna up and down like playing the piano. This is because the ligaments holding those two bones together have loosened up and this destabilizes the wrist joint itself. It results in more stress on the joint at the base of the thumb (called the first CMC). We can easily strengthen the ligaments of the wrist, particularly the DRUJ which helps create a foundation for the base of the thumb joint. Usually, the wrist, the DRUJ, and the base of the thumb respond well if treated together.

The Link Between Repetitive Motion and Thumb Osteoarthritis

Last but not least, I look at the hands and wrists. The most common area of osteoarthritis in the body is the first carpal metacarpal bone. This structure is at the base of the thumb near the wrist. This joint is a cup and saucer joint where the cup is the 1st metacarpal and the trapezium is the saucer. When the thumb moves in multiple directions repeatedly, like using a mouse, or steering wheel, doing carpentry work or any repetitive motion, the ligaments can be stretched or worn out (like a frayed rope). As a result, the cup moves out of the saucer. This is when people experience pain and swelling at the base of the thumb right near the wrist. There may even be swelling at the base of the thumb as well but this is secondary. If our patient sees a good chiropractor, osteopath or bodyworker they will apply traction to this joint and allow it to fall back into proper alignment. If the patient does not have to continue the repetitive motion, it may stay there. If the repetitive motion continues, or if they have well and truly worn out the joint, or if they are hypermobile, it may continue to go in and out of alignment which is very painful. In addition, when the cup is out of alignment with the saucer, it puts undue stress on the joint resulting in osteoarthritis of this joint. What is the treatment? PRP or dextrose prolotherapy strengthens the ligaments so that the thumb can stay aligned and work properly again.