Handy Advice
Whether in the yard or on the courts, regular activity can take a toll on our hands. Here's a look at some common conditions and how to treat them.
By Adrienne Foley

Jackie Couillard loves tennis. She plays four days a week on two different doubles leagues near her home in Chattanooga. 'If I’m not working, I’m playing tennis,' says the 49-year-old recovery room nurse who has enjoyed the sport for more than 20 years. But a year or so ago, pain in her thumb and wrist began to interfere with her sport and other activities. 'My hand would go to sleep on me while writing charts at work. I would have to stop what I was doing and stretch my fingers to get the feeling back in my hand,' says Couillard. Eventually, the numbness in her wrist and hand began to affect her at work, while driving, playing tennis and would often wake her at night.

A simple test of the nerves in her arm—called a nerve conduction study—confirmed her physician’s suspicion of carpal tunnel syndrome, a common condition brought on by increased pressure or a pinched nerve at the base of the wrist. Couillard postponed treatment of the condition as long as she could before scheduling a consultation with Mark Brzezienski, MD, a board-certified plastic surgeon with added qualifications in surgery of the hand. Dr. Brzezienski, who practices at the Hayes Hand Center in Chattanooga, Tennessee, says the diagnosis is not uncommon for people like Couillard who remain active with tennis, golf, gardening and other activities that involve the hands.

'As the population ages, we’re all wanting to become more health conscious,' he says. 'People are playing more racquetball, more golf, more tennis than ever before. As we get older, the less likely we are to recover from microtraumas in our tendons that tend to accumulate at a more steady pace.'

Brzezienski says carpal tunnel syndrome is just one of the five most common conditions affecting the hand. Others include trigger finger, tennis elbow, golfer’s elbow and DeQuervain’s tendonitis.

Trigger finger is an irritation of the tendon sheath that surrounds the flexor tendons. When the tendon sheath becomes thickened or swollen it pinches the tendon and prevents it from gliding smoothly. In some cases the tendon catches and then suddenly releases as though a 'trigger' were released.

'Trigger finger can affect any of the fingers and become very painful,' says Dr. Brzezienski.

Sometimes the swelling can be treated with rest, activity modification, oral anti-inflammatories or steroid injections. The tendon sheath will then return to its normal, pain-free condition. More severe cases may require surgery to release the tendon. This can be done as an outpatient procedure. Normal activity can be resumed as pain allows.

Tennis elbow is a painful condition on and around the bony prominence (epicondyle) on the outside (lateral side) of the elbow. This location gives tennis elbow its technical name: lateral epicondylitis. Pain may radiate down the arm and gripping or extending the wrist may intensify the pain. Golfer’s elbow describes a similar condition. The pain focus is the knobby bump on the inside of the elbow closest to the body (the medial side), so it is technically known as medial epicondylitis.

According to the American Association of Orthopedic Surgeons, both tennis elbow and golfer’s elbow typically result from repetitive arm movement. Overusing the muscles in the arm can lead to tiny tears in the tendons that attach the muscles in your forearms to the epicondyles. If you continue to do the activity without allowing the tears to heal, the tendons can become inflamed. This condition can be caused by excessive use of your arm in long sessions practicing your golf swing or tennis stroke and in many other activities, including painting, raking, pitching, rowing, hammering and using a screwdriver.

DeQuervain's tendinitis is an irritation and swelling of the tendons found along the thumb side of the wrist. The swelling can cause pain and tenderness in this area, usually noticed when forming a fist, grasping or gripping things, or turning the wrist.

'To treat any of these conditions, we always begin with conservative therapies first which may include steroid injections, splinting, therapeutic devices such as tennis elbow straps, for example, and anti-inflammatory drugs,' says Dr. Brzezienski. 'We evaluate the patient as a whole, not just the hands. For instance, if someone has diabetes or hypertension, we look at how that may impact the discomfort they’re feeling in their hands or upper extremities.

Certified hand therapists or occupational and physical therapists are also key to a patient’s treatment and recovery. They can help improve a patient’s ability to return to normal activities by:

• improving the joint range-of-motion and muscle strength;
• providing assistive devices such as enlarged grips and adapted scissors;
• teaching how properly to use heat therapy and cold therapy;
• fitting a patient with splints or braces; or
• teaching principles of proper joint use and energy conservation.

'As certified hand therapists, we see the whole gamut of conditions,' says Pamela Harrell, OTR, CHT, of Tennessee Orthopaedic Alliance in Nashville, 'from tendonitis to probably the most common ailment which is osteoarthritis at the base of the thumb.' Harrell says hand therapists typically rely on protective splints and adaptive devices, modalities to reduce pain and inflammation and exercises to increase strengthening in the muscles.

If treated early, many cases improve with short periods of rest in a splint, followed by stretching exercises designed to get the tendons gliding, injection with steroids and/or taking anti-inflammatory medications. Modification of the activities that caused the symptoms initially also may be required. 'Most hand injuries or conditions are usually repetitive problems and we try to evaluate what’s causing them,' says Harrell. 'In some instances, a patient may be referred to a tennis pro or golf pro who can focus on the mechanics of their stroke or swing.'

More severe cases or those that do not respond to other treatment may require surgery. 'Trigger finger release is probably one of the most common surgical procedures of the hand and carpal tunnel release is actually one of the top 10 surgeries performed across the board,' says Dr. Brzezienski.

After his consultation with Couillard, Dr. Brzezienski scheduled her for surgery to relieve her symptoms. 'I finally decided I couldn’t continue with the pain,' says Couillard. 'Dr. Brzezienski told me that if I didn’t have the surgery, I might permanently lose the muscle control in my hand.'

The carpal tunnel release, a surgical procedure to release or free the ligament thereby allowing more room for the median nerve in the carpal tunnel, was performed on an outpatient basis under local anesthesia with sedation.

'Post-operative care may involve after care visits, home exercises that the patient must do and anti-inflammatory drugs,' says Dr. Brzezienski. 'We also look at changing a patient’s kinematics in order to prevent them from falling into the same bad use patterns. It’s our goal to get people back to the same quality of life they had before their injury.'

For Jackie Couillard, the surgery accomplished just that. After a brief recovery, Couillard shed her mobilizing splint and picked up her racquet. 'I was back on the courts in just about two weeks. I was surprised when they told me I had carpal tunnel. It’s just nice to be back in my game without any pain.'