NonSurgical Treatment Options for Upper Extremity Overuse Injuries

Richard N. Norris, M.D. December 1994 - August 1995

This multi-part article will discuss the nonsurgical treatment options of (relative) rest, medications, injections, thermotherapy, electrical stimulation, massage, therapeutic exercise, returning to work after injury ("work hardening"), modification of posture and technique, "feedback" techniques, orthotics, splints, and assistive devices for daily activities.

Part 1

Reprinted From The RSI Network - Issue 21 - Dec'94

First, a note: Repetitive motion disorders can usually be treated nonoperatively with success, especially in their early stages. However, it should be kept in mind that nonsurgical treatment isn't always the conservative path, and there are many conditions that respond quickly and reliably to surgical procedures. In situations of prolonged pain and disability, nonsurgical procedures should not be pursued indefinitely when surgery would correct the situation and allow the patient a rapid return to work or play.

(Relative) rest: Perhaps the most important treatment of all is rest. We all know how difficult it is for professionals to take time off to rest, so we must borrow the concept of "relative rest" from sports medicine. Depending on the severity of the injury, this may mean cutting back, rather than completely stopping, work or (for musicians) performances. Office workers may need to cut down on work hours or space out the typing or writing over the course of the day. For musicians, it may be possible to modify or change the repertoire, such as avoiding piano pieces with large chord spans, broken or serial octaves, or triple forte playing. Relative rest really means avoiding pain-producing activities.

Medications: The most commonly used medications are nonsteroidal anti-inflammatory agents. (Caution must be used in patients with a history of ulcers, bleeding disorders, or hypertension.) They should be taken with meals. In general, anti-inflammatory medications tend to be more useful in acute than in chronic situations, and should probably be used not more than 3 or 4 weeks at a time. They should rarely be used as the sole treatment modality, but may be helpful in conjunction with other modalities and treatment strategies. There is evidence that topically applied salicylate cream (trolamine salicylate) may be effective for localized inflammation. In addition, low doses of antidepressant medication are often helpful as part of the treatment of myofascial pain. Narcotic medications, sedatives, or "muscle relaxants" should be avoided.

Injections: Dry needling or injection with anesthetic alone is routinely used in treating myofascial trigger points. Injections performed with a solution of corticosteroid and anesthetic are commonly used as part of the treatment regimen for de Quervain's disease, sub-deltoid bursitis, trigger finger, and epicondylitis. For median nerve entrapment at the wrist (CTS), it's best to avoid the colloidal steroid preparations and use only the soluble steroids, as colloid solution has been found lying on the median nerve at surgery, possibly causing mechanical irritation. Injection is generally contraindicated for patients with any weakness or thenar atrophy or advanced sensory loss.

Patients with minimal or intermittent symptoms of CTS tend to have the highest success rate. D. P. Green found steroid injections to give good to complete relief of CTS in 81% of patients. In most patients the symptoms recurred from 2 to 4 months after injection. He found a positive response to an injection to be an excellent predictor of a successful surgical procedure. The injection is performed by insertion of a 25-gauge needle proximal to the wrist crease and ulnar to the palmaris longus tendon. This avoids the median nerve and the transverse carpal ligament. The patient can be asked to gently flex the digits a few degrees; if the needle is in contact with the flexor tendons, there will be slight movement of the syringe, assuring proper position before injection. To avoid injecting into a tendon, the injection must not be forced against pressure. If injected proximal to transverse carpal ligament through the investing fascia of the forearm, the solution will easily flow into the tunnel and the area of tenosynovitis.

Part 2

Reprinted From The RSI Network - Issue 21 - Dec'94

Thermotherapy: Thermotherapy can take the form of heat or cold. Heat is commonly applied as either a hot pack, which doesn't have much depth penetration, or ultrasound, which has much deeper penetration. Ultrasound can be pulsed or continuous; pulsing helps prevent excessive heat buildup and should be used in bony areas such as hands and wrists. An ultrasound unit with a very small head works better for bony areas. In treating areas of nerve compression, ultrasound should be used only in very low doses (in the range of 0.5 watts/cm2). A normal dose (1.5 to 2.0 watts/cm2) actually has been shown to be deleterious to nerve healing.

Fluidotherapy is a type of thermotherapy using heated, pulverized organic material such as walnut shells or grain husks. Advantages include the ability to attain higher specific heat than with other methods of application, and the opportunity for the therapist to put his or her hands into the fluidotherapy bath to perform joint mobilization or soft-tissue massage concurrently. Although the heat of paraffin baths doesn't penetrate deeply within the tissue, these baths are very good for dry skin and for relaxing contracted areas. If inflammation is present, cold serves as a vasoconstrictor to prevent or reduce swelling. Ice may be applied for 15-20 minutes every hour or two as needed. When applying cold over sensitive, bony areas, it's best to use a gel pack, which remains soft even at freezing temperatures.

Electrical stimulation: The use of electrical stimulation is often beneficial when there is edema or swelling, as the current can help to polarize and drive interstitial edema back into the vascular system. This treatment should be combined with compression and elevation. Electrical stimulation can be used to induce gentle, rhythmic muscle contractions in sore areas, helping to relieve discomfort by removing interstitial edema and increasing blood flow to the muscle. Electrical stimulation can also be used with active muscle contraction to strengthen weak or atrophied muscles. Caution must be used with patients who have pacemakers and those with very sensitive skin, which can be irritated by the electrodes.

Massage: Massage is useful in stimulating blood flow, reducing edema, and breaking up localized areas of muscle spasm or trigger points. It's also helpful for general relaxation and stress reduction.

Therapeutic exercise: Physical exercise plays a vital role in keeping workers and performers fit and healthy. Sitting at a desk or making music, while not athletic in the strict sense of the word, definitely has its physical demands. Therapeutic exercise is useful in both preventing and treating specific ailments. Often, after a period of injury, the muscles in the hand and forearm become weak from disuse or nerve compression. Therapeutic exercise, along with a gradual return to working or playing, is necessary to restore muscle strength and endurance. Working on proximal strength, especially scapular stabilization, is greatly beneficial. Strengthening the wrist and finger extensors, a common area for pain and dysfunction, may be preventative as well as therapeutic. Hand exercises must be undertaken with caution and supervision because of the risk of overdoing the exercises and thereby worsening the condition. One of the chief offenders in causing further injury is therapy putty, which tends to be rather stiff, especially when cold. There are several different colors of putty available in varying degrees of stiffness and resistance. Putty must be used in a graded fashion and prewarmed. Rubber bands and manual resistance may also be used. A well-balanced therapeutic exercise program should address strength, endurance, flexibility, and gracefulness.

Read parts 3 and 4 about NonSurgical Treatment Options for Upper Extremity Overuse Injuries