Friday, November 09, 2007
Patients with neck pain and/or neck stiffness without pain may not associate that their hand and finger pain is related to neck problems. Usually they attribute the hand and finger pain and/or stiffness to arthritis. Initially, self treatments are usually applied to the fingers in terms of using balms, ointments and lotions. Patients may also take analgesic medications and anti-inflammatory medications to help ease the pain. When the pain is severe, they may receive injections into the fingers or wrists and sometimes even surgery to release trapped tendons and nerves in the wrist and hand.
Sometimes patients may exercise the hand against resistance such as squeezing a rubber ball or some gadget hoping to strengthen the hand muscles. If the pain is chronic, these resistive activities will make the pain symptoms worse and can accelerate the progression into bony deformities in the fingers.
One might notice early arthritic deformities such as swelling and formation of soft nodes especially at the tip of the fingers called Heberden's nodes which begin with sub chondral bone formation as a reaction against inflammation. Eventually, these will become more calcified forming bony deformities. A recent survey has shown that one in 12 United States adults have symptomatic hand arthritis and incidence increases with age (Dillon CF. Hirsch R. Rasch EK. Gu Q. Symptomatic hand osteoarthritis in the United States: prevalence and functional impairment estimates from the third U.S. National Health and Nutrition Examination Survey, 1991-1994. [Journal Article] American Journal of Physical Medicine & Rehabilitation. 86(1):12-21, 2007 Jan).
In the early stages before hand deformities occur, pain in the hands can be helped by helping to relax the muscles on the dorsal aspect of the forearm. Neck pain due to spondylotic radiculopathy (arthritis) usually involves the C6 and C7 nerve roots. These roots supply the muscles on the dorsal aspect of the forearm among other large muscles in the shoulder and arm such as the latissimus dorsi and triceps muscles.
When these dorsal forearm muscles which move the wrist and fingers into extension become shortened due to nerve root irritation at C6 and C7 levels, they will pull and tug on the joints of the wrist, knuckles and fingers causing pain in these joints. Additionally, shortening of the dorsal muscles of the forearm places an overwork syndrome to the flexor muscles of the forearm and hand since now the long flexor muscle must work harder to counter-act the resistance provided by the tight and short dorsal forearm muscles that not only cross the wrist but extend to the fingers (extensor digitorum communis, extensor pollicis longus and brevis extensor indicis, extensor digiti minimi and others).
These flexor forearm muscles also eventually become tight and stiff making it difficult for the fingers to bend. Initially, finger bending may be slow due to stiffness but eventually it can progress to the stage of significant pain when there is development of a trigger finger. Triggering of the finger means that there is a tenosynovitis of the flexor tendon (inflammation of the synovial covering of the tendon) such that the tendon becomes thickened. There is a size mismatch between the tendon and the tunnels through which it must pass through at the level of the palmar aspect of the knuckle or the finger joints. A nodule on the flexor tendon may prevent the thickened tendon from passing through the tunnel. The finger may stay locked in flexion at the knuckle joint and there will be significant pain on trying to release it out of its locked position using the other hand. A click may sometimes be heard as the tendon is able to pass through the tunnel.
Significant tightness of the long finger flexors can also lead to tenosynovitis of the long flexors causing compression of the median nerve. This develops into carpal tunnel causing not only pain but tingling and numbness and eventually weakness in the fingers especially in the median nerve distribution (the thumb, index and middle fingers and the thumb ½ of the ring finger) interfering significantly with activities of daily living.
In the early stages, relaxation of the muscles of the forearm especially those on the dorsal aspect can be obtained by constant massaging of these muscles. Relaxation of the muscles can also be helped by using heat over the dorsal aspect of the forearm. Massage should also extend to relax all the muscles of the neck, shoulders and arms. This approach will help to treat the root cause of the finger pain rather than focus the treatments only to the fingers and hand. Activity modification must accompany all treatments in order that progressive healing can take place.
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