Wrist pain, especially on the thumb side of your wrist, can at best be a persistent nuisance, and at worst be debilitating and restrictive.  You’ve tried stretching the muscles on the front of your wrist. You’ve tried icing it. You’ve maybe even tried wearing a splint or a brace, but this tricky condition requires a deliberate examination and prescription to make sure you’re addressing the right components of it at the right time to resolve it.  What’s the first step? Use these quick and easy screens to begin understanding what movement options your wrist, and hand, have available to them so you don’t waste your time chasing the wrong issue.  Understanding How Your Wrist Moves  Here’s some simple self-exams you can use to get an idea of what motion your wrist has, and what movements it might be lacking in.  [caption id="" align="aligncenter" width="1500"] Figure 1: Movements at the wrist. Source: https://www.crossfit.com/essentials/movement-about-joints-part-3-wrist.[/caption] Wrist flexion and extension, plus radial deviation (movement towards the thumb side, “abduction” in Figure 1) and ulnar deviation (movement towards the pinky side, “adduction” in Figure 1) are the motions that are available at the wrist joint.  The wrist joint itself is the connection of the carpal bones of the hand and the radius and the ulna, or your forearm bones. (Figure 2)  [caption id="" align="aligncenter" width="1024"] Figure 2: Bony Anatomy of the Wrist and Hand. Source: https://www.assh.org/handcare/servlet/servlet.FileDownload?file=00P5b00000tFPX8EAO[/caption] Step 1: Take your wrist through those motions above. Do any of them reproduce your discomfort near your radius? Which ones feel limited relative to the others?  Most of the time, when I’m working with clients with wrist pain near their radius, I find that they are missing traditionally measured wrist extension and wrist abduction.  Now, to really figure out WHY they are missing that, we have to appreciate how the position of the hand relative to the wrist. Enter the Pistol Test.  If you’ve got a positive Pistol Test, as demonstrated above, you’ve got a hand that is positioned more internally rotated relative to your radius. What this means, is your wrist is biased towards already being in a position of wrist flexion, instead of extension!  Most of my clients with this limitation frequently have their wrist pain occur when they’re trying to extend their wrist. Like in the bottom of a push up, or in most weight bearing positions through the hand.  Having a hand internally rotated compared to your wrist is biasing your hand to be starting in a position of wrist flexion. If we can compare your wrist joint to an elevator and say that it is in a ten story building, that’s analogous to starting your wrist on the fourth floor and then asking it to go up ten more floors. You’d hit a constraint at the top of the building, which is happening when you’re trying to challenge your end positions of wrist extension, and then winding up with a jam at the inside of where your wrist meets the hand.  Instead of trying modalities like icing, or wearing a brace that can alleviate your pain by keeping your wrist out of symptomatic positions, let’s address the movement impairments that are causing your issue. Let’s take the elevator back to the ground floor.  First step: we need to get your hand to externally rotate relative to your wrist. I like Staggered Stance Curls to accomplish this. Use a light weight and make sure to hook your thumb behind the bar of the dumbbell to lock in the hand external rotation.  [embed]https://youtu.be/N4WWxUmvcw8[/embed] Once you’ve worked on that for a while, recapturing your wrist extension requires you to learn to get your wrist to internally rotate relative to a fixed hand. Enter the Low Oblique Sit with Pronation! This side plank type activity uses a towel to fix your hand while you internally rotate your radius.  [embed]https://youtu.be/D7LhuuTcMD0[/embed] We’ve recaptured our hand position, we’ve learned to move our radius relative to our hand, now let’s challenge our wrist position. I like bear crawling to progress to this point.  [embed]https://youtu.be/1HdyUZsZr_c[/embed] As you load one side, you want to feel your weight shift from the outside of the hand towards the inside. Don’t lose contact with the outside of your hand when that weight shift happens!  Begin working on appreciating what motions your wrist can or can’t do, and then work on training the movement strategies you need to obtain that motion, so your wrist has plenty of freedom to move.  Using these activities can be a great start towards the end of your wrist pain! 

If you were to assess how great a pitcher in baseball truly is, you might find yourself looking at a lot of statistics…specifically the ERA or Earned Run Average. With the goal to strike out everyone who dares to step into the box against them, they must not only possess a superior amount of talent and skills, but an ability to demonstrate a large amount of power. Multiplied by about 100…pitches that is. Across sports, only a small number of athletes have to exert the same level of power quite as frequently as a baseball pitcher. Now, if specialized at a young age to be a pitcher and across several teams per year, this amount of power, volume and overall stress placed on the elbow and its surrounding structures can not only take a toll, but potentially wreak havoc on the players future…at least that is what we thought.  Typically beginning as a low level condition, such as Little League Elbow (a condition that is simply a byproduct of insufficient rest periods between pitching outings) or Acute bursitis (inflammation of localized fat pad), a baseball player’s elbow joint has to be able to absorb a tremendous amount of force and repetitive stress across seasons. This type of overhead throwing irritates not only surrounding tendons and ligaments that are responsible for support, but predisposes pitchers to more serious issues, such as an Ulnar Collateral ligament (UCL) injury.  As a result of increasingly large prevalence in young players over the last few years, this once seen injury in mostly adults has prompted many governing bodies to change the rules. The American Sports Medicine Institute (ASMI), USA Baseball, Little League Baseball, Major League Baseball organizations to establish Pitch Count Guidelines.  With many efforts being made to protect the new generations of baseball, higher level players continue to remain at risk.  The Ulnar Collateral ligament (UCL) injury The ulnar collateral ligament (UCL) has been amongst the most commonly injured ligament in repetitive throwing / overhead athletes. In order to accommodate the large volume of power that is created to throw a baseball 60 feet, the ligaments stretch and elongate until it can no longer bear the capacity to maintain the elbow’s integrity. Like any ligamentous injury they can range in severity and true structural damage/complexity. They range from a minor sprain with light damage and inflammation to a complete tear.  UCL Symptoms Include:  Pain with throwing or inside of the elbow Instability  Decreased strength or power in throwing Increased sensitivity around the ulnar nerve “funny bone” causing numbness and tingling in the ring and pinky finger Diagnosis and Treatment A UCL injury is diagnosed following the results and clinical presentation together after a physical examination, in conjunction with diagnostic imaging, such as X-ray & MRI. Indications on next best step are contingent upon severity of structural damage, healing time, rehabilitative exercises, inflammation management, further evaluation may be indicated. Further assessment with a physical therapist or athletic trainer may be warranted to determine if throwing mechanics, inefficient body positioning, compensatory techniques/strategies, and sequencing caused excessive stress on the elbow. Oftentimes if a pitcher does not have full access to shoulder motions required to pitch effectively, the torque to generate the power required needs to come from another place…I bet you know where that is! INSIDE THE ELBOW!  Yes, inside the elbow. Now, normal pitching mechanics on average require 300 N (67 lbs) of torque along the inside elbow… normal. Can you imagine the level of stress taken on by the elbow due to abnormal pitching mechanics multiplied by 100 pitches per game over the course of a full season? Tommy John and His Influence Named after former LA Dodgers Pitcher, Tommy John, the surgery has dramatically impacted baseball and throwing athletes. Used as a last resort now for UCL injuries, outcome measures have drastically increased since this surgery gained traction in the baseball community. TJ Surgery is a surgical graft procedure where the injured UCL is replaced by a tendon graft taken from the forearm or hamstring tendons. The procedure is followed by an intense rehab program that consists of several phases on average lasting 6 to 12 months.  What was once a career ending injury is now a symbol of hope for many overhead athletes looking to continue the sport they love! Today the UCL Reconstruction is a commonly performed procedure and emphasized in rehabilitation education programs.  If you have any questions regarding this topic please consult your primary care physician or stop by Next Level Physical Therapy and we will gladly speak with you about it.

Carpal tunnel syndrome is a collection of symptoms that most commonly appear in the thumb, index and middle fingers on the palm side of the hand.  The hallmark symptom of this is aching or a loss of sensation in those three fingers specifically.  Typically, these symptoms are arising because the median nerve is experiencing a prolonged compression where it crosses into the hand at the “carpal tunnel” – or a small loop of tendon overlapping several muscles that run into the hand and the median nerve at a very small space near the bones of your wrist. (Figure 1).  [caption id="" align="aligncenter" width="600"] Figure 1: Anatomy of the carpal tunnel region and the median nerve. The nerve in the middle that runs to the thumb and middle finger is the median nerve. Source: https://qph.fs.quoracdn.net/main-qimg-2effc0be8c4ff02f065339aebda08596-c[/caption] The most common courses of treatment that I see recommended are prolonged static stretches of the muscles on the front of the wrist and forearm, active range of motion exercises for the wrist and hand in all motions, stretching of the thumb muscles, and tendon and nerve glide activities.  What all these activities have in common is that they are being prescribed with the goal of reducing the compression on the median nerve. Nerves love movement, blood flow, and space around them. The intent of what needs to happen during treatment is spot on – it’s why the surgical option to try to alleviate the symptoms is to cut that white-colored tendon you see running between the thumb and pinky muscles, to make more space over the median nerve.  While there is nothing wrong with these activities, not all interventions have the same effect. If we are trying to create room around the carpal tunnel, we need to appreciate the position of the hand versus the wrist, because many of the muscles that cross the carpal tunnel cross or directly attach to these bones.  Stretching muscles statically mostly just increases the tolerance of a muscle to being lengthened, and does not do much to address the qualities or behavior of muscles or tendons from what the latest research on stretching tells us (PubMed ID# 28801950). Plus, prolonged tension put onto a nerve that is already compressed can be like stretching an already taut rubber band more – it’s not going to help to reduce the tension in that structure. So, instead of just focusing on a muscle or muscles that are “tight”, let’s instead focus on helping the bones of the hand and wrist be able to get into a position to “unstretch” the rubber band and help give that nerve more space around it to help it be able to move more freely.  The picture below shows an example of a thumb that is internally rotated (the yellow area) relative to the position of the wrist. The blue arrow shows a thumb that is better able to externally rotate relative to the wrist than the yellow arrow. (Figure 2) [caption id="" align="aligncenter" width="960"] Figure 2: An example of differing thumb and wrist orientations. Source: https://i2.wp.com/plasticsurgerykey.com/wp-content/uploads/2020/06/10-1055-b-002-98003_c049_f001.jpg?w=960[/caption] Can you see how stretching the muscles of the yellow hand might have a completely different result than the blue hand?  The same solution applied to these two different hands does not yield the same outcome.  In the next part of this discussion, we’re going to talk about how to tackle getting a more effective solution to create space and movement around the median nerve and possibly eliminate symptoms in the carpal tunnel that are tailored to the specific presentation of the yellow hand.