What are some of the most common hand, wrist, upper extremity, and shoulder pain issues that you regularly see?
Jung Park, MD (Orthopedic Surgeon, specializing in hand/wrist): The most common diagnoses that I see are carpal tunnel syndrome, trigger finger, tendinitis and trauma related conditions, such as fractures and ligament injuries.
Kieran Cody, MD (Orthopedic Surgeon, specializing in shoulders): I see a lot of shoulder arthritis, rotator cuff tears, and impingement syndrome. Other common diagnoses are frozen shoulder and shoulder instability. My older patients tend to have more problems with arthritis and rotator cuff tears, while my younger patients more frequently come in with instability or a frozen shoulder.
Kraig Bano, MPT, CHT (Physical Therapist/Certified Hand Therapist): One of the most common things I see is that patients are not sure of the origin of their pain. They will often say, “I just woke up with it.” However, pain is often caused by an underlying condition. For example, pain in the upper extremity (shoulder, arm, elbow, forearm, wrist and hand) can be could be caused by conditions such as arthritis, tendinitis or nerve related issues such as carpal tunnel syndrome, cubital tunnel syndrome or the cervical spine.
Are there any issues that you’ve seen exacerbated during COVID-19 because so many people are now working from home and are finding themselves spending far more hours during the day sitting and typing on keyboards?
Cody: COVID-19 and social distancing has changed everything in so many ways!
Some people are becoming deconditioned because they are not able to get to the gym like they used to, while others have taken this opportunity to work out like crazy, even though their bodies might not be prepared. As a result, I’m seeing patients who haven’t been working out enough, and others who did too much and ended up with overuse injury issues
Bano: COVID-19 has also changed the way many of us complete our work duties. People have switched from using their ergonomically designed desks at work to a home work station that may be a laptop on the dining room table or a seat on the sofa.
For most people, a high table coupled with a low or un-adjustable chair causes them to have to raise their arms and flex their wrists to reach the keyboard. Essentially, they are holding their arms out to their sides at 45 degree angles for an entire work day! Over time, this can lead to shoulder, elbow, wrist and/or hand pain.
Park: I agree. Typing for extended periods of time at the kitchen counter, on the sofa or on the bed can lead to tendinitis around the forearm, elbow and wrist. Many people also experience neck spasms and overuse syndrome.
At the same time, I find that some patients are taking advantage of the home quarantine to tackle extensive house projects. While I applaud the initiative, I have seen some traumatic injuries caused by doing tasks that are outside of patient’s regular routines.
For each of these common issues, what do you typically recommend to patients to alleviate the pain?
Cody: These problems can often be treated with conservative, non-surgical care. I always like to start with a combination of relative rest, anti-inflammatory medications or cortisone shots, and physical therapy. I would say the majority of patients get better with nonsurgical management.
Bano: Physical therapy can go a long way towards alleviating pain. After a very thorough evaluation, we can design a customized plan that may include manual therapy, stretching, strengthening exercises, and pain relieving modalities such as heat, ice and/or electrical stimulation. We also look at the activities that worsen the pain or increase dysfunction, and work with the patient to find ways to modify them such as ergonomic changes, assistive devices or changes in duration or intensity.
Park: I agree with Dr. Cody and Kraig. Conservative treatment along with physical therapy is often highly effective. I also find that if the condition is particularly isolated to one tendon for instance, steroid injection can be very helpful. Sometimes, if the issue is due to trauma, surgery may ultimately be needed.
What are the best exercises to help with common hand, wrist, or shoulder pain issues?
Park: There is not one exercise that helps for all conditions. However, I generally recommend stretching all muscle groups from the neck down to the fingertip. I recommend doing these exercises in front of a mirror to make sure that both sides are symmetrical. A physical therapist can also help create an exercise regimen that is designed specifically for the diagnosis.
Cody: I often find that for the shoulder, exercises that emphasize shoulder blade positioning are usually the most helpful. I often tell my patients that pulling exercises are better than pushing for the shoulder. For example, a row is more beneficial than a bench press, and a lat pulldown is better than a military press.
Bano: There are many exercises that are designed to alleviate pain but ultimately, it is not a “one size fits all” situation. At Fitness Physical Therapy (part of Bucks County Orthopedic Specialists), we use years of experience and knowledge to determine the most appropriate exercises for each patient’s unique situation in order to get maximal results with pain reduction and return to all activities.
Let’s Focus on Carpal Tunnel Syndrome
Carpal tunnel syndrome is a very common issue that many patients have. What causes this condition and how can patients tell if they have it?
Park: Although there are some risk factors to developing carpal tunnel syndrome, there is no one reason why the patient gets this condition. It can lead to numbness and tingling on the thumb, index and middle finger. Symptoms are usually aggravated at night and by keeping the hand and wrist in a flexed position.
What are the different levels of severity with carpal tunnel syndrome and how does a patient know when to see a specialist?
Park: I recommend seeing a specialist when symptoms are becoming more frequent and ideally, before they become too severe. As the syndrome progresses, patients can experience more severe or frequent numbness or tingling that can become almost constant. When the condition becomes severe, the patient may also notice weakness, particularly in the thumb. Through examination and imaging studies, a specialist can determine the severity of the carpal tunnel syndrome.
What treatments for carpal tunnel syndrome do you recommend for pain management and symptom relief?
Park: Conservative measures, such as stretches, exercises, and wrist braces work best in the early stages of carpal tunnel syndrome. I only recommend surgery in severe cases. For example, if patients find no relief with conservative treatments or their imaging studies show severe compression, surgery to release the carpal tunnel may be needed.
Bano: In some cases, when the carpal tunnel syndrome symptoms are intermittent or mild, conservative treatment including stretching, nerve gliding and bracing to prevent extremes of wrist motion can help alleviate pain and numbness. However, when the symptoms (such as pain, tingling or numbness) progress to be more constant or significant weakness develops with pinching or squeezing, further options need to be explored with a hand surgeon to prevent permanent deficits, such as loss of sensation or strength. If surgery becomes the treatment of choice, physical therapy will help with scar management to prevent a thick and painful scar and to regain range of motion, strength and overall function.
What are some of the newer approaches in anesthesia for carpal tunnel surgery?
Park: Because of advances in local anesthesia, I am now able to perform carpal tunnel surgery without sedation (putting a patient to sleep). Benefits of this approach mean that there is no need for fasting and none of the risks associated with anesthetic drugs. Patients can even drive themselves to and from surgery.
Let’s Focus on Shoulders
What are the common causes of shoulder pain?
Cody: Rotator cuff tears and shoulder arthritis are two common causes of shoulder pain.
Rotator cuff tears can occur either from a sudden injury, or more gradually over time. The rotator cuff is composed of four muscles and tendons that help elevate the arm overhead. When there is a tear, the patient will notice both weakness and pain with overhead activity.
Shoulder arthritis is typically a gradually progressive problem in which patients will notice both pain and limited range of motion. They may even notice a grinding sensation as the cartilage wears out and the bones start rubbing against each other.
What treatments for shoulder pain do you recommend for pain management and symptom relief?
Cody: This is a great question, because patients are often surprised at how incredibly effective conservative treatments can be. For example, I frequently have patients who come to my office with acute and severe shoulder pain that is often related to bursitis. Patients are sometimes apprehensive about trying physical therapy for a pain that is so severe, but ultimately they are able to return to normal without needing any surgery at all. I love hearing their stories down the road when they tell me they were unsure that physical therapy was going to help them and yet, it truly did.
So, in terms of managing shoulder pain, beyond rest, ice, and anti-inflammatory medications, working with a physical therapist can be extremely beneficial. With PT, a patient will have an exercise program aimed at regaining range of motion and gradually strengthening the area, with an emphasis on shoulder blade position and stability.
Bano: I agree with Dr. Cody. In many cases, people are able to return to their normal activities with minimal to no pain following skilled physical therapy and continuing with their prescribed home exercise program. Following a thorough examination by the physical therapist, a plan of care will be developed that may include manual therapy (soft tissue mobilization, joint mobilization, stretching, strengthening, stabilization of the shoulder blade) and return to activity training. In the past, I have seen people with severe rotator cuff injuries or arthritis return to their activities of daily living following physical therapy.
What are the different levels of severity with shoulder pain and how does a patient know when to see a specialist?
Cody: We are frequently asked when is the correct time to see a specialist? I would say the time to get it checked out is when pain interferes with your life, sleep, activities of daily living, enjoyment of recreational activities, and/or it has not gone away after trying a week or two of rest and over-the-counter anti-inflammatory medication. Minor problems often resolve on their own, but if a pain persists, it could be a more serious problem that will require a trip to the doctor’s office.
What are some of the newer approaches with anesthesia for shoulder surgery?
Cody: For shoulder surgery there have been tremendous improvements in anesthesia and pain control. The biggest improvement has been a nerve block with a long-acting, delayed release anesthetic. Patients can typically get 2 to 3 days of excellent pain control from just the nerve block alone. Most of my patients use very little narcotic medication and depend primarily on Tylenol with an anti-inflammatory medicine after surgery.
The doctors and therapists at Bucks County Orthopedic Specialists and Fitness Physical Therapy have extensive training and experience with all hand, shoulder, and upper extremity issues. If you’re struggling with pain and are looking for either surgical and non-surgical solutions, call (215) 918-7845 to schedule an appointment with Dr. Jung Park, hand specialist or Dr. Kieran Cody, shoulder specialist, or call (215) 918-7883 to schedule with Kraig Bano, CHT.