Is My Wrist Pain Carpal Tunnel or Arthritis?

Here is a common scenario that we see in the clinic. Patient comes to us with wrist pain. They may or may not have seen a doctor and been prescribed with “carpal tunnel.” Here is the problem. Just because you have wrist pain doesn’t mean you have carpal tunnel. I’ve found that people get misdiagnosed all the time. The most common injuries that get prescribed as carpal tunnel are either wrist osteoarthritis, or cervical radiculopathy. Let me give you a couple of tips to help you self-diagnose, if this patient is you.

Is it Really Carpal Tunnel Syndrome?

Carpal Tunnel Syndrome (CTS) is a VERY specific diagnosis. If you have true “carpal tunnel,” you will have complaints of pain and/or numbness in the first three fingers (thumb to middle) on the palm side of your hand. You might have some pain in the palm side of your wrist too where the median nerve is getting compressed. An orthopedic test that we use in the clinic is called Phalen’s test.

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If you compress the wrist joint, it should start to intensify your numbness and pain IN YOUR HAND. If you do this test and it doesn’t reproduce your symptoms, or if you have symptoms that are not consistent with what I described, you probably don’t have CTS. 

What do I Have?

So you did the Phalen’s test and it didn’t reproduce hand pain. Or, you have pain in other parts of your arm and hand. Now what? The two most common diagnoses that I see associated with CTS are wrist arthritis and radiculopathy. Here is how you tell which of the two you may have. 

Wrist Arthritis:

Wrist arthritis is common and does hurt a lot. Think of how much your wrist moves in a day, especially in your dominant hand. The wrist is 8 tiny little bones, and each one can show signs of degeneration. When a joint degenerates, the bones rub on each other and that will lead to intense pain. That is why people get joint replacements in their hips and knees. Unfortunately, no one has developed a wrist joint replacement yet (golden opportunity for anyone reading BTW). 

Here is how you can tell if you have wrist arthritis vs. CTS. Perform the Phalen’s test again from before. If you have pain in the wrist, try performing the reverse movement placing your palms together. If that position lessens your wrist pain, and you don’t get any symptoms into your fingers, you probably have wrist arthritis. 

Cervical Radiculopathy:

Radiculopathy is a fancy medical term for “sciatica” in your arm. What is happening is a peripheral nerve is getting pinched in your neck and giving you symptoms down your arm and into your hand. Carpal Tunnel Syndrome is a specific compression of the median nerve in your wrist. That is why the symptoms should only be in your hand after the point of compression. If you are having tingling/pain in your hand but not in your first 3 digits, you could have an irritation of one of the other two nerves in your arm (radial and ulnar nerve). Here is a nice nerve distribution map of your hand.

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If you need to figure out if you have radiculopathy here are a couple of nerve tension tests to try. If either of these tests reproduce your symptoms, you have radiculopathy, not CTS. 

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Facet Joint Back Pain

I treat a lot of people with back pain. The hard part about treating patients with back pain is getting the work we do on the table, to translate to standing and walking. Patients who are older (I’m talking 35+) will usually have pain due to a facet issue, degeneration in the back, or both. Lying down is a great position for those issues because it doesn’t put pressure on the back. Once you stand up, the back compresses, puts pressure on the joints, and the pain returns. If this sounds like you, let me give you a simple solution to provide you with some relief for your back pain with standing.

What’s a Facet Joint?

Unless you went to PT school, or some form of medical school, you have no clue what a facet is or what degeneration looks like in your back. Well...that is what I’m here for. Let me school you on some anatomy. Facet joints are the joints of the spine. Just like any other joint in the body, the spine moves. It requires joints to allow that to happen. In your spine you have facet joints on each side of every vertebrae from your head to your hips.

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Like all your other joints, the facet joint can get inflamed. When you compress an inflamed joint, it hurts. Facet joints get compressed when you are standing and when you extend. Hence the reason why lying down feels better, and standing hurts.

What do I do for Standing?

Since most of us can’t lie around all day, what do we do when we’re standing to help alleviate back pain? The key to having less pain with standing is understanding the position of your pelvis. Most of us have what is called an anterior tilt at our pelvis. That means that the front of our pelvis sits lower than the back part of our pelvis.

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Speaking in generalities, this usually happens because our hip flexors are tight and our abdominals are weak. In the game of tug-of-war, a tight muscle always beats a weak muscle. In therapy we will try to stretch the hip flexors, and strengthen the abdominals to correct the imbalance. That doesn’t always carry over to a standing position though. Sometimes, you have learned to stand like that so you need to retrain the brain to stand in a neutral pelvis. What is the best way to do that? Train your hips in a standing position. Here is a simple exercise that I like to give my patients that have back pain with standing.

Give this a try to help alleviate your back pain with standing. You can perform as many of these as you want. The exercise is meant to help you retrain your brains standing pattern. There is no resistance involved so you don’t have to worry about overdoing it.

I hope this helps correct your back pain you are getting with standing. If you have any questions please contact us. If you want a free session to review how to perform the exercise properly just mention this post and OrthoCore will give you a free 15 min session at any of our clinics. Thank you for reading!







Running with Knee and Back Pain

So, I’ve been running more lately. To anyone reading this that knows me, knows that comes as an enormous surprise. I used to be a huge runner (3-4 times/wk) but, running and I fell out of love when I started to get injured. My knees and my back were always bothering me. I was getting tired of showing up to work and feeling worse off than my patients. Instead of working on the flexibility and strength deficits that I had, I decided to just stop running. Not exactly what I would recommend to any of my patients but, effective at eliminating my pain nonetheless.

Well I’m back on the team! I credit my return to three things. 1. Like most other people who run, it’s easy to just get out of the house and run. It doesn’t require driving anywhere, or signing up with any gyms, etc to participate. 2. I can do it with my kids in a stroller. I get to spend more time with them, and it gives my wife a little break (double bonus). 3. I was intrigued when I saw that “Headspace” had a running packet. To those of you who don’t know, Headspace is a meditation app. I’ve been using it for a while now and the running specific pack piqued my interest. I was pleasantly surprised it actually made it really enjoyable to run. It didn’t feel like the mental struggle that I remember from the past.

Unfortunately, with my renewed love of running, my knee and back pain returned as well. It’s like when you get back together with an old girlfriend and realize part of the reason why you broke up was her annoying best friend. Well this time the friend isn’t going to break us up again. Instead of running from my problems (see what I did there), I’m going to address them and make sure that I can keep my feet on the road.

My main issue (as is the case with many runners) is that I have very tight hip flexors and IT bands. Those muscles run in the front of the hip and can restrict your hip extension and stride length.

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The problem with the hip flexors, and the reason why I get back pain, is that they anchor at the lumbar spine. When they are tight, your spine will flex with every stride and put excess pressure on your spine causing pain. The IT Bands run all the way down to your knee. When they are tight they will pull your knee out of alignment. That misalignment with every step will eventually lead to pain. Hence, the reason why I get knee and back pain when I run.

The good news for me (and anyone reading this with similar problems) is that it’s really easy to fix. All I have to do is stretch those muscles regularly to keep my body aligned and moving properly. Here is my favorite hip flexor and IT band stretch. If you are stretching pre-run then perform 15 repetitions holding the stretch for just a couple of seconds. If you are stretching post-run then hold for 30 seconds to a minute and perform the stretch a couple of times.

I hope this helps you stay flexible and keeps your feet on the pavement. If you have any questions please contact me here at OrthoCore Physical Therapy. Otherwise, HAPPY RUNNING!

When it Comes to Swing Length Size Really Does Matter, and Shorter is Better

Something that always comes up when I’m working with my golfers is their backswing length. Many golfers, and teachers, think that it’s vital to get to the top of their backswing, and get the golf club parallel to the ground. While I don’t disagree that players need to get to a good position at the top of the backswing, I do think that everyone has a unique backswing point. That point is very dependent upon how much flexibility you have.

How Many Degrees Do You Need?

Most professional golfers have 60 degrees of rotation in their shoulders, and 60 degrees of rotation in their hips. If you add those up it’s 120 degrees of rotation that is available (I know, difficult math). Now, you don’t need 120 degrees of rotation to get to the top of a “normal” backswing (lets just use parallel to the ground as a point of reference). You only need about 90 degrees of rotation to get there. There are two problems that most amateur golfers are faced with though. 1: They don’t have even close to 90 degrees of rotation. 2: If they do, that still isn’t enough.

Some of you are probably saying “what the heck! You just said I only need 90 degrees to get to the top of my backswing.” Let’s look back at those numbers though. Pro’s have 120 degrees and you only need 90 degrees to get to the top. That gives us a 30 degree difference (I know, hard math again). The pro golfer will get to the top of their backswing and then start the swing with their hips without moving their shoulders. That gives a greater stretch through the trunk and shoulders, and requires those extra degrees of rotation to prevent the shoulders from coming along for the ride. This gives them power and consistency with their swing.

So What Does an Amateur Do?

If you don’t have 120 degrees of rotation all is not lost. You should certainly do some stretching to improve your rotation if you don’t. What I do with my golfers is find the spot in their swing where they can still move their hips in the downswing. From there we use the K-vest system for biofeedback to memorize where that point is and prevent their swing from getting too long. It also helps them to coordinate the start of the downswing with their hips vs. their arms like most do. Once they do the flexibility exercises and improve their rotation we can continue to lengthen the swing without affecting the power and consistency they have created.

If you don’t have a fancy K-vest system but still want to find the correct length of your backswing watch this video.

The biggest thing to look for is the ability to start your hips without your arms. I always err on the side of short. You will be surprised how short you can make your swing and still hit the ball a far distance.

I hope this helps to improve your power and consistency with your golf swing. If you have any questions please contact me. Visit OrthoCore and learn more or make an appointment. Enjoy your new shorter, more powerful, swing.

Balance with Pitching

Balance and posture were the first two mechanical flaws I was taught to look for when I became certified through the National Pitching Association (NPA). The NPA is a group that was founded by Tom House who is the throwing coach for the G.O.A.T. (Tom Brady for those who live outside of New England), Drew Brees, Randy Johnson, Nolan Ryan, and so many other top athletes that this blog post would be 18 pages in just names alone. Their mission is to focus on strength and conditioning techniques that enhance a players skills and reduce their risk of injuries. In short, they look at the body first and performance second. You can’t be a division 1 pitcher if you can’t stay on the mound. Balance and posture is so important to this group that they don’t even look at anything else until this mechanic is fixed.

When we talk about balance we aren’t talking about a pitchers ability to stand on their drive leg for a long period of time. Quite honestly that doesn’t even matter that much. What we’re looking for is the pitchers ability to keep their shoulders level, through their stride, and delivery of the baseball to home plate. Any deviation from this level position will lead to a compensation which can lead to arm injury and break down over time.

Here are a couple of examples of good posture through delivery.

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Here are some examples of bad posture through delivery. They most common coaching mistake we see is telling a player to “get on top” of the ball.

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Now some of you reading at this point might be thinking, “Hey Matt Harvey was a dominant pitcher and Okajima was an World Series winning All Star.” That is all true but how long were they dominant and, at what cost.

A players inability to maintain their balance and posture through the delivery can be caused by a multitude of reasons. Literally any restriction in anything from the ankle up to the trunk can cause a loss of posture in the players delivery. I always recommend that a player get screened by a qualified movement specialist to be sure you are attacking the correct strength and flexibility deficits that are causing the problem. That being said here are some of the most common causes of loss of posture that I see with my pitchers.

Flexibility:

If a players hips and trunk are tight it will limit their ability to rotate which can lead to a loss of posture while throwing. Here are two simple stretches that you can do to help improve your hip and trunk mobility. If you try to do these exercises, and its really easy, then flexibility probably isn’t the reason behind why you are losing posture. It’s still a good idea to perform them regularly to maintain the flexibility that you have. Try doing 15 repetitions holding each repetition for about 3 seconds

Hip IR/ER with Twist:

Sit on the ground with a bat. Rotate one leg in and the other leg out keeping a 90deg bend in the knees. Once your legs are touching the ground rotate your arms towards the leg that is rotating in.

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Open Book:

Lie on your side with both legs bent up to 90deg. Rotate your arms open like a book.

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Core Strength:

Your core muscles are what keep your trunk upright while you are twisting as you throw. They also help to transfer the energy from your legs up to your arm. That means that by doing this exercise not only will you be able to better maintain your posture, you will also be able to throw harder (and who doesn’t like that). Perform 15 repetitions on each side and hold this reach/kick position for 3 seconds.

Plank with Reach:

Get into a tall plank position focusing on squeezing your glutes and keeping your core tight. Stay stiff and alternate reaching with your hands out in front of you. It’s important to prevent your hips from twisting while you reach.

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Plank with Kick:

Get into the same tall plank position. Alternate kicking a leg up in the air. Make sure that your hips don’t twist. Also make sure that your back doesn’t arch as you kick up.

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Balance:

Well it’s what we’ve been talking about the whole time. Didn’t you think I was going to give you an exercise to work on? Balance is important in your trail leg but also your landing leg so be sure to work on this on both legs. You may notice a difference between your legs which is completely normal. The more you work on it, the more your legs will equal out. Try to do 15-20 repetitions on each leg.

Single Leg RDL:

Stand on one leg. Keeping your back straight, balance on one leg and kick the other leg back. The goal is to get your body parallel to the ground without rounding you back. This is a really challenging exercise so don’t get frustrated if you have trouble with it. Just keep practicing and eventually you will master it.

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I hope this helps you improve your strength and flexibility to limit any loss of balance and posture that you might have in your delivery. If you haven any questions or problems please don’t hesitate to contact me on our website, www.orthocorept.com , or via email, IanM@orthocorept.com.

Making Time for Physical Therapy

Let’s face it, nobody has enough time anymore. It’s the number one reason that we hear from our patients as to why it takes them so long to get started on a rehabilitation program. Once people do start on a program, they finally commit to getting better. The thing that makes us crazy, though, is when people throw all of their hard work away by not sticking with their program once they are discharged. Why do patients fall off the wagon once they are done with treatment? Time, not enough time.

We’re here to offer some solutions for people who are looking to stay on top of their program and stay pain-free especially during this busy holiday season.

1. You don't have to do every single exercise, every single day.

Rehabbing from an injury is a huge commitment. You usually have to go to PT 1-2x/week for about an hour per visit. When you are not at PT you have "homework" that you are supposed to do at least once per day. It all starts to add up. Patients think that once they are discharged they need to keep up with the pace of doing everything once a day. Add that to everything else that people have to do during the day and it starts to get overwhelming

We always try to educate our patients that rehabilitating is different from maintaining. When a patient is rehabilitating, they are working on correcting whatever strength, flexibility, or motor pattern issues that are leading to their pain. It takes more repetitions to make those changes, and that’s why we usually ask the patient to perform their program daily. 

Once they make those changes and are now pain free, the patient transitions to the maintenance phase. During the maintenance phase patients only have to perform the exercises 1-2 times/week. What a relief! Think of all that extra time you will have on your hands. 1-2 times/week is all that is needed to maintain that new strength and flexibility you have worked so hard to obtain. 

2. You don’t have to do all the exercises at once. 

Most patients’ rehabilitation "homework" consists of at least 5-6 exercises that you are supposed to do multiple repetitions of. That can add up to a lot of time in one sitting. Instead of trying to carve out a block of time to perform the whole program you can do each exercise at least once per day. If you have a free couple of minutes, do one of the exercises. If your program consists of some exercises that have you lying down you have two opportunities during the day where you start and end in that position (yes, we’re talking about sleeping, people!). Take a little extra time to do those exercises when you are already in the starting position. That way you can get to the whole program throughout the day, rather than feeling like you need "extra" time to perform the whole thing at once. 

3. You probably don't have to do every exercise on your program for the rest of your life. 

If you feel like your program is really extensive by the end of your rehabilitation, you are probably correct. If you truly feel like you can't do every exercise then be honest with your therapist. We always try to work our programs around what the patient is willing to commit to. Sometimes that is only two exercises. If that is all you can commit to, it just means you have commitment issues and that’s fine (…or is it?). In all seriousness, we would rather give someone a couple of exercises that will highlight the biggest areas of dysfunction vs. a program that is aimed at fixing everything that they won't stick to.

4. Pain sucks, so why would you want it to come back?

It drives us CRAZY when patients come back with the same injury. This drives us up a wall because the typical answer as to why their pain returned is because they didn't stick with the program. It’s like failing a test that you have the answers to. 

One of the best ways that we've found to keep people on track is setting a schedule. Set reminders on your phone, place sticky notes around your house, whatever reminders you need to stick to the schedule. That will give you the best opportunity to stay on track and live pain free!