Online Health Chat with Steven Maschke, MD
September 12, 2012
Cleveland_Clinic_Host: We use our elbows, wrists and hands an incredible number of times during the day for activities of daily living, work and play. With how much we rely on our upper extremities, it’s no wonder that painful conditions develop. When this pain interferes with your daily living, it’s time to consult your physician.
Pain in the elbow, wrist or hand can follow trauma or from various medical conditions. Arthritis, ligament and tendon injuries can produce elbow pain. Tennis elbow (lateral epicondylitis), can affect those who play tennis or do activities involving repetitive motion of the elbow. Radial nerve impingement produces a similar pain. Golfer’s elbow affects the medial epicondyle bone and nerves. The wrist can become painful from overuse, which can be due to typing on the computer, but is likely not the source of carpal tunnel syndrome. The hand and fingers also can be affected by painful conditions, including arthritis and trigger finger.
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The Cleveland Clinic
All specialists and surgeons at Cleveland Clinic’s Upper Extremity Center have extensive training in the diagnosis and surgical and nonsurgical care of a wide range of problems, including those of the hand, wrist and elbow.
Cleveland Clinic's Orthopaedic & Rheumatologic Institute offers expert diagnosis, treatment and rehabilitation for adults and children with bone, joint or connective tissue disorders. The institute blends the strengths of Cleveland Clinic's orthopaedic and rheumatology programs, both ranked among the top three nationally by U.S.News & World Report with the top rankings in Ohio.
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About the Speakers
Steven Maschke, MD, is a staff physician at Cleveland Clinic, as an orthopaedic surgeon specializing in hand, wrist and elbow surgery. Dr. Maschke completed an orthopaedic surgery residency and internship at Cleveland Clinic, and a hand surgery fellowship at the Curtis National Hand Center at Union Memorial Hospital in Baltimore. He earned his medical degree from The Ohio State University College of Medicine and Public Health, in Columbus, Ohio. Dr. Maschke is board certified in orthopaedic surgery. Dr. Maschke’s interests include hand, wrist, elbow and peripheral nerve surgery, along with arthroscopy, tendon-ligament injuries, arthritis, joint replacement and reconstruction, fractures and congenital deformities.
Let’s Chat About Options for Hand, Wrist and Elbow Pain
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Steven Maschke, MD. We are thrilled to have him here today for this chat, ‘Options for Hand, Wrist and Elbow Pain.’
lxr145: I'm a 24-year-old woman who was diagnosed with carpal tunnel syndrome about one year ago. After resting my hand and using aspirin, my hand was OK for a while. But now it started again, and it’s way more painful than it used to be. I can barely move my hand without a stinging pain that goes to the back of the elbow. I am also experiencing tingling in the fingers now. I went to the doctor and they gave me ibuprofen again and ordered rest, but the pain still doesn't go away. Is there something else I can do? Should I go to a specialist?
Dr__Maschke: My first concern is whether there is more than carpal tunnel syndrome going on. I would recommend evaluation by a specialist and consider getting an electromyogram and nerve conduction velocity testing if deemed appropriate.
mgm: I have carpal tunnel from years of playing the piano, working on the computer and gardening (on my hands and knees). I am concerned about my children. They are constantly on the computer, playing their video games, texting on their phones, etc. What types of hand and wrist problems are they going to be looking at in the future? Is there anything they can do now to help prevent those problems? I don't want them to suffer the way I have.
Dr__Maschke: The correlation of carpal tunnel with activities such as typing has been refuted. Working with vibration equipment (like jackhammers, etc.) can cause carpal tunnel, and other activities over prolonged periods can exacerbate carpal tunnel. Routine breaks and regular exercise should help diminish the risks, but with tendonitis—that’s a different story.
songcanary: I was diagnosed with chronic writer's cramp many years ago and was not given any treatment options. I lost a good job over this and have since been very limited in what I can do. How would you address writer's cramp today?
Dr__Maschke: I would rule out causes of cramping in the hand (for example, carpal tunnel syndrome). If there is not a neurologic cause of the cramping, than I would suggest frequent breaks and using adaptive technology to limit the amount of stress on the hand.
cdame: I've had chronic pain in the base of my left thumb for over 10 years now. I've been tested by three neurologists over that period, with the latest evaluation completed within the last two years. The latest round of testing showed some arthritis along with slight ulnar nerve compression. But neither the neurologist nor my family doctor has suggested any treatment plan to lessen the regular, periodic aching pain other than to wear a carpal tunnel brace for a few weeks. That definitely did not lessen the painful incidents from occurring. In fact, it felt worse the longer I wore the brace. I can reproduce the pain almost at any time, even when there is no pain by manipulating the thumb in certain directions. Once the pain begins, it continues for a considerable period of time from a few hours to a few days, and then gradually subsides.
Dr__Maschke: It sounds like arthritis at the base of your thumb, which can often be associated with carpal tunnel syndrome. My first line treatment is splinting, followed by judicious use of cortisone injections. If all else fails, we have surgical solutions.
kleefeld: I have intermittent sharp pain in my left thumb, which is possibly arthritis. Blue Stop™ seems to ease it considerably. Is it safe to continue my regular routines, or is it time for an examination?
Dr__Maschke: I would not be concerned about doing activities. Certainly, more aggressive activities could aggravate and possibly accelerate the arthritis. However, if you are limited daily by the pain, it’s time for a check-up.
coyotetoe: As an active 75 year old I notice that the joint closest to the wrist on my left hand is painful if manipulated. What drugs are available to reduce this pain?
Dr__Maschke: Oral anti-inflammatories often can be effective. Check with your regular doctor prior to starting these medications to evaluate and recommend their safe use.
coyotetoe: I wanted to provide clarification on my question. The joint in question is the base of the thumb, closest to the wrist on my left hand. As I am working on mechanical projects, cars, woodwork, etc., my ability to grip is limited by pain from this joint, and it’s getting worse. Would you estimate that it is arthritis? By the way, I can cause a sharp pain in the area if I manipulate (or pinch) the joint between my right thumb and forefinger.
Dr__Maschke: These are the classic symptoms for thumb carpometacarpal (CMC) arthritis.
fragrancefree: Any suggestions for exercising with basal joint arthritis (specifically lifting dumbbells and yoga)? I'm a 54-year-old female, and was told I could have surgery any time I want it. Surgery is my last resort and I don't take any medications either. But it's pretty painful sometimes!
Dr__Maschke: Cortisone injections can be helpful in the short-term. Wrist wraps with weight training at times can help reduce the stress on the carpometacarpal (CMC) joint. Also, in yoga do planks on your knuckles and avoid pressure on the palm.
secret: Can you please talk about tendon release surgery? What is involved? What is recovery like?
Dr__Maschke: If you are referring to trigger finger release, it involves a small incision in the palm and splitting the A1 pulley (which holds the flexor tendon close to the bone). The surgery usually is done with local anesthesia and mild sedation, and often takes under 10 minutes. The recovery time is usually four to six weeks.
Trigger Finger Treatment
heartspouse: What are the treatment options for ‘trigger finger,’ which is causing me increased stiffness, pain and lack of dexterity? Cortisone shots only seem to mask the problem.
Dr__Maschke: If cortisone has not been effective and the definitive diagnosis of trigger finger is established, the most effective long term solution is surgical release of the A1 pulley in the palm.
tamara88: Regarding the trigger finger inquiry, Dr. Maschke treated me with one cortisone injection and a night finger splint, and it is now completely healed!
Dr__Maschke: Thanks, and I’m glad you are doing well!
lumina120: What options are available for severe wrist and forearm pain that keeps getting worse—even after a carpel tunnel release and arthroscopic wrist debridement with denervation? The pain has been getting worse since its sudden onset in May 2009, even with all of the surgeries.
Dr__Maschke: You’re in a difficult situation. First, the correct diagnosis needs to be established. Often, continued pain has no definable cause and pain management consultation is recommended.
lumina120: Would an orthopaedic surgeon be the correct doctor to follow-up with?
Dr__Maschke: The next step sounds like re-evaluation—either by orthopaedics or pain management.
spencer: Do previous injuries (such as a broken wrist) often preclude or enhance future arthritis or tendonitis?
Dr__Maschke: The most common causes of arthritis in the wrist arises from either an injury to the scapholunate ligament or non-healed fracture of the scaphoid bone. Certainly, fractures that either enter the joint or change the geometry of the articulation can lead to progressive arthritis in the wrist.
Bkosar19: My nerve is entrapped between a muscle and bone. I also have psoriatic arthritis. I have been on every NSAID (nonsteroidal anti-inflammatory drug), cortisone injections, hot yoga and acupuncture. Are there any exercises that might help?
Dr__Maschke: If the nerve is entrapped in the supinator muscle and all else has failed, and exercises have not been effective, splinting the wrist in slight extension can help. Rarely, surgical decompression is recommended.
elbertg: What can be done to eliminate pain in the right hand and wrist when you are on computer all day for work?
Dr__Maschke: Take short breaks, work on stretching, and if the pain continues, have an evaluation for common medical issues.
rmull: My son has some swelling around the wrist and some pain. He was approximately 13 years old when he injured his wrist,, and is 23 years old today. My question is related to the wrist injury that per the orthopedic doctor did not heal correctly after a fracture-type injury. The doctor who redid the X-ray stated that if it bothered my son, he should use a wrist support at night. However, I am concerned that since it did not heal correctly, are there any long-term illnesses that can be related to injuries that have not healed correctly? What can be done medically?
Dr__Maschke: The answer is not simple. We would need to know the bone has not healed correctly, whether the mechanics of the wrist have been altered, and if any arthritis has set in.
fragrancefree: Are there any new surgical advances for the carpometacarpal (CMC) arthritis? (I know I will have to have it done.)
Dr__Maschke: There are new metallic implants that in the short run have promising results. However, traditional CMC arthroplasty continues to be the gold standard.
fragrancefree: Are the carpometacarpal (CMC) arthroplasty results pretty good (like getting dexterity and grip strength back)?
Dr__Maschke: Pain relief is very good, but strength does not return to normal. Subjectively, though, strength seems improved as pain is no longer a limiting factor). There are very good operative results, but be prepared for a long recovery.
coyotetoe: Could you describe carpometacarpal (CMC) arthroplasty?
Dr__Maschke: Basically, the trapezium bone is removed, and the thumb is either pinned in place or soft tissue is used to stabilize the joint and fill the void left by the bone removal. Casting is typically four to six weeks, followed by a removable splint and motion.
Tennis Elbow Relief
elbertg: What are good exercises for tennis elbow pain relief?
Dr__Maschke: The best options for tennis elbow is to wear a wrist splint when you sleep at night to avoid stretching the involved tendons, avoid lifting objects with the palm down, and stretch the wrist in flexion with the elbow fully straight.
Eyeman9: I have had tennis elbow for two years. I had three injections which helped for about four to six months, and then I get the pain again. I have tried all the exercises, etc. Will this ever get better or do I need surgery?
Dr__Maschke: I have seen tennis elbow ‘burn out’ many years after the onset. Continue the exercises and wear a rigid wrist brace at night.
Felicia: My husband is a golfer and has severe elbow pain interfering with his golf swing. There is tenderness right above the elbow. What could be going on and should he have this evaluated, or should he just take lessons and change his golf swing?
Dr__Maschke: ‘Golfer's elbow’ is most often tendinosis along the medial epicondyle (inside part of the elbow). Lateral epicondylitis has also been reported. The swing changes are difficult, but frequent stretching and possible occupational therapy can help him continue and enjoy his golfing.
Bkosar19: I have radial nerve entrapment in both arms. I have had nerve testing three times. The doctor gets no reading at either wrist. I can't hold a golf club, determine items in my pocket, and have pain. What can I do?
Dr__Maschke: My protocol is to get a neuromuscular ultrasound to look at the radial nerve directly for evidence of swelling and to rule out a compressive cause (including cyst or previous injury).
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Steven Maschke, MD, is now over. Thank you Dr. Maschke for taking the time to answer our questions today about ‘Options for Hand, Wrist and Elbow Pain.’
Dr__Maschke: Thanks for all of the great questions. I hope you all found this helpful!
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