What Your Hand and Finger Pain Is Telling You with Dr. William Seitz Jr.
What Your Hand and Finger Pain Is Telling You with Dr. William Seitz Jr.
Nada Youssef: Hi, thank you for joining us for this episode of the Health Essentials Podcast brought to you by Cleveland Clinic. I'm your host, Nada Youssef and with me today here at Cleveland Clinic Lutheran Hospital is Dr. William Seitz. Thank you so much for being here today.
Dr. Seitz: My pleasure. Thanks for having me.
Nada Youssef: Dr. Seitz is a Cleveland Clinic orthopedic surgeon and today we're talking about hand pain, what causes it and what can be done to relieve that pain. And please remember, this is for informational purposes only and it's not intended to replace your own physician's advice. So because our hands and our arms are so interconnected, could hand pain be stemming from a different part of the body all together?
Dr. Seitz: Absolutely. The fingers are the antenna that start to explore the world when we're infants and we use them as tools as we get older. In fact the very tips of your fingers are interconnected by nerves to the opposite side of your brain. So there's direct circuitry from your brain to your fingers. So anywhere in between if there's a problem, one can perceive pain in the hand or the wrist or in the upper arm and it doesn't matter where the problem may occur, it can be referred down to the hand or if it's in the arm, it can be referred up towards the neck as well.
Nada Youssef: So besides nerves, what can hand pain stem from?
Dr. Seitz: Hand pain can stem from a lot of things. Actually the nerves are the entities, the actual physical vessels that perceive pain and transmit it to our brains and make us realize that something is wrong because it hurts. But all of the structures throughout the limb have nerve endings on them. So the skin, the subcutaneous tissue, the tendons, the joints, the ligaments in the joints, the [inaudible 00:02:30] bones that span joints, all of them have nerve endings in them. When they're injured, when they're stressed, they can transmit symptoms which feel like pain.
Nada Youssef: Wow. So there's a lot to diagnose there, but before knowing where that pain is coming from, let's say I do have hand pain at home. How do I know the cause of that pain? Are there questions I should ask myself before seeing a physician?
Dr. Seitz: Sure. Well, first of all obvious things like do I remember that part of my body? Does it look red? Is it swollen? Does it feel hot, things that might suggest an infection? Was I playing sports or did I start a new workout that was very strenuous? Things like that can give you a really good sense of whether or not there was an instigating cause of this. There may or may not be, but those are simple things to ask. The other thing is to ask how long has it been there? Did it just start this morning? Because a lot of times we'll wake up with a new ache or pain. If you give it a little time, it'll quiet down. You don't need to go running off to the doctor.
Nada Youssef: So it needs to be consistent before you go to a physician.
Dr. Seitz: It can be a repetitive. It can be recurrent and become chronic and then that's certainly something that you want to look into.
Nada Youssef: All right, thank you. So let's talk about the most common condition involving hand pain. What would you say that is?
Dr. Seitz: Well, probably it depends on the age group. In young active people it's probably stress from over-activity, not necessarily overuse, but over-activity. It could be from repetitive minor trauma or a single substantial trauma. As we get a little bit older, it can be more from some wear and tear on our tendons, a tendonitis, or as we get even more senior, or as I like to say, collect more miles on our bodies, our joints can start to wear. That's what's called arthritis.
Nada Youssef: Okay, so arthritis meaning joint inflammation, right? Because we have over ...
Dr. Seitz: Correct.
Nada Youssef: ... 100 types of arthritis, so let's talk a little bit about that and how we would know what kind of arthritis that I have on me.
Dr. Seitz: Sure. Well, you're exactly right. Arthritis means inflammation of a joint and again, the lining of the joint has nerve endings and when it gets inflamed they don't like it and they respond by telling our brain we have pain. More often than not this is a wear and tear arthritis. It can come from wearing down of the cartilage and we start to get bone on bone and that can start to cause reactive inflammation in the joint. As a result then we start to perceive pain. That's probably the most common source of the pain. This type of arthritis, osteoarthritis, if you will, can be the result of multiple repetitive traumas over years or it can be the result of a single trauma which injured the joint and therefore what once was a nice smooth fitting engine part if you will, now is out of round and it's irregular and it's rough.
Dr. Seitz: That's what triggers these symptoms. Other forms of arthritis include inflammatory types of arthritis and this can be something that can be caused by rheumatoid arthritis or other rheumatoid-like arthritis entities such as lupus arthritis. There can be other inflammatory arthritities such as the arthritis associated with psoriasis, the arthritis that it may be the result of gout where crystals build up inside the joint because someone is not processing certain chemicals well, and so these chemicals build up in our blood. The chemical’s called uric acid. And when it gets too high, it precipitates out just like salt in a pot that has become too concentrated. These crystals come into the joint and they act as sand in the crankcase of an automobile. It doesn't work well.
Nada Youssef: So does then that pain then come gradually or-
Dr. Seitz: It can and a lot of times you can have arthritis, IE, the wear that we see in joints and substantial changes in the joint but without a lot of pain. There's no rhyme or reason really why some people have more pain with less arthritis or very little pain with very severe arthritis. Probably has to do with people's tolerance, but I guess it all depends on how hard they're using those joints.
Nada Youssef: So what do these symptoms look like for arthritis in your hand and how is it different than other conditions that can be causing hand pain?
Dr. Seitz: They focus around the joint. So all of our moving parts in our musculoskeletal system are bones that are connected together at a joint. That joint is covered with joint cartilage and they're held together with ligaments and they're motored by muscles and tendons. So it is where the two bones come together, on their surface has got a coating, a very smooth cartilage. That cartilage normally tracks very nicely like two little machine parts. When there's something that causes inflammation, they will swell. If it's an acute inflammation, they will swell substantially, they will get red, they can get hot and they can become stiff and even immobile. That can be the sign of an acute flare up of something like gout or pseudogout or rheumatoid arthritis or even other rheumatoid-like arthritis or arthritic conditions such as psoriatic arthritis or lupus arthritis.
Dr. Seitz: There are many other inflammatory type arthritis. Additionally, there may have been an acute injury that we sort of brushed off and suddenly we realize that the joint isn't moving. Again it's inflamed. It may not be as hot but it may be discolored, it's black and blue. Those also can be signs of pain, of an arthritic condition. But they occur actually in the joint itself where there's movement as opposed to if there's just sort of some more vague diffuse pain that goes above and below the joint which may be a sign of tendinitis. It may be a sign of some nerve irritation. It could be a sign of a ligament sprain, so forth.
Nada Youssef: So let's talk about the cause of arthritis and whether it is genetic. For example, a lot of people think typing too much can cause maybe arthritis. Is that a factor [inaudible 00:09:45]?
Dr. Seitz: Well, it's not so much that something like typing can cause arthritis, but if you have arthritis, if you have a joint that has some worn surface areas and you do a lot of movement, that can irritate it. So the movement can cause some irritation. But the reality is that the arthritic condition itself isn't really caused by typing. Now you asked about genetics. We all have a certain amount of genetic predisposition to certain things just simply because we have inherited our frame, our body size, habitus, muscle mass from our parents, so it's not uncommon where you see that over a series of generations there are certain joints which tend more to be arthritic. There are other types of arthritis, however, which are distinctly genetic traits which are transmitted and they tend more to be in the inflammatory arthritic categories such as rheumatoid disease and inability to handle certain proteins, which can lead to the cause of gout, that sort of thing.
Nada Youssef: That's considered an autoimmune disease, correct?
Dr. Seitz: Rheumatoid diseases and other types of inflammatory diseases are. Not gout, but again, one's inability to process certain proteins can lead to the buildup of these elevated levels of uric acid in your system. But for the most part, the genetic characteristics are more just what you inherited from your parents in terms of your skeletal architecture.
Nada Youssef: Okay, great. Now how do you diagnose arthritis in hands? What kind of tests are done?
Dr. Seitz: Well, first of all you take a good history. You listen to the patient. You talk to the patient. You have them tell you the answers to some of the questions that I alluded to in the beginning. How long has it been there? Did you have an injury? Has this been recurring? Has it been there for a long time? Does it have peaks and valleys? Have you tried taking any anti-inflammatory medication? Does that make it better? So those are a lot of questions that we ask and based on the answers, when there's a lot of yeses in there and we focus more on the possibility that this could be arthritis. We then do a careful examination and we determine is it movement of the joint that causes the pain?
Dr. Seitz: Is it the joint itself that's tender and sore when we stress it or is it some other structure that may be mimicking an arthritic condition? Then based on the history and the physical examination, we should have a pretty darn good idea. Now, especially in the hand there's very little meat if you will, covering our skeletal architecture. So if a hand has some arthritic conditions where a wrist or an elbow even have significant arthritic conditions, we can see the swelling. We can see the reactive bone that may form the bumps and so forth. That can be a pretty good indicator that this arthritis has been around for a while. Maybe it's only becoming symptomatic now, but it's probably been there for some time.
Dr. Seitz: Finally, then after we've taken a good history and done a physical examination, we look at imaging studies. For the most part plain x-rays, simple x-rays are usually more than enough to determine whether or not there's arthritis. I can't tell you how many people I see come in without having had a good history taken, a good physical examination or a simple x-ray. They come in with a very expensive test like an MRI in their hand, which really doesn't add an awful lot.
Nada Youssef: Right, because you need background information.
Dr. Seitz: Yeah, the simple things first. We have to also recognize that we need to conserve our healthcare dollars. Now, are there roles for things like an MRI or a CAT scan? Of course there are, but not in every case.
Nada Youssef: Okay. That's very good to know. So let's talk about treatments. Now, arthritis has no cure, so what kind of treatments do you give someone with arthritis?
Dr. Seitz: Well, most arthritis doesn't have a cure. Some with some of our newer drugs that our rheumatology colleagues are using today can actually reverse some of the inflammatory arthritis or at least arrest it. So that's been a huge advance in the last generation and a half, if you will. But there are a lot of things that we can do to identify not just that there's arthritis and treat what we see on an x-ray for example, but to ask are there things that are being done on a daily basis, which we could do differently? If somebody knows that when they go to play tennis and they grip the racket and they hit the ball, their hand hurts, their wrist hurts, maybe we can make some modifications in the racket.
Dr. Seitz: Maybe we can make some modifications in the stringing. Maybe we can do some exercises before playing which get the flexibility and the ability to safely play better. Maybe we just avoid some strokes for a while and that sort of thing. But the reality is that again, it goes back to taking a good history and figuring out what the instigating causes are. Once we know that, then we can avoid some of those things. Heat is in the long-term is much more effective than cold in most cases. Think about it yourself, if you have a little bit of acreage somewhere and you get up in the morning, you get under a hot shower, your body goes, "Oh, that feels good."
Dr. Seitz: If you accidentally get under a cold shower, everybody tenses up like that. So the idea is if you can get the joints relaxed through some heat, and the best way to do that really is to soak your hands and wrists in warm water, let them sit there for a couple of minutes and then just work on flexibility exercises. That can help dramatically. There are certain joints which you maybe irritated during the night when you sleep just because when we're asleep we don't realize how much we're moving our limbs and so sometimes a little splinting at night can help. During the daytime we want to keep the joints moving or maybe they need a little support. So we have flexible little supports for joints that can be used.
Nada Youssef: Excellent. So I kind of want to talk about diet. Now there's some food that is known to cause inflammation, like sugar. Are there types of foods that you should avoid if you are having pain or arthritis in your hands?
Dr. Seitz: I think honestly an individual's diet doesn't really cause arthritis, but if you have arthritic joints and you're overweight, you want to make sure to control the calories. When you take a can of soda and you bring it to your mouth like this, your hand has to grasp it, it has to lift it. It should be reminder to you that maybe something without calories or unnecessary calories would be better. But the other thing is that there are disease entities such as diabetes, which if you have a predisposition to, all the more reason to eat well and avoid consuming products that can elevate your blood sugar in the test called the A1C, which can keep the diabetes much more active than it should be. So we can control a lot of that by diet.
Dr. Seitz: But there really isn't any good food or bad food in terms of arthritis. People always ask me about the food supplements like Chondroitin and Glucosamine. They're proteins and proteins which looks similar to a lot of the proteins that are in cartilage. But the reality is you have to eat them. You have to digest them. They get broken down into their smallest molecules to get into the bloodstream and then for them to get miraculously reassembled in a joint somewhere that happens to have some arthritis is a long stretch.
Nada Youssef: Okay. So what is the good food to eat?
Dr. Seitz: I think protein is good. I think just a good balanced diet. Vegetables are very good. I'm not a nutritionist and my wife and I might differ on what I consider to be a good meal and what she considers to be a good meal, but I think everybody's that way. Just everything in moderation and just make sure you're getting enough vitamins and so forth. Now, in Ohio, this part of Ohio, we have a lot of cloudy days and so bone health is important, right? So you can't get vitamin D activated without exposure to ultraviolet light. Everybody runs around drinking processed bottled water. That doesn't have fluoride in it. You need fluoride.
Nada Youssef: Processed water bottle, never heard about that. Okay.
Dr. Seitz: So when you turn on the tap water and you drink a glass of tap water and you get fluoride. So you need to have fluoride. If you are drinking bottled water all the time, then you need to take some fluoride supplement. You need to take vitamin D, but in order for vitamin D to get activated, you need to have exercise. Your skeleton needs to be impacted and it turns on your bone-making cells to be able to make new bone. But vitamin D is activated in the skin under the influence of ultraviolet light, and so, especially if you live in an environment like ours where we don't have that many sunny days or if you're just like me indoors all the time, if it's worthwhile getting evaluated, making sure that your bone structure is good. Because you can have little micro fractures and then that can be a source of collapse and weakness around the joint.
Nada Youssef: Now, since it always seems to be always cloudy in Cleveland, do you use the just supplements or are you saying eat your vitamin D? Can you eat your vitamins?
Dr. Seitz: There are vitamin D supplements that you can take, but the problem is your body will only absorb so much. The same is true with calcium. So you need vitamin D to be able to turn on your bone-making cells to take the calcium out of your bloodstream and converted into bone.
Nada Youssef: Okay. That's great. So let's say I am vitamin D deficient. Is there a certain milligram that we should go for when we are getting our vitamin D supplements?
Dr. Seitz: Yeah, that's something that you should ... I think there's a certain amount of vitamin D that's sort of recommended, probably about 500 milligrams or something like that. But the reality is if you think that you may be vitamin D deficient, you should see your primary care doctor or a nutritionist and get assessed to see what you need or don't need. Not everybody who lives in Cleveland is vitamin D deficient.
Nada Youssef: Okay. So I want to talk a little bit about carpal tunnel syndrome, which also seems like another common cause of hand pain. How do these symptoms present themselves?
Dr. Seitz: Carpal tunnel syndrome can present in a number of different ways. Typically, there's some numbness and tingling that people notice, but this is what we call a compressive neuropathy. It results from compression of a nerve in the wrist and that nerve sits right in the middle of your wrist here, deep down. On the two sides and on the floor is bone. There's a big hollow, if the entire volume may be about the size of my thumb, and there are nine tendons that move your fingers that go through that tunnel. Most superficial structure is this nerve called the median nerve. That nerve gives you feeling your thumb, index, middle finger and a little bit of your ring finger. The small finger or pinky and the outer portion of your ring finger get their sensory innovation from a different nerve called the ulnar nerve on the outer side of the arm.
Dr. Seitz: So these fingers in particular tend to be ones that people feel discomfort in or some change in sensation in. Remember that nerves have a multiple different types of fibers and nerve endings. As such, they're responsible for everything we feel, cold, hot, vibration, buzzing, tickling, burning, pressure. So people can wind up having different descriptions of what they're feeling but some of the classic things are that it happens with a lot of activity, happens when talking on the phone, happens when using a computer. It happens when doing a lot of writing. It happens specifically when sleeping at night. So what happens when we sleep at night, once we do fall asleep, frequently our wrists flex and keeping it flexed like this will cause pressure on the nerve and that prevents the normal circulation of getting to the nerve.
Dr. Seitz: Nerve tissue in your wrist or hand isn't very different than nerve tissue in your brain. If it's not getting its blood supply, it lets you know and these feelings can be numbness, tingling. People will typically describe waking up at night, shaking their hand like that. The same thing is true if you're driving your car, that sort of thing. The reality is that there are very few actual jobs that cause or job activities that cause this, especially in white collar jobs. It's not caused by using a computer. It's not caused by writing. But if you have it, those activities can really exacerbate the symptoms.
Dr. Seitz: Now, if you're a jackhammer operator, different story, right? Or if you're a lumberjack or doing heavy construction with a lot of vibrations or a machinist, those can be sources of the actual stimulation and irritation. What happens there is that the tissues around the nerve within this tight little canal start to build up. Think of it like when you have a suitcase that's completely filled normally and you just decide you're going to throw in three more sweatshirts. You put them in, you close it. Everything inside gets a little tighter. Well, the problem is that what gets compressed first is the nerve and that starts to give you symptoms of these odd sensations.
Nada Youssef: And I just want to go back to the three fingers that you were pointing to that would be affected the most by carpal tunnel is the thumb and the pointing finger and the middle finger. The other two are-
Dr. Seitz: And sometimes a little bit of the inside of the ring finger. But it doesn't have to be all of them. It can be one or a couple of them. And again, it depends on which part of the nerve is being irritated the most.
Nada Youssef: Okay, so let's talk about prevention for that as well. Are there measures we can take?
Dr. Seitz: Yeah. Again, there are certain disease entities that exist that that can predispose to this such as diabetes again, where it can affect the small vessels that nourish the nerve. Now it may take less compression to cause the nerve to react badly. Thyroid disease untreated can, hypothyroidism can cause this. It can be caused by gout again, building up inside the wrist. There are certain proteins which don't belong in certain tissues, one of which is called amyloid, which can be sourced either by a genetic trait or by some other disease entity where proteins are being made abnormally.
Dr. Seitz: That tissue can get deposited in these tissues around the nerve and cause more buildup of pressure inside there. So yes, we can make sure that if we have a predisposition or a known diagnosis of diabetes, we treat it, that if we have hypothyroidism, we see our endocrinologist as well and make sure that that gets treated. If there's any family history of heart disease, not a bad idea to get it checked out and make sure you don't have amyloid. If there's a concern where you're having a lot of back pain and you may be having a problem with your bone marrow, again, that could be the sign of a more rare condition called myeloma.
Nada Youssef: So while carpal tunnel and arthritis seem to be a very common hand issues or pain, can we talk a little bit about what other things could be the cause of hand pain?
Dr. Seitz: Sure. There are many, many things that can. Again, it can be that there've been minor injuries or fracture. The so-called jammed finger where you're playing basketball and got hit on the end and sort of played through the game but the next morning it's stiff and it's sore. It could be a partial tear of a ligament. That's what we call a sprain. You can have a tendonitis, an inflammation of a tendon. That happens frequently in the flexor tendons of the fingers. It's a very common entity. It's called the stenosing tenosynovitis and when it gets bad the finger gets caught and we have to pop it open and it's called a trigger finger. The same sort of thing can happen in the side of the wrist. It's called De Quervain's tenosynovitis and that can cause pain when one tries to move their thumb or grasp something, that sort of thing.
Dr. Seitz: Can have tendonitis in the back of the wrist. There can be a rupture of ligaments in between the carpal bones and the wrist. There are eight little carpal bones that together form the wrist that articulates with the forearm and also then more out towards the fingers with the bones of the hand. Any of those can be the source of pain. You can also have pain in your hand because you have a pinched nerve in your neck.
Nada Youssef: Wow.
Dr. Seitz: You can have a referred pain because of something going on up around the elbow, again, a nerve compression or a pinched nerve at the elbow. The ulnar nerve here can cause pain in those last two fingers. The radial nerve, which is much less commonly involved on the thumb side of the forearm can get compressed. Tennis elbow or tendinitis of the elbow can cause pain radiating down the forearm into the hand as well.
Nada Youssef: Well, there's a lot for you to diagnose to find that where hand pain comes from, but I wanted to kind of go over again general tips for hand pain relief. I know we talked a little bit for arthritis, but just in general for any hand pain.
Dr. Seitz: I think the tips are the same for all of them. Try to identify if there's a causative agent and if there is, can you modify your activities to try to either eliminate or change how you're doing what you're doing to minimize that effect. Secondly, if we can identify certain specific diagnoses based on any of these things, warm water, heat, that sort of thing helps. Massage can help relax but for the most part you just want to keep joints moving and tendons moving. If we can identify some of these things that they need a little bit more support during the daytime, we can have patients see our hand therapists who are very adept at begging little supports that are flexible, that can allow people to move and function without being rigidly stabilized. Similarly, at night it can be helpful sometimes to try some simple splinting just to keep the hands from getting in unusual positions.
Dr. Seitz: And finally we can try things that are called anti-inflammatories. There are a whole slew of them, some which are first line, but we need to be careful because A, they're cleared by kidneys so we want to make sure you don't have any kidney disease. B, they can cause a stomach, some of them can cause a stomach to make extra acid which can cause gastritis or even an ulcer. Some can have an effect on your ability to clot, what's called platelet aggregation. So we want to be careful there that we don't have any bleeding disorders, we're not taking any blood thinners, anticoagulants, that sort of thing. But nonetheless, once we make sure that we know exactly what we're dealing with, we can outline and target a treatment regimen combining activity, careful flexibility exercises, and avoidance of provocative activities, medication when indicated with guidance and with the precautions of how those work.
Dr. Seitz: Ultimately, those are all the things that we try and occasionally an injection, but if these basic conservative things aren't working and we're dealing with a chronic persistent problem that doesn't go away, then we look more into other diagnostic tests such as imaging studies and maybe even some blood tests to look for inflammatory diseases. Ultimately we make a decision to discuss the possibility of surgery. But these are all non-life threatening conditions. They may be very troublesome. They may affect quality of life so we have conversations, but in every case the patient has to convince me that things are bad enough to want to consider surgery. That's always our last resort.
Nada Youssef: That's a good point. Then just one last question for you. Let's say I start having hand pain. Do I go to my primary physician? Do I go to an orthopedic physician?
Dr. Seitz: I would say the first thing to do would be to go to your primary care physician. A lot of these very common conditions are well-treated conservatively. We have a great battalion of mid-level clinicians, nurse practitioners, physician assistants who are incredibly skilled and well educated in the area of treatment of these as first line treatments before you go to see an orthopedic surgeon like me. So I would certainly recommend A, seeing your primary care physician or the primary care physician may say, "Well, I think this might be a rheumatoid issue. I'm going to send you to see rheumatologist." Or, "It looks like you just kind of really tweaked your wrist and I don't really see anything that looks structurally unsound. Why don't you go see one of the orthopedic PAs?"
Nada Youssef: I see. Okay, so you'd be referred based on the symptoms.
Dr. Seitz: Yeah. Of course, if it's an acute injury, if there's something that's badly damaged, that needs emergent intervention, you'll certainly get to me right off.
Nada Youssef: Right. Well, it's been a pleasure. Thank you so much for sitting with me today.
Dr. Seitz: My pleasure. Sure.
Nada Youssef: To download our free hand and wrist pain guide on common conditions and treatment options, you can go to www.clevelandclinic.org/handandwrist and to listen to more of our Health Essentials Podcast from our Cleveland Clinic experts, you can visit clevelandclinic.org/hepodcast or subscribe wherever you get our podcasts. And for more health tips, news, and information from Cleveland Clinic, make sure you're following ClevelandClinic, one word, on Facebook, Twitter, and Instagram. Thank you so much for joining us. We'll see you again next time. This concludes this Cleveland Clinic Health Essentials Podcast. Thank you for listening. Join us again soon.
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