Case of the Week 5-27-12: You Have to Live with It...Only If You Do Not See the Right Practitioner | Modern Manual Therapy Blog

Case of the Week 5-27-12: You Have to Live with It...Only If You Do Not See the Right Practitioner

This Case of the Week is about one of the stronger climbers in my area. I could totally relate to her case as prior to having my 3 beautiful kids, I used to climb (boulder mainly - Buffalo is so flat) - great for manual therapy hand strength!

History: 19 yo female who was climbing and slipped while her 2nd and 3rd digits were in a pocket, or small hole that only 2-3 fingers can fit in, and mainly from the PIPs or more distal. This was about 6-7 months ago. She saw several specialists, one who told her she had to live with it, the other recommended surgery for trigger finger. She tried resting for 3 months, which made the pain in her fingers and forearm go away, but it returned shortly after she resumed climbing.

Her complaints were pain with grasping, particularly with the 2nd and 3rd digits, with both FDS and FDP having 8/10 sharp pain. The pain radiated to her medial upper arm. Her complaints were felt 60% of the day, but intermittent based on activity.

Objective:

  • Cervical Screen
    • All motions FN except cervical SB and rotation to the left, both DN with mod loss, hard end feel
  • shoulder, elbow, wrist ROM all WNL, forearm pronation FP actively, FN passively
  • MMT of FDS and FDP was severely painful, 3/5 limited due to pain, worst on digits 2-3 on the left
  • Myofascia: mod restrictions along ulnar bony contours anteriorly, medial upper arm, left upper trap, levator scapula, cervical paraspinals
  • neurodynamics: painful, mod loss with reproduction of complaints with ulnar nerve bias
Assessment: Signs and Sx consistent with ulnar neuropathic pain with chronic tendinosis of the left finger flexors.

Treatment:
Day 1
  • IASTM to left upper trap, levator scapula, medial upper arm, anterior forearm ulnar bony contours
  • ulnar tensioners
  • instruction on self ulnar and median tensioners prayer stretch
  • upon leaving, able to grasp using MCPs pain free, PIP and DIP 50% less painful
Day 2
  • MCP grasp still pain free, 50% less pain with PIP and DIP grasp
  • IASTM as before
  • 1st rib mobilizations on the left
  • added functional release to anterior and posterior forearm restrictions
  • ulnar and median tensioners, specifically first three digits for median
  • added eccentric loading for MCP flexion, PIP, and DIP flexion
    • PIP flexion caused clicking, however it was no longer painful, instructed to perform just short of the click, which from 90 degrees MCP flexion was about 45 degrees into extension
  • also added cervical retraction with SB left overpressure for HEP
Day 3
  • no change in STM Tx
  • PIP and DIP grasp minimally painful, 1/10
  • cervical ROM now FN in rotation and SB
  • added eccentrics to neurodynamic ulnar and median nerve tensioners
  • allowed her to traverse at the climbing gym she works at (lateral movement along the walls only), and also only using "jugs" or very large holds with MCP grasp
Day 4
  • able to traverse pain free
  • PIP and DIP resistance now also pain free
    • tested by me pulling on digits 2-3 with MCP in neutral, and basically leaning 50% of my body weight into her isometric resistance
    • this was tested in various UE positions - overhead, to the side, etc
  • minimal clicking near MCP, PIP, and DIP neutral
  • added IASTM to tendon sheaths and bony contours of digits 2-3 and metacarpals - mod restrictions along these areas compared to other digits and other hand
Day 5 - cancelled due to sickness
Day 6 
  • no clicking with repeated eccentric loading
  • DIP and PIP resistance completely pain free
  • treatment as above
  • allowed her to traverse using more complex holds, and climb up to V2-3 in difficulty (not difficult, but better than nothing)
That's were we left off - next week I'll follow up after she tackles climbing again at the gym she manages.

It's fortunate that my friend/patient (also a climber) referred her because she did not want surgery, or to have to live with it. Initially, she most likely had a flexor tendon strain, which developed into a ulnar neurodynamic dysfunction with issues along the neural container. I don't think surgery for trigger finger would have helped!


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