From the elbow down

An assortment of specialized tendons, ligaments and bones in the arms and hands allows humans to perform amazing work. Farmers’ daily tasks often lead to pain and weakness that can result in dangerous work conditions and accidents.

Dr. Patricia Siegel, certified hand therapist and associate professor, University of New Mexico’s Occupational Therapy Graduate Program, said a prevalent hand issue for farmers is carpal tunnel syndrome (CTS). It’s the most common peripheral neuropathy treated by hand surgeons and hand therapists. Although there’s no single cause for CTS, conditions that may increase risk include wrist fractures, arthritis, diabetes, vascular disease, age and pregnancy.

“There’s a chance you will have CTS after a wrist fracture,” said Siegel. “If a hand surgeon is performing a correction, they will often release the carpal tunnel at the same time. Other causes that may be related to CTS are elevated pressure and inflammation within the carpal tunnel, and a lot of that can be caused by the work people do with their hands.”

The carpal tunnel is formed by the two carpal bones on the sides of the wrist, Siegel explained. In the tunnel are nine flexor tendons and a median nerve. That’s all the tendons that create the fist and move the thumb, plus the median nerve.

“Part of the problem with the carpal tunnel is that its rigid borders don’t allow for a change in volume,” she said.

Increased pressure in the carpal tunnel causes compression on the median nerve, resulting in pain primarily on the palm side and in the thumb and index, middle and ring fingers. CTS can be temporary, but continued pressure affects the sensory and motor function of the hand.

Many people first notice sensory symptoms such as pain, aching and a pins-and-needles sensation. Because CTS usually develops slowly, people don’t realize they’re losing the ability to sense what they’re holding and have difficulty manipulating small objects. In later stages, the thumb muscles weaken and deteriorate. Although carpal tunnel surgery may still help relieve pain, advanced wasting of the thumb muscle is often permanent.

Non-surgical management for CTS includes appropriate night splints to prevent pressure on the carpal tunnel caused by wrist bending. Exercises taught by a hand therapist may also help, and in some cases, ultrasound is effective. Surgery to release the carpal tunnel is highly effective, and it’s a short procedure with a relatively easy recovery. Most people are back to normal activities within a few weeks to one month.

The second most common problem is cubital tunnel syndrome. This involves the ulnar nerve, the most superficial nerve in the body, which makes it more susceptible to injury and compression.

Here, the ulnar nerve at the cubital tunnel (elbow) is compressed, said Siegel. “This area affects grip force, pinch motions and moving fingers apart from each other. The ulnar nerve is responsible for the tiny muscles in the hand.”

Some of the causes of cubital tunnel syndrome include prolonged repeated pressure such as leaning on the ulnar nerve, prolonged elbow flexion and bone spurs. One of the early symptoms is sharp, aching pain at the elbow that radiates above and below the affected area. Cubital tunnel syndrome is usually worse at night due to increased elbow bending.

“As the nerve becomes more compressed, there’s numbness and tingling in the ring finger and little finger,” said Siegel, adding that such signs help a hand surgeon diagnose the problem. “In the later stages, people notice a weak grip, the small finger migrates away from the other fingers and can’t be moved back and there’s difficulty holding certain small items.”

Mild cases of cubital tunnel may be helped by hand therapy. A therapist determines the cause and may recommend a “heelbow” device to help the patient maintain a straight arm, which reduces pressure on the nerve.

Osteoarthritis is a common condition among farmers, and is the most prevalent joint disorder in the U.S. The most affected areas are the finger joints closest to the fingertips, the middle joints of the fingers and the carpal metacarpal (CMC) joint at the base of the thumb. CMC arthritis can be extremely painful and may prevent someone from working safely due to favoring the area and devising shortcuts instead of using the entire hand properly.

Therapy for CMC arthritis involves splinting to rest the joint, exercises to enhance stability and joint protection. Many people find it helpful to perform certain activities in small time increments. Warm paraffin baths may help relieve pain.

CMC arthroplasty, a surgical procedure to relieve CMC arthritis, is highly effective but involves a fairly long recovery. The surgeon removes the arthritic bone and uses a piece of tendon from the forearm in place of the bone. Some surgeons use a hard cast for several weeks followed by a soft cast; others prefer a soft cast for the entire time to immobilize the wrist and forearm. Hand therapy and home exercises are usually prescribed following CMC arthroplasty to ensure a fully functional hand.

Farmers often have issues with tendonitis in the elbow due to repetitive tasks such as lifting, gripping tools and handling equipment. Lateral epicondylitis (tennis elbow) manifests with pain on the outer elbow. It’s due to overuse, often after new, prolonged activity. This problem involves swelling and/ or tiny tears of the tendons that assist during wrist extension. Weak grip strength and dropping objects due to pain are diagnostic signals.

Medial epicondylitis (golfer’s elbow) is a similar issue, with noticeable pain on the inner side of the elbow and along the inner forearm. Wrists and hands often feel weak, and the elbow may feel stiff. This condition is usually due to excess or repeated stress, especially of the wrist and fingers. Risk factors for medial epicondylitis include age (over 40), repetitive activity, obesity and smoking.

Treatment for both tennis elbow and golfer’s elbow include stopping the activity to allow the tiny tears to heal. An orthopedic surgeon can differentiate between the two conditions and may refer the patient to a hand therapist for strengthening exercises.

Anyone who experiences arm or hand pain should consult an orthopedic surgeon who specializes in hand surgery to diagnose, treat and possibly prevent permanent damage.

by Sally Colby