The other thing to remember is that carpal tunnel syndrome, like ulnar entrapment or tarsal tunnel syndrome, can be associated with certain underlying medical conditions. Diabetes is a big one. Hypothyroidism. I have picked up a few patients with hypothyroidism that were before undiagnosed. Occasionally gout, acromegaly because of changes at the specific sites, the wrist joint, pregnancy – obviously, that will resolve – synovitis at the wrist, particularly in RA, systemic sclerosis or scleroderma big time. These patients have severe problems and often don’t even respond to surgery. Amyloidosis is another one that can be very resistant. Chronic renal failure on hemodialysis they can get amyloid deposits with Beta 2 microglobulin as opposed to other types of proteins. This can also be very resistant. Again, I mention repetitive strain injury, where they will have typical carpal tunnel syndrome on history and physical.
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The treatment includes, if they have an underlying condition like thyroid disease or diabetes, treat the hypothyroidism, that will often help. Rheumatoid arthritis, treating the synovitis with an injection in the wrist or maybe systemic treatment. That may help. Antiinflammatory drugs may help. Wrist splinting will help, particularly at nighttime. Keep the wrists in good position so the patients at leas won’t wake up with the feeling that their hand is falling asleep. Cortical steroid injection into the carpal tunnel is very useful. If a patient does not respond to these things or they have significant motor involvement – really any motor involvement – I just refer them for surgical release. If I think a patient needs surgery, that’s the instance where I will get an EMG with nerve conduction study. Otherwise if I have a clinical diagnosis and I am just doing these rather simple treatments, I don’t even bother with the study. My personal thing, it’s just a waste of time and money. Very few patients enjoy having these studies done. If any of you have ever had it done – and I have as part of an experiment – it’s annoying at the least. It is uncomfortable. But before I refer a patient to a surgeon I want to document what’s going on and see how much motor involvement there is.
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This is the standard, this is a 3M splint, very similar to the Futura. It has a metal stay in the bottom of the wrist and you can take it out and wash the splint. It’s pretty hardy. The only problem is that you can’t switch it from left to right. It’s really for one hand only.
Treatment generally involves antiinflammatory drugs which often work quite well. Sometimes just modifying the shoes a little bit, getting some inserts. You can buy them in a drug store or sporting goods store. Sometimes a podiatrist can design an orthotics – or an orthopedic surgeon can design orthotics – that would help to relieve the strain of this plantar fascia. Corticosteroid injections can be useful. I don’t like to do them repeatedly, again because this structure has a tremendous amount of stress on it. So I’ll do it once, maybe twice. A lot of times that’s all you need. Sometimes patients do need ongoing antiinflammatory treatment if they continue to do what it is that caused the situation in the first place.
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Carpal tunnel syndrome is the most common thing that we see. The symptoms are pain and burning in the wrist and hands. Often it is not that well localized. Patients don’t read their neurology textbooks. They don’t know where the median nerve goes versus the ulnar nerve. Often they complain that the entire hand is numb. The pain may radiate up to the arm, even up into the neck if it is very severe and very acute. Paresthesia and numbness are classic. Symptoms are very prominent at night, especially if the patients just happen to fold their wrists in a certain position. They may actually wake up with their hand asleep and have to shake it out in order to get the feeling back into it. Also, clumsiness. They don’t have – even if they have normal sensation on exam – they don’t feel the dexterity is there in their hand. Physical findings; the Tinel’s sign. I find that that’s by far and away the best. You can do this with your finger, just like when you percuss or even with a reflex hammer over the carpal tunnel, which the best spot is over the area between the thenar.
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The hypothenar evidence marks the location of the carpal tunnel. If you tap there and the patient has pain, either radiating into their hands somewhere, their thenar evidence or their fingers, or up into their forearm, I consider that a positive sign. The Thalence is not quite as good. That’s where you bend the wrist, either flex it or extend it for the reverse Thalence and then let it sit there for awhile. I don’t find that is quite as useful. I don’t feel like wasting a minute, having them sit there if the Tinel’s sign is positive, that’s good enough for me. You may have abnormal sensory findings, occasionally weakness or even atrophy which is, in my experience, very unusual. Probably a hand surgeon or orthopedist see this a lot more. This just shows you the difference in nerve distribution, the median nerve is generally the first three-and-a-half fingers. Although it is very rare, I have had some patients say, “Why does the middle part of my finger feel strange and the outside of my finger feel normal?” I’ve had maybe twice that that’s happened, so most of the time they don’t differentiate it quite that precisely. You can see the ulnar nerve is the other part of the hands and also extends on to the dorsum, which the medial nerve does not affect the dorsum. That’s the radial nerve. This is one of the maybe two patients I’ve seen who had thenar atrophy. He had carpal tunnel syndrome for a long time and I just sent him right to the hand surgeon because that’s pretty serious when you get motor involvement.
Achilles tendonitis is going to be on the back of the heel and when you see this, you really should think of another cause, particularly spondyloarthropathies, fluoroquinolones antibiotics which are commonly used for urinary tract infections – at our hospital now the fluoroquinolones are first line for community acquired pneumonia. I guess they are just less expensive and easier to give, but it’s not cheap Cipro. I guess it’s Levaquin, seems to work pretty well for upper respiratory-type infections and it’s just easier than giving a combination of erythromycin and cephalosporin. But these antibiotics have been associated with Achilles tendonitis, among other tendonopathies, and it can occur very quickly and these patients can actually go on to rupture. So if you have a patient on a fluoroquinolone and they develop a tendonopathy, probably get them onto another antibiotic. Particularly Achilles tendonopathy. The amount of stress that is on that, it just may pop.
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That’s why we have a field of podiatry because these problems are very very common. One of the areas, the plantar fascia, can be involved with plantar fasciitis as it inserts into the calcaneus and also the Achilles tendon as it inserts into the back of the calcaneus. These are very common problems. If there is any sense that it is chronic inflammatory in nature and there are other systems involved, really think of a spondyloarthropathy because these areas are very commonly involved with things like ankylosing spondylitis and the like. But I do see patients occasionally and that’s all they have. They just have Achilles tendonitis or plantar fasciitis. Sometimes you can even get bursal inflammation although it’s very difficult to differentiate from direct tendon involvement. But plantar fasciitis, again the most common situation I see is someone who walks a lot. Mail carriers. They start out with a 50 pound bag of mail and it’s hard on their feet. They just walk around and deliver mail all day. But anybody who is on their feet a lot, walking, carrying extra weight, and the pain is usually in the sort of medial aspect of the bottom of the calcaneus. It’s not dead center, because that’s not where the plantar fascia inserts.
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When you examine you can put a stress on the plantar fascia either by pushing on the forefoot up, or just putting your thumb right into this area of the insertion. It will usually be tender.
Medial gastrocnemius rupture, tennis leg or medial head of the gastrocnemius strain can occur in the same population of patients, it occurs by the same mechanism, eccentric contraction, so the muscle is trying to shorten, while it’s actually lengthening because of the external force applied through the joint, and some musculotendinous disruption, so it’s higher up in the leg, it’s up in the sort of the meaty part of the calf and it’s more subtle, and perhaps even a less severe injury than Achilles tendon rupture. If it occurs in an older patient, you might confuse it with a DVT, you may get a duplex study, you may think it’s a palpable cord or a Homans sign, so make sure you see that it’s not the medial head of the gastrocnemius strain, and for that reason, there can also be a delay in presentation because the patient is able to walk on this and the pain may be less severe than with a frank Achilles tendon rupture. So, they are going to present with a painful, swollen calf, there are times when tests are going to be negative, so when you squeeze their calf, it may hurt, but you are going to watch the ankle plantar flex, because overall, the Achilles tendon is still in continuity, so the ankle is going to plantar flex, and there may be a severe sign and very severe tears, but it’s going to be more subtle, so I have to feel through the fleshy portion of the calf, they don’t need to be casted, they need to be protected in weight bearing, you put them in a boot to help alleviate the local symptoms and then physical therapy once the acute injury subsides. Achilles tendonitis is intrasubstance degeneration of the Achilles tendon and there is a water shed area between 3 and 5 cm or so up from it’s attachment onto the calcaneus. There is tearing, there is bleeding into that region so you can get intratendinous calcification, fiber scar tissue forming within the Achilles tendon, decreasing the compliance of the tendon, so that when patient’s try to be active on it, there is a lot of pain and swelling in that region.
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Ankle arthritis is probably rarer than knee or hip arthritis, but the patient still is going to be presenting to you with pain, limitation of motion, swelling about the ankle, with or without deformity. X-rays are going to show joint space narrowing with the loss of cartilage, there may be subchondral cyst formation on both the distal tibia and on the talus, and para-articular osteophyte formation. Then your options to treat them are, beginning with activity modification, use of anti-inflammatory medications to control pain and symptoms, some people with severe arthritis would do well with an ankle brace to help limit ankle motion, and assistive devices, getting them a cane or a crutch or a walker, and if they fail nonoperative management or so inclined, instead of doing an ankle fusion, now a days has been promising results with ankle replacement through artificial ankle joint replacement.
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Achilles tendon rupture is a weekend warrior injury; the recreational athlete that perhaps at the start of his or her recreational season, they are out to perform their activities, they haven’t sufficiently warmed up and it’s been a long winter and they haven’t really been doing much activity, they tear their Achilles tendon, and the mechanism here is an eccentric contracture, meaning, as they are trying to contract their Achilles tendon or put the foot into the ankle into plantar flexion, the ankle is actually is actually dorsiflexing from the stress applying to it, so you have that large force to pull the Achilles tendon apart. That patient may hear or feel a pop behind the ankle, they may say, I thought the ball hit me in the back of the ankle or somebody stepped on my at the back of the ankle, that is what they may complain to you, but it really was the Achilles tendon completely rupturing. In some case, the patient is not going to be completely incapacitated by this injury, they are going to be able to walk afterwards. Sometimes, in 20 to 30% of the cases, the diagnosis can be delayed in Achilles tendon rupture. We sort of suspect this injury perhaps in the man or woman in their late teens up to maybe their mid 40s or 50s, I have seen patient’s that are older than that in their 70s or whatever, that actually have an Achilles tendon rupture, they didn’t quite have this resounding pop, but they did feel something back there, they were able to walk around, despite the fact that the Achilles tendon is ruptured, and I would tell you perhaps it’s more anecdote than evidence-based, but I would say the older you are and less active you are, you are the one, if you have an Achilles tendon injury, the diagnosis may be delayed in making this, so always have a high suspicion. Here is how to make the diagnosis, there is pain and swelling over the point of disruption, there is a positive gap sign, meaning you run your finger up here, you feel the muscle belly, you feel the Achilles tendon and then you feel mush. There is a space there, there is an indentation where the tendon is not in continuity. The Thompson’s test can be done here if the patient is kneeling over a chair, they can be done on an examination table, they are squeezing the calf muscles, you’re squeezing the muscle bed of the gastrocnemius and soleus, you are shortening the tendon and if the ankle doesn’t plantar flex here because there is a disc continuity, that means you have an Achilles tendon rupture. So compare this to the other side, to make sure you are not being fooled, but if the ankle doesn’t plantar flex when you squeeze the calf, there is a discontinuity in the Achilles tendon, and suddenly, they are going to have limited plantar flexion if you are going to test that as well.
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So how to treat this, well, operative versus nonoperative, in a nutshell, the benefits of operative treatment are that there is a lower rate of rerupture associated with Achilles tendons as opposed to nonoperative management, if you are trying to anatomically restore the Achilles tendon to it’s length and bring those ends together, so the less scar tissue that intervenes the form between those two torn ends of the Achilles tendon, the likelier it is that it’s going to be a stronger repair, so that’s why operative treatment seems to be associated with less of a rerupture rate than nonoperative, but your patient certainly has to accept the associated risks of operative treatment to get the benefits, you have to consider what the patient’s expectations are. The young active male or female who has a very active lifestyle and recreation sports are quite important to them, their expectations might lead you to say that operative treatment is the best management versus someone who is older, has other medical problems, perhaps diabetes of peripheral vascular disease or something else that would increase their risk of having surgical treatment, they may need nonoperative management, it may be the best thing for them. Here is a demonstration of an Achilles tendon that basically is looking like spaghetti that needs to be put back together.
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