ELBOW, WRIST AND HAND

The following information is intended as a resource and should not be used to self-diagnose or treat. Use of non-steroidal anti-inflammatory drugs (NSAID’s) may be used to reduce inflammation and pain associated with that inflammation. Dancers should be aware that dancing while taking NSAID’s can mask pain, which can lead to further tissue injury.

Structure

The elbow joint is comprised of the humerus (upper arm bone) and radius and ulna (two forearm bones). Ligaments and muscles work together to provide stability and mobility to the joint. The wrist and hand together are made up of 27 bones, numerous ligaments, and muscles and tendons, which provide for fine motor capabilities of the fingers.

Common Injuries

Lateral Epicondylitis
Medial Epicondylitis
Carpal Tunnel Syndrome
Thoracic Outlet Syndrome
Wrist Dislocation

Lateral Epicondylitis (Tennis Elbow)
“The outside of my elbow hurts, especially when I have to grip things.”
Causes
Both the inside and the outside of the elbow joint are insertion points for tendon groups that direct wrist and hand movements. This common tendon attachment can become inflamed, particularly with repetitive movements involving gripping and twisting, such as with playing tennis or with turning a screwdriver. On the outside of the elbow, this is called ‘Lateral Epicondylitis’. Most dancers report first symptoms are difficulty holding onto objects, or a decrease in strength with partnering. There will usually be point tenderness to the lateral elbow, and with acute injuries some swelling can be present.

Treatment
As with other acute tendinitis injuries, the first course of treatment includes rest and ice to help reduce acute inflammation. Anti-inflammatory medications can be helpful at relieving pain and swelling. For more chronic conditions, a physician may wish to inject the inflamed area with anti-inflammatory medication to help reduce local pain and swelling. Physical therapy or athletic training treatments can also be helpful to manage any muscle tightness or weakness which may be associated with the injury. A proper analysis of technique with lifting or postural analysis may indicate other contributing factors.

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Medial Epicondylitis
“The inside of my elbow hurts, especially when I have to carry things.”
Causes
Although structurally very similar, Medial Epicondylitis (often referred to as “golfers elbow”) is less common than Lateral Epicondylitis. With Medial Epicondylitis, the common tendon attachment on the inside of the joint can become inflamed, particularly with repetitive movements involving gripping and carrying loads, or when a medial force is directed upwards, as occurs with golf. Most dancers report first symptoms are difficulty or pain with holding onto objects, shaking hands, or turning doorknobs. There will usually be point tenderness to the medial elbow, and with acute injuries some swelling can be present.

Treatment
As with other tendinitis conditions, acute medial epicondylitis responds well to rest and ice. Anti-inflammatory medications can be helpful to reduce pain and swelling. Physicians may wish to treat more chronic conditions with a corticosteroid injection to the inflammed muscle. Physical Therapy or athletic training treatments can be very helpful to manage any muscle tightness or weakness which may be associated with the injury. With dancers, a proper analysis of technique with lifting or postural analysis may also indicate other contributing factors.

Technical Tip:
• Keep your arm muscles strong so they can absorb the energy of sudden physical stress.
• Learn the proper technique for activities that require forearm motion.
• After repetitive movements of the arms stretch the whole arm to avoid tension build up.

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Carpal Tunnel Syndrome
“My wrist hurts and I get some tingling in my fingers.”

The carpal tunnel is a space at the base of the wrist formed by eight carpal bones on the back of the wrist and a ligament (transverse carpal ligament) along the palm side. Traveling through the carpal tunnel are wrist and hand flexor tendons and the median nerve. The median nerve is responsible for sensation to the thumb, index finger, middle finger, and half of the ring finger. The median nerve also supplies sensation to the thumb muscles (thenar muscles), which is very important in pinching or gripping actions.

Causes
A number of factors may contribute to the development of Carpal Tunnel Syndrome. Highly repetitive hand or finger actions are a common cause. The flexor tendons at the wrist can become inflamed and apply pressure to the median nerve within the tunnel. This pressure will compromise the nerve’s ability to function, producing pain and sometimes numbness and tingling in the thumb and fingers.

Symptoms
The signs and symptoms of carpal tunnel syndrome are progressive in nature and may include:
• Numbness and tingling in the hand or fingers
• Night pain, which may wake the individual
• Decreased feeling of touch in the thumb, index finger, and middle finger
• Reduced dexterity of the hand or fingers
• A feeling of swollen fingers, even in the absence of visual signs of swelling
• Reduced grip strength
• Noticeable reduction in the size of the hand muscles, especially by the thumb

Treatment
Treatment for carpal tunnel syndrome ranges from non-surgical approaches to surgical protocols, with varying degrees of success in each type of treatment. A full recovery is more likely and more rapid if symptoms are reported in the early stages and the appropriate treatment regime is implemented. With acute cases, ice, rest, and anti-inflammatory medications are helpful. Physical therapy or athletic training treatments can also be of benefit to help decrease local inflammation and identify areas of muscle tightness or weakness that may be contributing to the injury. Chronic cases may require immobilization and/or surgical intervention to release pressure on the median nerve. Ultimately, any effective treatment regimen should include the identification and minimization of aggravating activities.

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Thoracic Outlet Syndrome
“My arm and hand feel weak and cold.”

The thoracic outlet is a narrow space that runs between the collarbone, the first rib, and one of the neck muscles (scalene muscles). Through this tunnel run veins, arteries, and nerves that originate in the neck and travel down the arm. Thoracic outlet syndrome is a condition in which the nerves and blood vessels traveling through the thoracic outlet become compressed.

Causes
Various factors may contribute to compression of the nerves and blood vessels within the thoracic outlet, including:
• Repetitive activities involving a forward-head posture or drooped shoulders.
• Partnering dance movements involving awkward neck and shoulder movements.
• Carrying heavy loads, cases, and dance bags.
• Trauma to the neck or shoulder.

Symptoms
Dancers with Thoracic Outlet Syndrome will notice that symptoms may progressively worsen over time. Symptoms will vary, but can include arm or hand numbness, tingling, a cold sensation, or pain. Dancers may also report that they have generalized weakness or fatigue in the arm or hand muscles. Accurate diagnosis of Thoracic Outlet Syndrome can be difficult because it shares symptoms with other conditions, such as a herniated disc in the neck, carpal tunnel syndrome, cubital tunnel syndrome, or bursitis of the shoulder.

Treatment
Treatment for Thoracic Outlet Syndrome can vary depending on the type. True neurologic Thoracic Outlet Syndrome is generally effectively treated with surgery. Most other forms can be treated conservatively, using anti-inflammatory medications, postural awareness, and technique modification. Rehabilitation to increase range of motion of the neck and shoulders, strengthen muscles, and induce better posture can also be very helpful.

Technical Tip:
One of the keys to preventing Thoracic Outlet Syndrome is to minimize stress on the neck and shoulders. Dancers should avoid awkward postures to the neck and shoulder muscles, particularly those that require repetitive movements. Also, active recovery (stretching during rest breaks) may further reduce the risk of developing symptoms.

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Wrist Dislocation
“I fell on an outstretched arm.”
Causes
Wrist Dislocations are most often due to some type of trauma, such as falling on an outstretched arm. The dislocation typically involves displacement of the lunate bone of the wrist, but can involve the other bones in the hand or wrist. Dancers with a Wrist Dislocation will complain of excruciating pain in the wrist at the time of dislocation, along with a loss of hand and wrist function. There can be a visible deformity if the dislocated bones have locked in the dislocated position. Severe injuries may result in numbness or paralysis below the dislocation due to pressure, pinching or cutting of blood vessels or nerves.

Treatment
Wrist Dislocations need to be assessed by a physician. If there is no evidence of fracture, the physician may reduce the dislocation by manipulating the joint to reposition the bones. In the event of bony fracture, surgery may be indicated to restore the joint to its normal position. Acute or recurring dislocations may also require surgical reconstruction or replacement of the joint.

Following relocation, the wrist joint may require immobilization with a cast, splints or sling for 2 to 8 weeks. Complete healing of injured ligaments requires a minimum of 6 weeks. During the recovery period, ice and anti-inflammatory medications can be helpful to reduce acute pain and swelling. Rehabilitation is also helpful to restore full functional strength and motion in the hand and wrist. Upon initial return to dance activities if the dancer is required to perform lifts or weight bear on the involved wrist, he/she may wish to support the wrist with tape or a brace.

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