Hand & Upper Extremity

What’s that lump in my wrist? All About Ganglion Cysts

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You may have noticed it before, either on yourself or on another – a small lump appearing usually at the top of the wrist or hand. It may be a common condition called a ganglion cyst. Here’s what you need to know:

What is a Ganglion Cyst?

A ganglion cyst is a pocket of fluid that forms along the joint of usually the hand or wrist, but can appear in the foot and ankle as well. The cyst is usually round or oval, about pea-sized, and can increase in size.

Symptoms:

Most ganglion cysts do not come with any symptoms other than visual appearance. If the cyst encroaches a nerve, they can cause pain in the joint. Depending on where the cyst lies, movement of the hand or wrist can be affected.

Diagnosis/Treatment:

Any time you notice an abnormality in your joint, it’s important to have a consultation with a physician. For ganglion cysts, many go away on their own over time. A doctor will determine whether treatment will be necessary. Treatment options include draining the cyst or removing the cyst from the stem to prevent reoccurrence.

If you have noticed a new lump in your joint, don’t wait. Call the hand specialists at NEOSM for an assessment and to discuss any questions you may have.

What is Tommy John surgery? (And why the name?)

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If you follow sports, baseball in particular, you may have heard of a star player being out for Tommy John surgery. No, there isn’t a part of the elbow named “Tommy John” – the surgery is a reconstruction of the ulnar collateral ligament (UCL) and a baseball player named Tommy John was the first to undergo the procedure successfully, thus the common name. So what causes the injury that necessitates this type of operation? To answer, it’s important to understand the anatomy of the elbow and the function of the UCL.

Source: OrthoInfo

As shown in the diagram, the ulnar collateral ligament (UCL) attaches the upper arm (humerus) to the forearm (ulna). The UCL stabilizes movement of the elbow when throwing, but the more stress it endures through repetitive motion or force, the greater the risk of the ligament deteriorating. That is why UCL tears are particularly common in baseball pitchers, who contort their elbows in a series of different angles during a single hard throw, then repeat these motions over and over. 

Symptoms

There are different signs that you may have an injury of the UCL. These include:

  • A sudden ‘pop’ sensation in your elbow
  • Pain when in a throwing motion
  • Limited ability to throw
  • Tingling in the hand or fingers
  • Weakened grip strength

Treatment

Once non-surgical options have been exhausted, like physical therapy, rest or medication, your orthopedic may recommend surgery. Thankfully, since Tommy John first had his surgery, countless athletes have benefited from UCL repair or reconstruction surgery to get them back on the mound. During the operation, an orthopedic surgeon will either repair the tear in the ligament or reconstruct using a donor tendon from elsewhere in the body to graft a new ligament. Rates of return to sports 9 months after surgery are high for this type of treatment – 85%-95% of throwing athletes returning.

If you are experiencing any of the symptoms outlined above, remember, ignoring the issue can lead to further complications. The team of specialists at NEOSM are here to help you overcome your injuries and make the most out of life. Reach out to us anytime for a consultation.

Keeping Tennis and Golfer’s Elbow at Arm’s Length

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By: Dr. Barry S. Kraushaar

Tennis Elbow and Golfer’s Elbow are names for similar tendon injuries that occur at the tendon attachments on the outer (lateral) and inner (medial) sides of the elbow joint. If you have pain on or near the points of bone that serve as the origins of the muscles of the forearm, you may have this diagnosis. The forearm muscles, which give power to your grip, attach to these anchoring points called epicondyles. They can tear off of the bone or within their fibers. Tendons are injured throughout our lives, but they usually heal themselves, making it rare to need medical help. When a tendon attachment to your elbow tears and fails to heal it can be Tennis or Golfer’s Elbow.

TENNIS ELBOW is an injury at the outer (lateral) bony prominence of the elbow. You can have this diagnosis even if you do not play tennis, but the name comes from the observation that tennis players get it as part of the sport. This is because the grip of a long tennis racquet and the wrist motions of the tennis swing put strain on the muscles which originate at the lateral epicondyle. Expert tennis players rarely get tennis elbow because they have powerful forearms and good swing mechanics. If you have the wrong grip size, string tension, timing (late swing), racquet type, or stroke mechanics (wrist motion), you are at risk for Tennis Elbow. In fact, any type of forearm overuse can cause tennis elbow, and the treatment options, described below, are the same.

GOLFER’S ELBOW refers to pain on the inner, medial side of the elbow. In this sport, the problem is caused by the combined effect of the long club length being gripped by the trailing arm (the right arm in a right-handed swing) as the club-head strikes the ground, such as in the rough, the sand or when taking a divot to get under the ball. The forearm is driving forward as the hand is held back, causing strain in the muscles that control the wrist. The damage occurs at the tendinous origin on the inner side of the elbow. Ironically, golfers can also get Tennis Elbow, because the leading arm sees strain on the outer, lateral side during the same movement.

Treatment

There are many additional reasons for tendon injuries about the elbow, usually involving pulling or twisting motions during exertion. It can happen from low level stresses or big motions. From an orthopedic view, the approach is to identify the causes and help the patient adjust activities to allow the tendons to heal themselves.  This may involve a period of partial or complete rest from the aggravating activity. It may involve different equipment or technique. During a flare-up, you may benefit by using a brace. If you wear a wrist brace it may help the elbow by limiting the motions that are traumatizing the injured tendon. A tennis elbow strap is different, as it works by re-directing forces coming up the forearm and deflecting the pulling effect on the tendon origin. Pills, such as non-steroidal anti-inflammatory drugs (NSAIDS like ibuprofen) or analgesics (acetaminophen, Tylenol) may temporarily help the symptoms, but they do not cure tendon injuries. Similarly, a steroid (cortisone) injection may relieve pain for now, but the chemical may damage tendon, and after a few months the problem can come back even worse. Sometimes, a small injection is used as part of a bigger plan.

The most effective and lasting way to manage Tennis or Golfer’s Elbow is to perform exercises to strengthen the forearm. Since the elbow is injured, the exercises need to be rehabilitation type, which is different than fitness exercise. Doctors often prescribe Physical Therapy because a therapist should know the gradually increasing exercises that achieve the goal of lasting recovery without a setback. While many videos exist online, there is no substitute for personal guidance. Once you learn these exercise you can do them yourself. 

Other non-operative treatments exist but are less commonly used. One promising intervention is Stem Cell Injection Therapy. Currently, this technique involves having your blood drawn and spun in a centrifuge. The provider injects a small volume of your own special stem-cells back into you at the site of the pain, and you grow new tendon in the damage zone. Stem cells can also be harvested from your fat or marrow. The use of Stem Cells is usually not covered by insurance, and the statistics of success are still not high enough for many people to be willing to pay out of pocket (costs hundreds to thousands of dollars).  Ask your doctor if you want to know the current trends.

Ultimately, surgery may be necessary for tendon injury at the elbow. There is a minimally invasive technique that requires a brief, light period of sedation and/or local anesthetic injection. The doctor introduces a special needle through your skin over the injured area and activates a device that either causes the tip of the needle to heat up and melt the damaged tendon, or it injects a pressurized water jet into the tendon to break up the scar tissue and cause the tendon to react by developing scar tissue to replace the damaged area. During this process, the surgeon may also use stem cells, described above.

The open surgical technique for Tennis or Golfer’s Elbow is well established and has an excellent success rate. The operation is not usually very long, involves little or no risk to nerves and vessels, and recovers rather quickly, although you may need a period of protection and rehabilitation afterward to give the tendon a chance to heal and the muscle groups time to recover. Basically, the surgeon opens the tendon and removes the bad scar tissue, the tendon is given a chance to grow fresh tissue in the place of the old, painful region, which is usually right where the pain was. In my practice, fewer than ten percent of patients with Tennis or Golfer’s Elbow go to surgery, and nearly every patient reports real improvement from the intervention. Return to sports and full activities is possible in most cases.

Summary

If you think you have Tennis or Golfer’s Elbow, try to identify the causes and address them yourself. Try to gently strengthen your muscled without overdoing it. Consider a brace and careful usage of medicines, if you can do so safely. If you do need orthopedic care, you may be discussing physical therapy and the other treatments described above. Know that if you have to go to surgery, the options in most cases are likely to be effective. Hopefully, you can continue to enjoy your active lifestyle, doing what you need or want to do. The specialists at NEOSM are there to help along the way.

Is Knuckle Cracking Bad?

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By: Doron Ilan, MD

Between 25-50% of people will crack their knuckles at some point.  In some of these people it becomes habitual. Parents across the world have been telling their kids (and spouses) “Don’t crack your knuckles. You are going to get arthritis!” Is this true? What is actually happening when someone cracks their knuckles? 

What happens when you crack your knuckles?

Our knuckle joints (metacarpo-phalangeal joints) are synovial joints. Meaning there are two cartilage covered bones that meet each other and are surrounded by a joint capsule which contains synovial fluid (lubricant). When our joints move normally the synovial fluid lubricates the ultra-smooth cartilage and the bones glide silently over each other. When someone pops their knuckle, the pressure exerted on the joint and synovial fluid forces dissolved gases out of the synovial fluid. This creates what is called a cavitation bubble. This forms very quickly and explosively. This cavitation bubble then pops. It is believed that the sound of knuckle cracking is due to the formation or popping of the cavitation bubble. This would be similar to either the opening of a champagne bottle (sound caused by formation of the bubbles) or popping bubble wrap (sound caused by popping the bubble). To this day, we are still not 100% sure which one it is. The thing we are sure about is that knuckle popping is not due to bone rubbing on bone or tendons popping.

Are all sounds coming from a joint due to gases?

No. In arthritis (loss of cartilage) you can get a crunching sound called crepitus as bone rubs on bone. Some people have loose joints and the joint can sublux or partially dislocate. A tendon can shift over a moving joint and cause a pop or clunk. A torn labrum (hip or shoulder) or meniscus (knee) can also cause popping in a joint. Note:  If you have pain associated with any noise from a joint you should consult your doctor.   

Is knuckle cracking bad for you? Does it cause arthritis?

This may come as a shocker to parents everywhere but there is no evidence that knuckle cracking is bad for you or causes arthritis. It is certainly annoying and there have been case reports where people tried to crack their knuckles with such force that they caused a sprain or fracture, but despite multiple studies it appears that routine knuckle cracking is safe. There was even one doctor (Donald Unger) who decided to do a study on himself. He cracked the knuckles on one of his hands for 50 years while not cracking the other. He found no difference between the two hands in the end.  

So go ahead and crack your knuckles.  Just don’t do it around me. 

For more from the experts at Northeast Orthopedics and Sports Medicine, feel free to contact us for a consultation.

Beware of “Avocado Hand”

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The popularity of avocados in the U.S. is undeniable. The fact is Americans consumed over 2.6 million pounds of the fruit (yup, an avocado is a fruit!) in 2019. But that’s not surprising, because, let’s be honest – it’s not a party without the guacamole and there are few things better than ripe avocado slices on toast. Unfortunately, though, preparing these delicious snacks can be risky when not done correctly. The soft flesh of the avocado combined with its hard pit plus a sharp knife can be a recipe for disaster or a condition now dubbed “Avocado Hand”. It all starts with an improper approach to cutting the avocado.

Any motion in which a sharp object is being moved towards your palm, and all the nerves and tendons that live there, is a bad idea. But time and time again, Americans are doing just that when slicing into their avocados. Fruit in hand, the knife can easily glide through and just as easily slip, resulting in serious injury from deep gashes to severed tendons or even digits. We encourage you to avoid a preventable situation by following these simple, safe tips for preparing an avocado.  

The safe way to cut an avocado:

1. Place the avocado on a cutting board and stabilize with your fingers on top. Be sure to choose a ripe avocado (gives slightly to the touch). This will make it easier to cut and peel.

2. With a sharp* knife, cut the avocado around midway, horizontally. *Make sure your knife is sharp. More kitchen injuries are caused by dull knives than sharp ones.

3. Hold the avocado on either side of the cut, twist in opposite directions to separate the halves.

4. With a large spoon, gently remove the seed from the center.

5. Cut each piece in half once lengthwise and use your fingers to gently peel the outer skin from the flesh.

6. Cut or slice as your recipe requires – and enjoy!

If you do injure your hand, what should you do?

First, assess the level of injury. Seek immediate medical attention if you or someone you know is seriously injured, including amputation, loss of function in the fingers, exposed bone or bleeding that won’t stop.

For wounds that can be treated at home, remove all jewelry from the wrist and hands, clean the area with warm water and soap, and continue to apply firm pressure until bleeding has stopped. Apply antibiotic ointment and a sterile bandage, being sure to change the bandage often. If you notice any of the following symptoms, call a physician, as this may be a sign of infection: redness around the wound, yellow or green pus, red streaking spreading away from the cut, increased pain or swelling, or a fever.

NEOSM’s expert hand specialists are here to answer any questions you have and to provide the highest level of care. Give us a call to schedule a consultation either in-person at one of our offices, or virtually through Telemedine.

Rise in eSports Injuries: What every gamer needs to know

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Everyone knows a gamer, and chances are, it’s you. With over 164 million video game players in the US and three quarters of American households having at least one gamer, that’s a statement we can make pretty confidently.

The incredible growth of the eSports industry has cemented it as one of the biggest forms of entertainment around the world. Live gaming events bring in viewers in the hundreds of millions, and some colleges are even setting up gaming teams and offering eSports scholarships. But like any other sport, there are physical demands to achieve success as a formidable opponent.

The fact that many gamers are in a sitting position for 5-10+ hours each day while repeating the same motions with their wrists and hands is leading to an increase in cases of musculoskeletal conditions, particularly in pediatric patients.

What are common conditions associated with gaming and how can they be prevented and treated?

Common Conditions

Orthopedic surgeons, Sports Medicine professionals and Hand specialists are seeing an increase of the following conditions within the gaming community.

  • Tendonitis of the forearm muscles
  • Carpal tunnel syndrome
  • “Gamers thumb” (De Quervain’s Tenosynovitis)
  • Ulnar nerve irritation
  • Upper back and neck muscle pain
  • Poor posture, core weakness
  • Obesity and poor balance
  • Sciatica
  • Eye strain

Preventing Injury

Being sidelined due to injury can make your average gamer disgruntled, but for serious players on the eSports scene, it can mean the loss of huge winnings in major events. That’s why prevention is key to be able to complete at the highest level. Here are some tips:

Limit play time

  • The less you put yourself at risk of injury the better. Limit play time and take multiple breaks during a long gaming session. Parents and caregivers should determine an appropriate daily limit for video games for their children, and encourage alternative physical activity throughout the day.

Evaluate your set up

  • Make sure the equipment you use is as ergonomic as possible. This includes your chair, desk, keyboard and mouse. Blue light glasses can help with eye strain.

Exercise

  • Build core strength to support proper posture. Stretching loosens the muscles to reduce risk of kyphosis (rounding of the back). Stretch your wrists, fingers and thumbs before playing and during breaks. Go on walks, runs, swim or engage in other sports.  It is important in all sports (even eSports) to cross train. 

Don’t play through pain

  • Continuing to play video games while in pain will make the condition worsen and take longer to heal.

Treatment

Some serious conditions caused by continuous gaming may require surgery, but most can be treated through a combination of activity modification, ergonomic adjustments, physical and occupational therapy, massage, devices/braces and medical injections or prescriptions.

If you or someone you know is experiencing a gaming-related injury, the specialists at Northeast Orthopedics and Sports Medicine are skilled in providing the custom treatment plan you need to get back to the sport you love. Reach out to one of our offices to make your appointment today.

Understanding Carpal Tunnel Syndrome

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By: Alan Gotesman, MD

Are you experiencing pain in your hand waking you up at night?  Do you have tingling in the fingers when you are driving or holding your phone? Is it getting difficult for you to manipulate small objects like buttons or clasps? You may have carpal tunnel syndrome. 

Carpal tunnel syndrome occurs when the nerve crossing your wrist is compressed, usually due to swelling of the tendons, which can cause pain and diminished sensation in your hands, particularly the thumb, index, middle and half of the ring finger. Typical symptoms are pain that wakes people up at night that needs to be “shaken out”, numbness and tingling as well as weakness and difficulty performing activities requiring fine manipulation. The diagnosis can usually be made with a detailed history and physical examination but confirmation can be performed with a nerve test called EMG’s that can determine the severity of the nerve compression and rule out other causes.

In milder forms, carpal tunnel syndrome can be treated with bracing, anti-inflammatories and cortisone shots. Once the compression is more severe, releasing the pressure on the nerve can be crucial to relieve the symptoms and prevent permanent nerve damage which can occur with chronic compression of the nerve. Newer minimally invasive techniques are available that allow the procedure to be done through a quarter-inch incision with the assistance of a camera. This technique allows for a quicker recovery process as well as less postoperative discomfort.  Results of surgery are generally excellent with many patients going back to all of their activities within 6-8 weeks.

If you think you may be suffering from carpal tunnel syndrome, the first step is to have an evaluation so schedule your appointment with one of our board-certified specialists today for an evaluation. 

Is the sport you love causing you pain? Understanding Tennis/Golfer’s Elbow

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By: Dr. Neal Shuren

Tennis and golf are two of the most popular sports, especially amongst adults. As enjoyable as they are to play, overuse can lead to pain of the elbow, commonly called Tennis or Golfer’s Elbow. Both tennis and golfer’s elbow are very common and affect both men and women, mostly between the ages of 40 to 50 but can occur at any age. It can also arise from activities not related to sports, such as household chores or work that requires repetitive gripping, like painting, but can also occur form a traumatic injury, such as a blow to the elbow.

Symptoms 

Pain with activities such as lifting, gripping and grasping that starts in the elbow but often radiates down the forearm to the hand. 

Diagnosis and Treatment  

The diagnosis of tennis or golfer’s elbow is usually made clinically by a thorough history and physical examination by your doctor. Sometimes your doctor may order different images such as X-Rays or MRIs to rule out other conditions.

Prevention and Treatment

  • Activity Modification 

If the pain is from playing tennis or golf it is often recommended that you be evaluated by a tennis or golf professional to make sure you are using proper equipment and have proper technique. 

  • Rest & Ice

It may be necessary to stop the aggravating activity all together, for a period of time to allow the soft tissues to heal. Try to avoid heavy lifting, pushing, pulling or repeated hand shaking. Using two hands for heavier lifting can help protect the injured arm. Apply ice 2 to 3 times a day for 15 to 20 minutes at a time when the condition first starts or after actively using the arm to help diminish the inflammation.

  • Stretching 

Stretching can help with tendonitis by keeping muscles and tendons flexible and preventing stiffness. It can also help break down scar tissue that may have formed.

  • Physical/Occupational Therapy

Therapy can help in many ways. Initial treatment is aimed at diminishing inflammation and stiffness while subsequent treatment helps strengthen forearm muscles, which can help prevent future episodes from occurring.

  • Medications 

If there are no medical contra-indications, over-the-counter pain medication, like Advil, Aleve or aspirin, can be taken to help reduce inflammation and pain.

  • Bracing

The counter-force brace is a padded strap that can be worn on the forearm, just below the elbow. By putting gentle pressure on the muscles, tension is released on the tendon. Bracing can be used for treatment and can be used to prevent recurrence in the future by wearing for all activities that put a lot of stress on the arm.

  • Cortisone Injections

Cortisone injections usually reduce the pain in the arm for an extended period of time but do not always diminish the time it takes for the elbow to fully heal. 

  • Platelet Rich Plasma (PRP)

PRP is a procedure where blood is withdrawn and then is processed to concentrate the platelets so they can be re-injected into the area of tendonitis. This procedure can usually be done in the office. This is a newer technique and research on this treatment modality continues.

  • Surgery

Surgery is the last resort. If conservative treatment fails and symptoms have been present for at least a year then surgery can relieve the pain. The aim of surgery is to remove degenerated or worn out tissue from the tendon and release tension on the tendon. Symptoms can take several months to fully resolve and a small percentage of people may still have some symptoms, even after surgery.

Prognosis 

Most cases of tennis and golfer’s elbow will resolve with conservative care but can take a long time to fully resolve.

If you have been suffering from symptoms of golf or tennis elbow, schedule a consultation with one of our talented physicians for an evaluation and treatment plan.