Recap and review the top pearls from recent episodes #339 Hand and Wrist Pain, #348 Foot and Ankle Pain, and #351 Myopathy and Myositis with Watto and Paul. It’s Tales from the Curbside! (TFTC), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.
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Featuring Ted Parks and production and graphics by Paul Williams
Both present as thumb pain often on the dorsoradial side. Differentiate the two by a positive Finkelstein’s test (De Quervain’s) or reproduction of pain by grinding the thumb like a mortar and pestle (CMC arthritis). Treatment for both is NSAIDS and rest using a thumb spica splint. Steroid injections are effective.
Don’t brace for too long with CMC arthritis because muscle wasting and joint stiffness may result!
Prescribe a cute little splint for the finger to prevent flexion and allow inflammation of the tendon to resolve. Steroid injections work well. Surgery to cut the first “pulley” is the last resort, but usually results in a cure.
Pathophysiology
The carpal tunnel has limited space. Thus, any swelling can lead to compression with distal ischemia and symptoms in the thumb, index finger, and radial second digit.
Clinical Clues
Dr. Parks points out that bilateral hand symptoms with an atypical distribution (e.g. involving all fingers on both hands) might originate from the neck, especially if their symptoms travel proximally to the wrist. Consider alternate diagnoses and EMG for patients with atypical symptoms or those who don’t respond to treatment.
Multiple systemic diseases are associated with carpal tunnel syndrome including hypothyroidism, rheumatoid arthritis, and diabetes (Cleveland Clinic). Notably, bilateral carpal tunnel syndrome can be a herald of later cardiac amyloidosis preceding it by several years (Donnelly, 2019).
Thenar wasting is a late finding that implies permanent damage and identifies folks less likely to respond to treatment.
Treatment is bracing, steroid injections (diagnostic and therapeutic), or carpal tunnel release surgery.
Featuring Joan Ritter and production and graphics by Paul Williams
These are common and can be managed in primary care with PRICE therapy and NSAIDs.
Ankle braces can restrict movement in one plane (stirrup splint), multiple planes (lace-up brace), or immobilize the ankle (walking boot). Dr. Ritter cautioned against long-term immobilization, which can diminish proprioception, weaken muscles that stabilize the joint, and lead to recurrent ankle injuries. Recall our discussion of the “glass ankle.”
Rehab exercises should be done as soon as possible, and include Achilles stretches and tracing the letters of the alphabet with the toes. Maintain a low threshold for referral to formal physical therapy.
Anatomy
Evaluation
Management
Featuring Joan Ritter and production and graphics by Paul Williams
These are common and can be managed in primary care with PRICE therapy and NSAIDs.
Ankle braces can restrict movement in one plane (stirrup splint), multiple planes (lace-up brace), or immobilize the ankle (walking boot). Dr. Ritter cautioned against long-term immobilization, which can diminish proprioception, weaken muscles that stabilize the joint, and lead to recurrent ankle injuries. Recall our discussion of the “glass ankle.”
Rehab exercises should be done as soon as possible, and include Achilles stretches and tracing the letters of the alphabet with the toes. Maintain a low threshold for referral to formal physical therapy.
Anatomy
Evaluation
Management
Listeners will recall key pearls from recent Curbsiders episodes
After listening to this episode listeners will…
The Curbsiders report no relevant financial disclosures.
Williams PN, Watto MF. “#369 Hand, Foot, Wrist and Ankle Pain, Myositis and Myopathy: A Rapid Review (TFTC)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date November 30, 2022.
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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