1. No category

A Patient With De Quervain's Tenosynovitis: A Case
Report Using an Australian Approach to Manual
Therapy
Margaret Anderson and Carol Jo Tichenor
PHYS THER. 1994; 74:314-326.
The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/74/4/314
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Injuries and Conditions: Shoulder
Injuries and Conditions: Upper Extremity
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Case Report
A Patient With De Quervain's Tenosynovitis:
A Case Report Using an Australian Approach
to Manual Therapy
Margaret Anderson
Carol JOTlchenor
This case report describes a 41-year-oldfemale patient who had chronic de Quervain's tenosynovitis, which had progressed to include involvement of the ceruical
spine, shoulder girdle, and upper extremity. The patient complained of aching
over the l e j scapula, a band of pain around the upper arm, and sharp shooting
pain in thefoream, with numbness and tingling in the fingers. On e.xamination,
she had abnormal palpatory findings in the ceruical spine, the shoulder quadrant
maneuver was limited, and the upper-limb tension tests (neural structures) were
positive. The case report demonstrates the use of a n Australian approach to manual theram as described by Maitland. This approach includes ( I ) development,
refinement, and rejection of working hypotheses as to the possible cause(s) of a
patient's symptoms; (2) development of a long-range treatment plan; and (3)use
of data from treatment responses to guide further treatment selection. [Anderson
M, Tichenor CJ A patient with de Queruain's tenosynovitis: a case report using a n
Allstralian approach to manual therapy. Phys T k r . 1994;74:314-326.1
Key Words: De Quervain's tenosynovitis,Maitland, Manual therapy, Mobilization,
Neural tension.
According to the Bureau of Labor
Statistics, reporting of cumulative
trauma disorders quintupled from
1977 to 1989.' De Quervain's disease,
an inflammatory disorder that can be
caused by cumulative injury, is one of
the most commonly diagnosed problems seen by hand surgeons.? Carpal
tunnel syndrome (CTS), also thought
to be caused by cumulative trauma, is
a major cause of lost workdays and
workers' compensation in the United
States.>
De Quervain's disease and CTS can
occur singly o r in ~ombination.4-~
Common clinical presentations and
diagnostic tests for d e Quervain's
disease and CTS will be briefly described in this case report. The purpose of this case study is to illustrate
the interrelationship among examination, assessment, and treatment response in the Australian approach to
manual therapy as pioneered by Maitland in the management of d e Quervain's disease and CTS.'
M Anderson, PT, is Private Practitioner, Marin Orthopedic Rehabilitation, Mill Valley, CA 94941, and
Senior Faculty Member, Kaiser Permanente-Hayward, Physical Therapy Residency Program in Advanced Orthopedic Manual Therapy, 27400 Hesperian Blvd, Hayward, CA 94545.
CJ Tichenor, PT, is Director, Kaiser Permanente-Hayward, Physical Therapy Residency Program in
Advanced Orthopedic Manual Therapy, 27400 Hesperian Blvd, Hayward, CA 94545 (USA). Address
all c,orrespondence to Ms Tichenor.
Revlew of the Literature
Cllnlcal Slgns, Symptoms,
and Pathophysiology of
De Quervaln's Dlsease
De Quervain's tenosynovitis is classically associated with localized tenderness and swelling in the region of the
styloid process of the radius and wrist
pain radiating proximally into the
forearm and distally into the thumb.H.9
Other findings may include decreased
abduction range of motion (ROM) of
the carpometacarpal joint of the
thumb, palpable thickening of the
extensor sheath and of the tendons
distal to the extensor tunnel, and
crepitus of tendons moving through
the extensor sheath.5
This article was submitted August 30, 1993. and was accepted November 8, 1993.
Physical Therapy /Volume 74, Number 4/April 1994
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Pathophysiology and
Diagnostic Tests
The abductor pollicis longus and
extensor pollicis brevis tendons pass
through the first dorsal compartment
of the wrist beneath the extensor
retinaculum and can angle sharply
when the wrist is deviated radially.'O
Various repetitive pronation and supination movements of the forearm,
ulnar and radial deviation of the wrist,
and abduction/extension of the thumb
have been described as movements
that create stress on tendons passing
through the extensor retinaculum.9~11
Muckan12 concluded that firm grip
(eg, wringing a cloth) or finger-thumb
grip combined with radial deviation
of the vlrist creates the greatest stress
on the structures of the first dorsal
compartment. This position causes the
taut abductor pollicis longus tendon
to apply a tensile force to the fibrous
extensor retinaculum. The extensor
retinaccllum thickens to resist the
strain, resulting in more pain and
pressure.ll.l2
Determination of whether a patient
has d e Quervain's tenosynovitis is
based on the location of the patient's
pain and the presence of swelling in
the hand and decreased hand function. Finkelstein's test1] is also frequently used in the diagnosis. The
patient is asked to place the thumb
inside his of her closed fist. If the test
is positive, passive o r active ulnar
deviation of the wrist then produces
pain over the styloid process of the
radius.
With d e Quervain's tenosynovitis,
there is potential for upper-extremity
symptoms other than those involving
the tendon.13 These symptoms can
result from the close proximity of the
nerves, tendons, tendon sheaths, and
fascia of the forearm to the site of
inflammation. According to MacKinnon and Dellon,'? when there is entrapment, tethering, or inflammation
of the superficial radial nerve, a sensory nerve, an incorrect diagnosis of
de Qu~zrvain'stenosynovitis can be
made. In the forearm, the superficial
radial rnerve lies beneath the brachioradialis muscle. The superficial radial
nerve courses between the forearm
musculature and runs subcutaneously
from the midportion of the forearm
to an area adjacent to the styloid process of the radius. Raskl4 has indicated that inflammation of the tendons of the first dorsal compartment
can result in superficial radial neuritis
because of the close proximity of
these structures. This results in pain,
paresthesias, and numbness of the
radial aspects of the hand and wrist.
Raskl4 reported that as the tenosynovitis resolves, so will the radial neuritis,
but at a slower rate.
The superficial radial nerve passes
between the dense fascia of the forearm and the tendons of the brachioradialis and extensor carpi radialis longus muscles. The tendons can press
on the nerve in a scissor-like fashion
when the forearm is pronated, causing a proximal tethering, according to
MacKinnon and Dellon,l3 on the distal
segment of the nerve at the wrist.
This tethering can lead to entrapment
of the superficial radial nerve, causing
pain patterns that can be mistaken for
CTS o r de Quervain's tenosynovitis.
This condition may require surgery.l3
Clinlcal Signs, Symptoms, and
Pathophysiology of Carpal
Tunnel Syndrome
Carpal tunnel syndrome is often seen
as the cause of progressive numbness
o r paresthesia of the fingers in the
median nerve distribution, nocturnal
burning pain o r hypesthesia, weakness of the hand, decreased dexterity.
and numbness o r pain that can radiate proximally.15 The pathophysiology
of CTS remains unknown, although
mechanical and vascular factors are
believed to play a major role.17 Nine
flexor tendons (four each from the
flexor digitorum profundus and superficialis muscles and one from the
flexor pollicis longus muscle) and the
median nerve pass through the carpal
tunnel under the transverse carpal
ligament.16 Alterations in the size of
these structures such as occurs with
inflammation, edema, o r fascia1 scarring can affect the perineural vasculature. According to Sunderland,17 this
inflammatory process can result in a
self-perpetuating cycle of hypoxia,
impaired nerve fiber nutrition, and
leakage of edema from damaged
capillary endothelium. Fibroblastic
proliferation secondary to chronic
edema may result in intraneural fibrosis of the median nerve.
Several clinical tests are used to confirm the diagnosis of CTS. Tinel's sign
is elicited by repeated light tapping
over the carpal tunnel. Tinel's sign
consists of a tingling in one or more
digits in the median nerve distribution.
Phalen's test is performed by having
the patient actively maintain maximal
wrist flexion for 1 minute. Reproduction of paresthesia o r hypesthesia
along the median nerve distribution is
considered diagnostic of CTS.lH%'hen
symptoms have been present for
several weeks o r several months,
electrodiagnostic testing may be used
to differentiate CTS from other entrapment neuropathies and to assist in
staging the disease.l9 Despite its common clinical use, nerve conduction
velocity (NCV) testing has not shown
consistent correlation with clinical
findings of CTS.2" Some patients with
symptoms requiring surgery have
been found to have normal NCVs.21
Consequences of Chronlc
Nerve Injury
Carpal tunnel syndrome is frequently
associated with cervical spine disorders.l9.22.23 Upton and McComas24
coined the term "double crush syndrome" to describe a process in
which proximal compression of a
nerve, involving disruption of the
axoplasmic flow, could have an additive effect on the nerve, lessening its
ability to withstand a more distal
g~~
a "reinjury. L ~ n d b 0 t - described
verse double crush" that occurs when
the distal injury occurs first. The association of d e Quervain's tenosynovitis
with superficial radial nerve entrapment13 and their coexistence with
more proximal syndromes such as
tennis elbowb lend support to the
notion that a proximal or distal entrapment of a nerve may make the
nerve more susceptible to subsequent
inj~ry.'~
Butler2"rgues
,~~
that with
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any neuro-orthopedic disorder such
as CTS, it is impossible to have only
one structure injured or only one
segment of a nerve injured. This may
explain the confusing array of symptoms in patients with long-standing
symptoms.
In order to assess the contribution of
the cervical nerve roots and peripheral nerves to upper-extremity pain,
E l ~ e developed
y~~
what he called the
"brachioplexus tension test," later
called the "upper-limb tension test
(ULTI')."2H
The UL'IT is designed to
place tensile stress on the cervical
nerve roots and their associated peripheral nerves by using a "longitudinal traction force."2*With the patient
lying supine, the UL'IT consists of a
series of joint movements applied to
the shoulder girdle and upper limb.
These movements will be described
in detail in the case report. Butlerz6
asserts that the UL'IT assesses the
mobility of neural tissues in relation
to other "mechanical interfaces" (eg,
the adjacent muscles, ligaments,
bones, fasciae, and vascular tissues).
Tendinous swelling, fascia1 scarring,
or edema may constitute a "pathological mechanical interface" that could
hamper the mobility of a peripheral
nerve.26
Brieg29 and Butler and Gifford3O contend that nerve fibers can move in
relation to their surrounding connective tissues (epineurium, perineurium,
endoneu rium) . Intraneural movement, for example, could be affected
by intraneural fibrosis or edema.
Elvey.9 uses the term "adverse neural
tissue tension" to describe restrictions
in intraneural and extraneural mobility. There are no data relating test
findings to the mechanism we have
described, though the concept often
guides clinical practice.
Theoretical Basis for the Use of
Upper-Limb Tension Tests In
Examination and Treatment
DeBuermann,j2 in 1884, demonstrated
"marked nerve stretch" of the sciatic
nerve in cadavers during a straight leg
raise (SLR) and concluded that
stretching of the nerve tissue was the
cause of pain in the SLR. Other studies have attempted to measure excursion of the lumbosacral roots in cadavers when the trunk is flexed33
and/or o r during an SLR.33.J4
Fajersztajn,35 in 1896, suggested sensitizing or provoking further symptoms
of sciatica by adding ankle dorsiflexion at the end of SLR in order to
place additional traction or tension on
the sciatic nerve. More recently, Brieg
~
adding medial
and T r o ~ p 3suggested
(internal) rotation of the hip to increase tension on the lumbosacral
plexus.
y ~ ~Butlet-37are
The UL'ITs of E l ~ e and
designed to be tests for neural mobility, much like the SLR test for restriction of the sciatic nerve. Cadaver
studies by Elvey2' have confirmed
movement of the brachial plexus
when the ULR is applied to the upper limb. Other studies-0
have
demonstrated longitudinal sliding of
median nerve and cervical nerve
roots when the upper limb is moved.
These studies provide support for the
use of UL'ITs in examination and
treatment.
We believe the clinical findings of CTS
and de Quervain's tenosynovitis reinforce the need for careful examination
of cervical nerve roots and peripheral
nerves because these neural structures
traverse the fibrous retinaculum, pass
through the deep fascia, and cross
between muscles, and as a result decreased mobility of nerves13 can occur.
There are multiple sites in the upper
quarter in which nerves can be susceptible to mechanical irritation o r
"friction fibr0sis."~1
Description of Upper-Limb
Tension Tests
The radial nerve dominant test is a
ULR that is designed to place tensile
stress on neural tissues of the upper
limb along the course of the radial
nerve. With the patient lying supine,
the therapist applies the following
motions sequentially to the patient's
upper limb: shoulder girdle depression with approximately 10 degrees of
shoulder abduction, elbow extension,
medial rotation of the shoulder, pronation of the forearm, wrist and finger flexion, and ulnar deviation and
further shoulder abduction.26
The median nerve dominant test is a
UL?T that involves the application of
shoulder girdle depression, shoulder
abduction in the coronal plane to
approximately 110 degrees, forearm
supination, wrist and finger extension,
shoulder lateral (external) rotation,
and elbow extension. In applying each
motion for the UL'IT, the therapist is
supposed to move the patient's limb
through its available ROM until the
therapist perceives tissue resistance
and/or there is reproduction of the
patient's symptom limiting the ROM
that the limb can be moved through.
Each position must be maintained
while the next motion is applied.26
Kenneally et alz* have suggested that
the positions of the upper limb for
the different tests place tensile stress
on particular nerve structures. Butler26 argues that the complexity of the
anatomy and joint axes of the upper
limb prevents these UL'ITs from being
mutually exclusive from each other.
For example, when the radial nerve
dominant test is applied, nerve trunk,
soft tissue, and joint structures are
also having forces applied to them.
When UL'ITs are administered, patients will normally demonstrate full
joint ROM. The patients may report
mild tingling along a nerve distribution (eg, along the radial nerve distribution for the radial nerve bias test).
In general, reports of pain and comparing joint ROM with the opposite
side are done with the ULR in the
same fashion as they are with the
SLR.28
A tension test is considered positive if
(1) it reproduces the patient's symptoms, (2) there is tissue resistance o r a
decrease in the ROM on one side of
the body as compared with the other,
(3) the patient's responses are different
from what is expected for asymptomatic subjects, and (4) the test responses
can be altered by a sensitizing maneuver that provokes an increase in symptoms. An example is when the patient's
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left de Quervain's tenosynovitis and
possible left CTS. Symptoms started 6
years previous to the referral as a dull
pain in the palmar aspect of the patient's left wrist, with occasional
numbness in her fingers. The patient
was a 41-year-old right-handed bookkeeper. At work in the morning, she
sat at a desk and rotated her upper
trunk toward a table on her left to
count bills and receipts with her left
hand. This task required repetitive
pronation and supination movements
of her left hand. In the afternoon, she
used a computer keyboard. She had
no hobbies, but did routine housework and cooking for herself and
husband. We believe that this routine
indicated that the patient's symptoms
were work-related.
Flgure I. Body chart illustrating where the patient reported pain when first
examined
symptonls are worsened by movements that are generally away from the
site of symptoms or restriction (eg,
lateral flexion of the neck away from a
limb on which the ULlT is being applied). Lateral flexion of the neck
increase:^ the tension on the cervical
nerve roots and peripheral nerve
trunks of the upper limb.26
The use of ULlTs in musculoskeletal
examination is relatively new to physical thera.pists. Studies on the validity
of U L ~ T and
S ~ ~normative data on
ULlT subjective re~ponses~*<~3
have
been described, but largely in symposium proceedings. The ULlTs are also
used to treat problems of restricted
mobility of neural tissues by selectively utilizing components of the
ULTT that provoke the patient's
pain.**,45
Research studies that include patient
groups and research designs for testing the reliability and validity of the
findings of ULlTs are needed. The
literature is currently devoid of such
research.
Case Study
In the following case study, we will
demonstrate how we used theoretical
knowledge and clinical experience to
develop an effective treatment plan
for a patient who initially had de
Quervain's tensynovitis and symptoms
that later progressed proximally to
involve other structures in the upper
quarter.
lntenrlew Data
The patient was asked to describe her
symptoms. Maitland46describes the
"subjective examination" as the patient relating his or her account of his
or her complaints and previous history through the therapist's interview.
The use of the term "subjective" by
Maitland is different from that generally agreed on by measurement experts.47 The area, depth (superficial
versus deep), and constancy of symptoms (ie, pain, tightness, and paresthesia) were represented on a body chart
(Fig. 1). Her symptoms were an occasional ache and tightness over the left
scapula, a band of pain near the deltoid insertion, sharp shooting pain
from the wrist and thumb into the left
forearm, and numbness and tingling
in the fingers. The body chart is used
by the therapist to describe the patient's problems and enables the therapist to formulate an initial working
hypothesis as to the most probable
cause(s) of the patient's symptoms.
This working hypothesis enables the
therapist to frame further questions
regarding how the "behavior of syrnptoms" relates to the patient's activities
and positions (eg, arm movements,
sleeping, sitting). The therapist notes
what aggravates and eases the patient's symptoms in addition to the
onset, intensity, and location of the
symptoms (ie, whether pain is local
or referred.)
The patient was referred for physical
therapy with the diagnoses of possible
Physical Therapy /Volume 74, Number 4lApril 1994
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We believe that by determining how
symptoms change over a 24-hour
period, we can decide whether there
are musculoskeletal components that
can be treated with manual therapy.
The severity (intensity of symptoms)
and the irritability of the condition
are also evaluated. Irritability, according to Maitland,46 is the amount of
activity required to provoke symptoms. Irritability also reflects the intensity of those symptoms and the
time it takes for the symptoms to
return to the resting or nonaggravated
level. Severity and irritability set limits
on how much physical examination
and treatment a patient can tolerate in
a session. The assessment of severity
and irritability is based on the therapist's interpretation of the patient's
report or perception of his o r her
symptoms. In our view, information
regarding symptom behavior establishes a level with which progress can
be measured.
The patient in this case study complained of a constant, deep left wrist
pain that radiated anteriorly up the
forearm to the cubital fossa. After
flipping and filing pages o r counting
bills with her left hand for half an
hour, her wrist would throb and give
occasional sharp, shooting pains to
the cubital fossa. There was intermittent sharp, shooting pain at the carpometacarpal joint of the thumb,
radiating proximally along the lateral
aspect of the radius of the midforearm. She reported needing to
stop for 5 to 10 minutes to alleviate
the shooting pain. She needed to stop
every half hour for relief of
symptoms.
There was an intermittent band of
throbbing pain approximately 2.5 cm
(1 in) wide around one half the circumference of her arm laterally at the
level of the deltoid muscle insertion.
At work, the band of pain occurred
when the wrist pain increased and
radiated up the forearm. The patient
reported experiencing n o decreased
mobility of the shoulder girdle except
a sensation of "tightness" over the
supraspinous fossa and across the
base of the left scapula when putting
her arm behind her back to fasten
her bra in the morning. Her shoulder
pain also occurred in the afternoon
while she was at the computer, especially when she had a busy schedule.
She did not report pain o r restriction
of cervical movements.
The patient reported a reduction in
symptoms when she did not use her
arm o r after she took NaprosynB* (275
mg). She had worn a splint at night for
3 years prior to her being seen by a
physical therapist. The splint appeared
to reduce the wrist pain. The patient
reported a throbbing sensation in her
entire upper extremity before she fell
asleep. She stated she would awaken
every night between midnight and 1
am with tingling and numbness in her
hand, but that she was able to return
to sleep within 15 minutes after shaking her hand and fingers for a few
minutes.
The patient reported that in the moming her only symptom was the constant, deep wrist pain radiating up to
the cubital fossa. She did not describe
any sensation of stiffness in the shoulder girdle and upper extremity. She
said that by the end of most afternoons
her shoulder girdle and upper extremity ached. The patient also reported
that her wrist ached on weekends,
when she was inactive. She complained that her hand and arm felt
"weak" when gripping pot handles.
After the onset of this patient's symptoms (ie, dull wrist ache and numbness in the fingers, which developed
6 years previous to seeing a physical
therapist), she worked her normal
hours for 3 months. Because the
patient's condition was not improving,
she went to a physician, who told her
that she had a "wrist sprain." The
prescribed treatment was to again
wear a neutral-position splint at night,
to take 275 mg of Naprosyna as
needed, and to take 2 days off work.
In addition, the sitting position of
turning to the left to count money
and flip pages was adjusted to enable
her to work directly in front of herself. As a result of following this regimen, she became essentially
symptom-free.
Three years after being given the
splint, the patient's symptoms recurred. At that time, she reported
having a constant, deep ache in her
wrist and numbness and tingling in
her fingers. The pain was worse than
in the previous episode. Another
physician diagnosed her condition as
CTS and muscle strain, and she was
given the same type of splint. This
splint held her wrist in a neutral position. She was instructed to use the
splint as needed on the job. All symptoms decreased, although she was not
symptom-free. During busy weeks at
work, however, her symptoms
throughout the upper extremity
would return.
Prevlous History
Maitland46 contends that by collecting
information about the onset of different symptoms during the latter part of
the interview, the physical therapist
can determine the sequence in which
structures became involved in the
clinical presentation. This information,
according to Maitland, contributes to
a further understanding of the pathology of the condition and its stage (ie,
*Syn!ex Laboratories Inc, 3401 Hillview Ave, PO Box 10850, Palo Alto, CA
401318
whether the condition is acute,
chronic, stable, o r deteriorating).
The patient continued working as a
bookkeeper. A year before the patient
went to a therapist, her wrist pain had
increased to the point at which it
radiated proximally to the elbow. An
ache at the deltoid muscle insertion
was felt and was diagnosed as "arm
strain" by another physician. She was
given a sling and told to wear it for 2
weeks. This led to a decrease in all
arm symptoms. The patient could not
describe the sling but said that while
wearing it, she developed severe neck
pain that spread over her scapula. She
was unaware of any restriction in
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-
Table I. Working Hypotheses After the Patient Interview
Supporting Data
Worklng Hypotheses
Data Reiutlng Hypotheses
Left wrist problem
Degenerative changes at the
wrist and thumb pathology
Constant deep wrist ache
radiating to cubital fossa
as a sharp, shooting pain
Repetitive motions of
wristlhand
Intermittent sharp, shooting
pain over thumb
Numbness/tingling in the
hands, waking at night,
wearing splint at night,
weakness n the hand
Possible carpal tunnel syndrome
Glenohurr~eralproblem
Band of pain around
deltoid muscle insertion
Superimposed cervical component
Ache over upper trapezius
muscle and scapula, arm
ache, numbness/tingling
Poor posture related to
prolonged sitting at work
> 7 years
cervical spine movements during that
period.
The patient remained without treatment until her employer referred her
to an industrial orthopedist nearly 1%
years later. The orthopedist examined
her neck, shoulder, elbow, and arm.
Nerve conduction velocity tests were
within normal limits. She was referred to physical therapy for stretching and strengthening of the upper
quarter.
Physical Examination Data
At the completion of the interview,
our working hypotheses for this woman's symptoms were (1) a wrist problem, including possible degenerative
changes (early osteoarthrosis) at the
wrist, thumb pathology, and CTS, and
(2) a superimposed cervical component, possibly from wearing the sling.
The band of pain around the deltoid
muscle insertion could have been
from a ~:lenohumeralproblem46 o r
interrelated with the other symptoms.
Onset atypical of
glenohumeral
involvement; no
aggravating movement to
implicate glenohumeral
structures
No restrictions in cervical
movements, onset in
wrist in nondermatomal
pattern
Based on data from the interview,
initial working hypotheses were generated. These hypotheses are summarized in Table 1.
Because the patient demonstrated a
complex array of symptoms, multiple
areas of the upper quarter were examined. We used what Maitland46
calls "comparable movement signs" to
monitor the patient's progress during
treatment. Abnormal active, passive,
or functional movements that reproduce the patient's complaints o r appear to be related to the patient's
symptoms are referred to as comparable signs. Abnormal movements can
be loss of physiological o r accessory
ROM because of pain, stiffness, o r
muscle spasm in a structure that appears related to the patient's
symptoms.
Range-of-motion measurements for
selected extremity joints were taken
by one therapist, using a universal
goniometer. Readings were taken to
the nearest 5-degree increments.
Reliability of goniometric ROM readings was not assessed. Cervical ROM
was determined by visual inspection.
Mobility assessments included the
assessment of "end-feel" o r the resistance of tissues at the end of the available passive range of motion (PROM).
Slttlng posture. The patient had a
slight head-fonvard posture, an increased kyphosis at C-7fl-1, and
rounded shoulders. The general impression was one of tightness (adaptive muscle shortening) and inability
to relax the cervical spine and shoulder girdle with the left upper trapezius muscle elevated. The patient's
symptoms in this position were minimal wrist and scapular ache.
Cewlcal range of motlon. The
patient was unable to complete axial
extension of the cervical spine to
neutral (dorsal glide) because of a
sensation of "stiffness" and central C-7
pain over the spinous process. Active
cervical rotation to the left was 70
degrees according to visual inspection. When overpressure7 (firm pressure producing oscillatory movements
at the limit of ROM) was applied
passively, the left rotation remained at
70 degrees with a stiff end-feel. There
was no change in the symptoms when
the patient was resting. Rotation to the
right was pain-free according to the
patient, and there was full ROM as
determined by visual inspection and
overpressure.
Shoulder. Active shoulder abduction,
flexion, and rotation were pain-free
according to the patient, and there
was full ROM as observed by the
examiner. In response to the glenohumeral quadrant maneuver on the
left, the patient reported a "pulling
sensation" at the elbow. This glenohumeral quadrant maneuver is described by Maitland46as a passive
movement test designed to maximally
stress the shoulder girdle to reveal
minimal signs (ie, abnormality of
movement, pain, o r stiffness). The
arm is placed in approximately 130
degrees of abduction and flexion,
with the forearm in 90 degrees of
elbow flexion. The arm is then rotated medially and laterally to repro-
Physical Therapy/Volume 74, Number 4/April 1994
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(shoulder abductors, medial and
lateral rotators, and biceps) were
pain-free.
Elbow. All active ranges of motion
(AROMs) were considered full as
determined by visual inspection with
overpressure.
Wrlst.The left wrist displayed weakness throughout the range of flexion
and extension based on a manual
muscle test (MMT)4"rade of 4/5 for
both movements.
Flgure 2. Glenohurneral quadrant: The humerus is placed in approximately U O
degrees of abduction and,flexion, with elbow flexion at 90 degrees. The humerus is
then rotated medially and lateral111to reproduce pain or assess limitation of molfement
that is comparable to the patient's complaints.
duce pain or assess limitation of
movement comparable to the patient's
complaints (Fig. 2). Routine isometric
tests'ix for the rotator-cuff musculature
Figure 3. IILTT, median nerve dominant test, utilizing shoulder girdle depression,
shoulder abduction in the coronal plane to approximately 110 degrees,foream supination, wrist and,finger extension, shoulder medial rotation, elbozv extension, and
cendcal 1ateral.flexion away.from the limb on which the test is being applied.
42 / 320
There was increased pain across the
carpal joints when the patient gripped
the therapist's middle three fingers.
Active wrist flexion with overpressure
was 60 degrees and extension was 50
degrees of ROM, and a sharp pain in
the region of the carpal bones was
reproduced at the end-range of these
tests. Tests of accessory movements of
the carpal bones, especially the lunate
and capitate, resulted in crepitus and
decreased mobility. The patient's wrist
ache was reproduced.
Phalen's test was not performed because of the patient's limited wrist
ROM. Finkelstein's test elicited a
sharp, shooting pain that radiated
proximally along the radius from the
carpometacarpal joint of the thumb.
Deltoid and biceps brachii muscle
strength were both diminished to an
MMT grade49 of 4/5. Deep tendon
reflexes (ie, biceps brachii, triceps
brachii, and flexor digitorum longus)
and sensation in the upper limb were
intact. Tinel's testing at the left wrist
elicited a tingling sensation into the
hand.
Upper-limb tenslon test. The median and radial nerve dominant ULlTs
described by Butler26were used to
assess the mobility of neural structures in the patient's left arm. In the
median nerve dominant test (Fig. 3),
the patient was restricted to 45 degrees of elbow extension, with wrist
extension limited to 45 degrees. The
application of this ULlT requires the
therapist to use both hands to maintain all components of the test; therefore, goniometric measurements were
not taken and angles were estimated.
Physical Therapy/Volume 74, Number 4/April 1994
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working hypotheses, and we expanded the hypotheses (Tab. 2). The
structures that appeared to be involved were (1) the carpal bones of
the left wrist, (2) the tendons of the
first dorsal compartment (suggesting
d e Quervain's syndrome), (3) the
flexor tendons and retinaculum of the
wrist (suggesting possible CTS), (4)
the glenohumeral joint, (5) the C-5 to
C-7 spinal segments, and (6) the neural tissues. We believe there was
strong evidence of extra neural and
intraneural components to the problem, as suggested by the positive
response to the ULITs.
Figure 4. [ J L T , radial nerve dominant test, utilizing shoulder girdle depression,
shoulder abduction oj'approximate(v 10 degrees, elbow extension, shoulder medial
rotation, and,forearm pronation, with the wrist and hand in the Finkelstein's test position. The head is laterally Jeered away from the limb on which the test is being applied.
When the patient's head was laterally
flexed to the right (presumably adding tension to the neural tissues from
the cervical spine to the upper limb),
she experienced an increase in sharp
pain in her left wrist. The pain was
relieved by left lateral neck flexion.
This change in distal symptoms produced bly the patient's head movements suggested to us that there may
be impaired mobility of neural tissues. We believe this provides the
therapist with a justification to examine areas with structures capable of
referring pain into that area.26
When the radial nerve dominant test
was applied to the patient's left upper
extremiry, the test was modified by
placing the shoulder girdle and elbow
in the normal test positions, with the
patient's hand in the Finkelstein's test
position (Fig. 4). The maneuver resulted in a positive test result. The
thumb pain increased sharply, and
pain in the deltoid muscle also occurred. Both thumb pain and deltoid
muscle pain became worse when the
patient attempted to laterally flex her
head to the right. The pain was re-
lieved by left lateral flexion. A positive
response in this test position (ie,
increased pain and restriction of
movement) suggested to us that the
patient, in addition to having a problem tendon at her wrist, also had
decreased mobility of neural tissues
that contributed to her symptoms.
Palpation. The patient found it difficult to relax her cervical and upper
thoracic musculature because of a
sensation of "tightness" in these
areas. Central posteroanterior (PA)
accessory intervertebal movements
with the thumb tips over the
spinous processes7 of C-5 to T-6
showed that these segments were
prominent (posterior to the expected normal lordosis of the cervical spine) and demonstrated marked
resistance to thumb pressure. Left
unilateral pressures7 over the apophyseal joints at these levels also were
painful and indicated that there was
resistance to movement. The right
side was asymptomatic.
Our conclusions at the end of the
examination supported our initial
The patient's functional limitations
were that she was working with pain,
and at home she was unable to vacuum and lift heavy pots. She needed
to work for financial reasons, and she
appeared to be stoic and have good
pain tolerance. Her employer was
cooperative and helped with ergonomic changes in her work situation.
Her work space was changed so that
she n o longer had to rotate her trunk
to count bills, and her keyboard position was adjusted to support her
wrists.
An assessment of her overall prognosis needed to be made so that a real-
istic treatment plan could be formulated. The patient had the problem
for 6 years, and the condition appeared to have worsened over this
period to incorporate many interrelated structures. She had continued to
work with limited physical therapy
intervention. Because we believed her
problem was multifactoral and because her symptoms continued to be
aggravated by activities at work, treatment over several months was anticipated. We expected that the patient's
symptoms would be exacerbated by
excessive activity.
Treatment Plan
The physical therapy goals were (1)
to decrease wrist and deltoid muscle
pain, (2) to increase cervical and
thoracic mobility, and (3) to restore
mobility of neural tissues. The overall
functional goal of the physical therapy
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-
bral column to determine how
groups of symptoms change.
Table 2. Working Hvpotbeses After Physical Examination
Worklng Hypotheses
Supporting Data
Data Refutlng Hypotheses
Left wrist problem
Degenerative changes
at the wrist
Increased central pain
across carpal joints with
gripping
Decreased range of motion
of wrist, flexion of 60",
and extension of 50",
with sharp pain on
overpressure
Accessory movements of
carpal bones
accompanied by
stiffness, crepitus, pain
Thumb pathology (de
Quervain's disease)
Possible carpal tunnel
syndrome
Finkelstein's test positive
"Thickened" tendons on
palpation at extensor
retinaculum
Tinel's test positive
Electromyographic test
results negative
Wrist flexorslextensors at
415 strength
Glenohumeral problem
Left glenohumeral quadrant
"tight," with "pulling"
sensation to elbow
Band of pain not
reproduced by
glenohumeral maneuvers
Superimposed cervical
component
Unable to dorsal glide
Sensation intact to pinprick
in fingers
Left cervical rotation to 70"
with stiffness
Central posteroanterior
pressure to C-5 to T-2
accompanied by marked
stiffness
Biceps brachii muscle jerk
decreased
Biceps brachiildeltoid
muscle weakness (415)
Unilateral posteroanterior
pressure to C-5 to C-7
accompanied by stiffness
and pain
Adverse neural tissue
tension comDonent
ULTT,=radial nerve
dominant test results
positive
ULTT, median nerve
dominant test results
positive
"Ul.7-l'=upper-limb tension test
was to enable the patient to be painfree at work.
There were two options at the beginning of treatment. One option was to
begin treatment distally at the hand
and focus treatment on the individual
44 / 322
signs and understood pathology:
Finkelstein's test and the decreased
mobility at the wrist. The other option
was to look for patterns of symptoms
in the musculoskeletal system and
treat several bony o r soft tissue structures in one area, starting in the verte-
A "pattern-recognition" approach is
the foundation of the Australian approach to manual therapy. By beginning treatment centrally (ie, at the
cervical and thoracic spines) to restore mobility to the dorsal glide and
left rotation restriction, the therapist
would anticipate changes in some
distal signs and symptoms (eg, band
of pain at the deltoid muscle insertion, wrist problem). This approach
will provide information to the therapist as to what portion of the patient's
symptoms can be changed by treating
centrally and what portion will require treatment of peripheral structures. Thus, after treating the cervical
and thoracic spine, the plan was to
add treatments to other symptomatic
areas: the wrist and thumb, the tight
muscles in the upper quarter, and
finally the neural tissues throughout
the upper quarter.
Treatment
The patient was treated three times in
the first week with mobilization (both
central and left unilateral PA accessory
movements)' to the lower cervical
(C-5 to C-7) and upper thoracic (to
T-6) spines. She reported a decrease
in the general arm ache and stated
her left wrist pain that radiated anteriorly up the forearm was absent for up
to 4 hours per day. The intermittent
numbness in her thumb and fingers
was n o longer present. The sharp
local pain in the thumb returned
while working but did not radiate
proximally along the lateral radius.
There was no pain at night, and she
reported no longer wearing the
splint.
Based on our visual inspection, we
noted left cervical rotation increased
to 90 degrees and the patient was
able to dorsal glide her cervical spine
to neutral. There was decreased tightness and less pain with the glenohumeral quadrant maneuver. There
was minimal change in findings with
the ULRs. Finkelstein's test reproduced local pain only. The patient's
deep wrist pain, which radiated ante-
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riorly to the cubital fossa, was no
longer present. Wrist flexion and
extension ROM improved to 70 and
60 degrees, respectively, with goniometric measurements. The PA accessory movements of the lunate and
capitate were less restricted.
We believe the identified changes
confirmed our hypothesis that there
was a central cause for the patient's
constant deep wrist pain that radiated
anteriorly to the cubital fossa and for
the decreased wrist mobility. The
sharp pain in the thumb was only
partially related to cervical structures.
The presence of de Quervain's tenosynovitis became evident. Similarly,
we believed that the decreased wrist
mobility was also related to degenerative changes at the wrist. The cause of
the band of pain around the deltoid
muscle insertion remained unclear.
After the initial improvement in the
patient's symptoms following 1 week
of treatment applied to the cervical
and thoracic spines, the therapist
added 1:reatment to other areas. At
week 2, mobilization of the carpal
bones utilizing PA and anteroposterior accessory movements on the
capitate and lunate were incorporated; this treatment brought wrist
flexion and extension to full ROM.
Gentle transverse friction4Hwas applied to the abductor pollicis longus
and extensor pollicis brevis tendons.
The superficial radial nerve at the
wrist was mobilized by gently pulling
a thumbnail across the region where
the nerve passed. Following this combination of treatment to the wrist
area, Finkelstein's test was no longer
positive in the wrist area, indicating
that de Quervain's tenosynovitis had
resolved.
The tightness in the patient's upperquarter musculature was treated by
stretching the upper trapezius, scalenus, bi.ceps brachii, and triceps
brachii muscles with hold-relax techniques. Soft tissue massage techniques
were applied to muscles along the
course of the median and radial
nerve5 in an attempt to restore normal mobility between interfacing
neural and muscular tissue.26To in-
crease the vigor of the treatment,
these muscle groups were stretched
utilizing the ULTT positions.
Treatment was directed toward mobilizing the interfaces between muscles
and nerves by the therapist pulling
her index finger pad across the region of the nerve at easily accessible
sites (ie, the distal axilla, the spiral
groove in the humerus, the cubital
fossa, and the forearm above the
wrist). When the radial nerve was
mobilized along the spiral groove of
the humerus, the patient had an exacerbation of wrist symptoms and severe deltoid muscle pain for 5 days.
In our view, this outcome confirmed
the hypothesis that the deltoid muscle
pain was related to the neural tissues.
Furthermore, this result led us to
eliminate any possibility of glenohumeral involvement.
When the patient's deltoid muscle and
wrist symptoms returned to their
resting level, neural tissues of the
upper quarter were mobilized in the
ULTT positions and a self-mobilizing
pr0gram2~was designed for her to
carry out at home. With the patient's
arms by her side, the therapist instructed her to depress her shoulder
girdle, then gently flex and extend
her elbows and wrists. For ease of
coordination, this movement was
performed bilaterally. Later, when
able to tolerate this activity without
symptoms, these stretches were progressed to the shoulders, with the
shoulders abducted to 90 degrees.
This movement was done in a painfree ROM and to tolerance. Later,
strengthening exercises for the interscapular musculature were included
to help her postural endurance while
sitting at work. These exercises were
cervical and scapular retraction while
the patient was positioned supine
over a green "Gymnastik Ball." The
exercises were performed morning
and night in groups of 10 repetitions
and were only partially successful
because repetition with light resistance exacerbated her arm ache.
Results of Treatment
The patient was treated three times
per week for 3 months, two times per
week for 2 months, and once weekly
for 1 month. A physician reviewed the
patient's progress every 6 weeks and
prescribed continuation of physical
therapy because of the favorable responses to treatment. Despite the
extended period of physical therapy,
the therapist considered intervention
to be cost effective because the patient was able to continue uninterrupted full-time employment while
her symptoms improved. The rate and
progression of treatment were governed by the fact that structures involved in the upper quarter could not
tolerate aggressive treatment.
Over the 6-month period of treatment, the patient's symptoms varied,
but she reported improvement over
time rather than at each treatment
session. Table 3 summarizes the status
of the patient's signs and symptoms
before and after treatment. When
discharged, she reported having no
pain at night, no wrist and hand pain,
no numbness, and no sharp pain in
the thumb o r radiating pain up the
lateral aspect of the radius. The pain
in the deltoid muscle remained the
most resistant to change, with exacerbations occurring for no identifiable
reason. The patient reported she was
still unable to vacuum or lift heavy
pots because of weakness.
After the first week of treatment, active cervical rotation to the left was
pain-free and full. The glenohumeral
quadrant, which is used to assess
end-range shoulder girdle mobility,
remained tight. Wrist flexion and
extension were full, with a springy,
tight end-feel, This finding suggested
to us a secondary change resulting
from a chronic problem. Accessory
movements of the carpal bones were
full and pain-free.
The ULTT, radial nerve dominant test
was pain-free, with tightness and a
pulling sensation radiating from the
deltoid muscle down the patient's
arm at end-range. The previous sharp
thumb pain was now gone. The ULTT,
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-
Quervain's tenosynovitis or CTS. The
importance of this case study lies in
the therapists' analysis of signs and
symptoms to implement treatment
and to obtain a response that dictated
the direction of future treatments.
Table 3. SurnrnaqJof Findings Before and After Physical Therapy
Slgns and Symptoms
Treatment
Results
Constant deep wrist pain
radiating to elbow, night pain
Central and unilateral PAa
pressure, accessory
movements to carpal
bones
Pain-free
Numbnessltingling in hand,
waking at night,
questionable carpal tunnel
pattern
Central and unilateral PA
pressure
No numbness and
tingling
Intermittent band of pain at
deltoid muscle insertion
Wrist and deltoid muscle
symptoms worsened by
transverse friction to
radial nerve at spiral
groove of humerus
Continued to
exacerbate
Patient interview
Helped by U ~ l - r ~
Physical examination
Cervical ROM,' dorsal glide,
rotation to left 70"
Central and unilateral PA
pressure
Full ROM, pain-free
Glenohumeral quadrant
limitation
Central and unilateral PA
pressure, ULl-r
Remained "tight"
Wrist flexion of 60" and
extension of 50", sharp
pain at end-range
Central and unilateral PA
pressure, local
mobilization to carpal
bones
Full ROM, pain-free,
springy end-feel
Central PA pressure
Radiating pain to
forearm now
resolved
F~nkelstein's
test positive
Transverse friction to
tendons of first dorsal
compartment and
superficial radial nerve
Local pain at
carpometacarpal
joint of thumb
remained
U L T , radial nerve dominant
test with hand in
Finkelstein's test position
yielded increased thumb
pain, increased deltoid
muscle pain
Soft tissue mobilization,
ULll
Pain-free with
"tightness' and
"pulling" sensation
from deltoid muscle
down arm, no sharp
thumb pain
ULl-r, med~annerve
dominant test yielded 45"
of elbow extension, 45" of
wrist extension, increased
pain in wrist with lateral
head flexion to right
Soft tissue mobilization,
ULl-r
30" of elbow extension
with "pulling"
sensation to wrist
"PA= posteroanterior.
" ~ ~ ~ . T T = u ~ ~ e tcnbion
r - l ~ m rest.
b
'ROM=range of motion.
the median nerve dominant test was
30 degrees of elbow extension, with a
pulling sensation to the wrist. This
residual restriction in UL?T was expected because of the chronicity of
the patient's problems and involve-
46 / 324
ment of soft tissue structures throughout the upper quarter.
Dlscusslon
Physical therapists frequently treat
patients who have a diagnosis of de
After the patient interviews, the initial
working hypothesis was that the patient had a wrist problem, a cervical
problem, and a possible glenohumeral problem. By focusing treatment
on the cervical spine, information was
gained o n the relationship between
the cervical area, the shoulder girdle,
and the wrist-thumb complex.
We believe the improvement in cervical ROM, the decrease in arm ache,
the presence of periods without wrist
and thumb pain, and the increase in
carpal joint mobility supported the
effectiveness of cervical treatment and
the hypothesis of a cervical component of the patient's problem. We
contend that loss of mobility of carpal
bones was partially reduced by treatment of the cervical spine. The residual stiffness decreased further following treatment involving carpal
accessory movements. After treatment
of the cervical region, numbness and
tingling in the fingers also disappeared, which suggested to us that
the carpal tunnel symptoms were
from structures other than those under the flexor retinaculurn. We therefore rejected the hypothesis of possible CTS.
Symptoms that did not respond to
cervical mobilization were addressed
directly. The treatment plan was progressed to focus on wrist joints and
tendons and on the superficial radial
nerve at the wrist and thumb. The
patient's favorable response to treatment, in our view, confirmed the
working hypothesis that pain was
caused by involvement of the first
dorsal compartment tendons and
possible superficial radial neuritis.
The tightness and muscle guarding in
the upper quarter and positive UL?T
response were addressed first by muscle stretching and soft tissue massage,
and finally by mobilizing the neural
tissues, utilizing various components of
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the ULITs. The positive responses to
UL?Ts at discharge suggested a mild
residual restriction of neural tissue
mobility. f i self-mobilizing and
strengthening program was given at
in maindischarge to assist [he
taining the gains achieved.
Summary and Concluslon
The patient had a wrist problem,
starting 6 years previous to our seeing
her, that deteriorated over time to
incorporate multiple structures
throughout the upper quarter'
dischargc~d,the patient achieved considerable reduction of symptoms
but
.
.
was not symptom-free. We contend
that patients with multiple ~ U S C U loskeletal ~ r o b l e m smav have diagnoses that sometimes can be inadequate o r incorrect, causing the
physical therapist to inadvertently
limit the scope of the examination
and treatment, The Australian approach to manual therapy we described provides, in our opinion, a
systematic process for identifying the
working- hypotheses
and using treat.men[ to continually reassess
confirm or reject these hypotheses.
-
and
We believe that if the patient in this
case study had been treated only for
the de Quervain's syndrome, only
some of her functional problems
would have been addressed. In patients with chronic musculoskeletal
problems, we contend that focusing on
patterns of signs and symptoms
throughout the upper quarter and
responding to emerging data from the
patient enable the physical therapist to
develop an effective treatment strategy
for addressing multiple structures.
The
approach we described
is one of several manual therapy approaches to examination and treatof' ~atientswith musculoskeletal
d~rsfunction.Physical therapists should
recognize that the efficacy of this
approach still needs to be studied and
compared with that of other manual
therapy approaches.
hen[
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A Patient With De Quervain's Tenosynovitis: A Case
Report Using an Australian Approach to Manual
Therapy
Margaret Anderson and Carol Jo Tichenor
PHYS THER. 1994; 74:314-326.
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