Hand therapy aims for the optimisation of your hand function whilst simultaneously minimising pain or discomfort. How we will reach this goal depends on certain factors. We take a look at the origin of the complaints and how they limit you in your daily functioning.

When surgical intervention is not needed, we call this treatment conservative therapy.

Besides conservative therapy, there is also post- and pre-operative therapy. Post-operative therapy entails the therapeutic care that follows surgery. After surgical intervention, our treatment goals will emphasise on the development and guidance of the healing process by means of:

  • wound care
  • minimising post-operative swelling
  • scar treatment
  • exercise therapy
  • splint therapy

At times, general practitioners or specialists will refer their patients ahead of surgery to our practice. This customarily entails pre-operative screening. The intention of the screening is to map the hand function and its functional limitations in great detail. This information will facilitate the surgeon’s decision regarding which surgical intervention you will receive. Additionally, a pre-operative screening makes it easier to evaluate the post-operative results.

The final outcome and healing of a hand injury or disease is strongly correlated with the quality of the (post-operative) treatment. Specialised therapy greatly enlarges the chances at succeeding, resulting furthermore in a faster and superior return to independence, work, hobbies, and sport.

When you experience a longstanding pain in your elbow, hand, or wrist, and you find it difficult to pinpoint the pain with one finger. Then it can be that this pain is caused by small spasm in the muscle. These spams (also known as trigger points) are effectively treated with the aid of dry needling. Your physiotherapist will treat the trigger point with a small sterile needle relieving you of the referred pain.

Trigger points can arise in situations such as sitting in the same position for a prolonged period of time, or with repetitive movements when doing sports or when playing a musical instrument. Trigger points also commonly develop after wearing a cast. A trigger point refers pain to a certain area; every muscle has its own fixed area of referred pain.

You can try pressing your finger on the muscle that runs over the shoulder blade. It is likely that you will find a painful spot in the muscle that when you press on it triggers a sharp pain. When you continue to press on this point for a prolonged period of time, you will perhaps notice that the pain will radiate to the front of the shoulder. This is an example of referred pain.

For that reason, it can be that you experience pain or a restriction in range of motion in your elbow, hand, or wrist that has an origin that lies higher up, around the shoulder. In the case that your hand therapist expects that the complaints are caused as a result of trigger points, (s)he will be able to treat you with the aid of dry needling. When the needle is in the vicinity of a trigger point, the muscle will shortly contract and relax subsequently. Our hand therapists who will treat you using dry needling have completed a special training and are required to follow yearly classes to keep their knowledge up to par.

In our opinion dry needling is always a part of a bigger treatment plan. It will help reduce pain and creates a condition that will ameliorate recovery. Using a training program and/or alterations in your daily life you can prevent the recurrence of your complaints.

If your wrist hurts on the side of the tumb, you could be suffering from de Quervain’s disease. In that case your two extensor tendons that operate your thumb are irritated. They slide through small compartment (a kind of tunnel), when you move your thumb. When this compartment gets irritated, it will shrink in size. However the tendon will expand resulting in an inflammation of the tendon’s sheath.  This will lead to even more irritation when moving your thumb. People with rheumatoid arthritis and diabetes have an increased chance getting de Quervain’s tendosynovitis.

On the image you see Finkelstein´s test, if this is painful (more painful than on the unaffected side) then it can be that you have Quervain’s disease.

Hand therapeutic treatment

We can help you by producing a personalised orthosis (brace/splint) that will relieve the irritated tendons. It is the intention that you wear this orthosis 24 hours a day, for six weeks. Furthermore, we take a look at the way you use your hand, also called the tension pattern. Sometimes it will be necessary to adjust the way you operate your hand to minimise the chance for the complaints to recur.

In many cases we see good results. However, if it does not improve, we will refer you (back) to the general practitioner. (S)he will be able to administer an injection or refer you to the hospital. There they will be able to decide if you are eligible for a surgical procedure.

In the case that your finger stays in a bent position and you are not able to straighten it on its own, then there is a large chance that you have a trigger finger. Often you are able to feel a painful thickening in the palm of your hand on the flexor tendon. This tendon normally slides through a compartment (a kind of tunnel) in the palm of your hand. However in the case of a trigger finger, it is not possible and the tendon sheath will get inflamed.

Hand therapeutic treatment
We can help you by creating an orthosis (splint/brace) for you finger which will relieve the tendon and tendon sheath. This orthosis still enables you to do everything. When the results are unsatisfactory we can refer you (back) to the general practitioner. (S)he will be able to administer an injection or refer you to the hospital. There they will be able to decide if you are eligible for a surgical procedure.

After surgery we would like to welcome you back for follow-up treatment. We can provide exercises to retrain the flexibility in the finger.

The carpal tunnel syndrome is one of the most common hand injuries. If you suffer from a carpal tunnel syndrome, you can experience a tingling sensation and/or numbness in the index-, middle-, and ring finger, and in some cases also the thumb. It can also be that you experience a decrease in muscle strength in your hand. During pregnancy the chances of getting carpal tunnel syndrome are increased.

The medial nerve (one of the three nerves that innervate the hand) gets compressed just above the wrist. In this place there is a tunnel. When the nerve gets compressed, it will get irritated and thicken, something that will aggravate the complaints.

Hand therapeutic treatment
We can help you by making a personalised orthosis (splint/brace) for during the night. The splint will prevent you from flexing your wrist which as a result will minimise the compression of the nerve.


Additionally, we can give you advice to irritate the nerve as little as possible in your daily routine. Sometimes this does not help enough, and we will refer you (back) to your general practitioner. (S)he will be able to administer an injection or refer you to the hospital. There they will be able to decide if you are eligible for a surgical procedure.

After surgery we would like to welcome you back for follow-up treatment. We can provide exercises to retrain the flexibility of the wrist and/or diminish the post-operative pain complaints of the scar and fingers.

Hand or wrist fractures are common. When you expect to have a fractured wrist or hand, it is important to visit the general practitioner. Your hand/wrist will be examined and when the general practitioner expects a fracture (s)he will refer you for an X-ray.

Hand therapeutic treatment
Treatment options regarding fractures vary. Some minor fractures in the fingers do not require a cast, whereas a different type of fracture can result in wearing a plaster for 2 to even 12 weeks. Seldomly surgery is needed after fracture. In the case that you are not in need of a cast, we can, if needed, make an orthosis to protect the fracture. After a period of having your hand/arm in a cast, your fingers and wrist are usually rather stiff and there is a loss of strength. We can help you to regain that flexibility and strength.

After an accident it can happen that one or multiple tendons in your hand have lacerated or been cut. In most cases the tendons must be surgically reattached.

Hand therapeutic treatment
After surgically reattaching the tendons there are multiple possibilities regarding hand therapeutic treatment. The surgeon, usually in consultation with the hand therapist, determines the treatment plan.

Usually when the reattachment of the tendons is located near the wrist, you will receive a cast to immobilise the fingers for 3-4 weeks. When the reattachment took place in the hand, it is important that you start mobilising your fingers early on to prevent stiffness and formation of adhesions from scar tissue. Within 5 days post-surgery we will make a hand-tailored orthosis (splint/brace) with special elastic bands, as shown on the picture. You will be able to move your fingers without straining the sutured tendons. Making sure that the risk of a re-rupture is minimal. The orthosis is worn for 3 weeks, afterwards we will increase the load gradually to regain strength.

Sometimes you will receive an orthosis in which you may start moving your fingers 5 days post-surgery. You will be given specific exercises to slowly start training the operated fingers without putting too much strain on the tendons. Naturally we will guide you intensively during this process.

The total rehabilitation trajectory lasts approximately 3 months. The aim is that you will then have regained a normal hand

The cause, or pathophysiology of Dupuytren’s disease is unknown. Cells that produce scar tissue become overactive and form adhesions in the hand palm. These adhesions cause the fingers to maintain a bent position.

Hand therapeutic treatment
In the case that you did not receive surgery, there is little we can do. The only advice is: Do not forcefully stretch your fingers with the other hand! When creating a stretch on Dupuytren adhesions, the cells become more aggressive and this will only speed up the process.

After surgery we can help. If necessary we will manufacture a hand-tailored orthosis (splint/brace) for you. Furthermore, you will receive exercises that will help you regain the finger’s flexibility, and we will keep a close eye on the surgical wound.

Volar plate injury, more commonly known as ‘jammed finger’. If you have overstretched your finger and luxated the joint, there is a chance that you injured the volar plate. This can happen when a hard ball hits your finger or when you fall. The volar plate is a tough plate of collagen on the inside of the joints of your fingers. It prevents your finger from overstretching.

Hand therapeutic treatment
It is important that within 5 days of the injury treatment is started. In the first three weeks the injured volar plate of the finger joint should be protected, so that it can heal. We will manufacture a hand-tailored orthosis (splint/brace) in which you can bend the finger but can’t stretch it, as shown on the picture.

After three weeks we will re-examine the joint. If the joint is stable, you can stop wearing the orthosis, and you will receive exercises to maintain the mobility of the joint. If your finger became stiff, you will receive a new orthosis to improve the extension of the joint. If the joint remains instable we advise you to continue to wear the orthosis for a week or more. Naturally we will regularly monitor the rehabilitation.

It may happen that your finger has already become stiff when you come to see us. For instance, due to the fact that you only came to us after a couple of weeks. Or you might have a tendency to develop stiff joints. If this is the case, we start directly with an orthosis that allows extension in combination with exercises to retrain the flexibility and mobility of the finger.

In the case that the extensor tendon of your finger ruptures at the tip of the finger, we call it a Mallet finger, also known as a hammer finger. This can happen while making the bed or when a hard ball hits your finger. A Mallet finger can be recognised by a hanging tip of the finger, with an inability to extend it. When you think you have a Mallet finger, it is important to see your general practitioner. (S)he will want to make an x-ray to exclude a fracture. Sometimes a Mallet finger comes with a small fracture, it’s then called an ossal Mallet. When only the tendon is ruptured, it’s called a tendinous Mallet.

If the ossal fragment of the fracture is out of place, or simply too big, you will need surgery.

Hand therapeutic treatment
We can treat both the tendinous Mallet as well as the ossal Mallet by making a hand-tailored orthosis (brace/splint) for your finger. This ensures a straight and fixed position of the top of the finger, so that the tendon can reattach. You will need to wear the orthosis for 6-8 weeks, afterwards we will help you slowly decrease the time you need to wear the orthosis.

Sometimes medical professionals will prescribe small pre-made braces/splints. Often these will irritate the skin, and the tip of the finger is not positioned straight enough. This means that it’s not the right fit. Therefore, we prefer to manufacture a hand-tailored orthosis (brace/splint) specifically for your finger.

Osteoarthritis is the result of wearing and tearing of cartilage in the joints. The most common location of osteoarthritis in the body is the thumb basal joint. This is due to the high mobility of the joint. If you develop thumb basal joint osteoarthritis (also known as CMC 1 osteoarthritis) you will experience a nagging pain at the base of your thumb, close to the wrist. Activities that burden the thumb base joint, like wringing out a cloth, will aggravate the pain. Osteoarthritis also occurs in other joints of the finger, and in the wrist.

Hand therapeutic treatment
We cannot treat or cure the osteoarthritis itself. What we can do is to alleviate your pain complaints as a result of the osteoarthritis as much as possible. We can produce a hand-tailored orthosis (brace/splint) that protects the joint, as shown on the picture. Furthermore, we will advise you and provide you with appliances for e.g. writing and cutting that diminish the pain during these activities.

A common problem with osteoarthritis is the disbalance between the load and the load capacity of the joint. The load capacity obviously decreases due to the disease, whereas the load on the joint remains the same.

Together we can assess how you will be able to perform your important activities with as little hindrance as possible.

If the osteoarthritis has reached an advanced stage there are surgical options. After surgery we can help you regain strength and flexibility in the wrist and hand.

Rheumatoid arthritis is an autoimmune disease. Symptoms from rheumatoid arthritis usually start in the hands and feet. Lately there have been some advancements regarding medication for rheumatoid arthritis that can be beneficial for you.

Hand therapeutic treatment
We will start with a thorough physical examination of the hands. We will check if the rheumatoid arthritis already manifests in the wrist, and we will modify the treatment accordingly.

With splint therapy we try to optimise the function of the hand. A splint should ensure that you carry out more tasks with your hands. Sometimes we will produce a splint that is worn during the night to prevent a deviating position of the fingers.

Additionally, we will give you exercises to restore the muscle balance in your hand. The muscle balance is often disturbed in rheumatoid arthritis. You will also receive exercises that are focused on the relaxation of the hand.

A common problem with rheumatoid arthritis is the disbalance between the load and the load capacity of the joint. The load capacity obviously decreases due to the disease, whereas the load on the joints remains the same.

Together we can assess how you will be able to perform your important activities with as little hindrance as possible.

Sometimes, in spite of intensive hand therapy, surgery is necessary. After surgery we will be able to help you with the rehabilitation. The hand therapeutic treatment will then be focussed on the recovery. We will monitor the surgical wound and will manufacture a hand-tailored orthosis (splint/brace) if necessary to protect the area around the surgical wound. This is always done in consultation with the surgeon. Furthermore, you will receive exercises to retrain the hand function.[/

It can happen that you suffer from wrist complaints but that the cause cannot be found. These are called a-specific complaints. Chronic indicates that the complaints exist over a longer period of time. A-specific wrist complaints are a common problem, and has a higher incidence in young females. Most of the times, these complaints start with mild overstraining. The load on the wrist increases due to a e.g. a change in job, or the strain that comes from a new-born. The load capacity of the wrist remains the same, and can sometimes even be reduced.

As shown on the diagram below, complaints often aggravate due to the fact that the pain makes you change the way you use your wrist. This causes the wrist function to diminish and the amount pain to increase.

 

source: Oefentherapie voor chronische onbegrepen polsklachten door: A.J. Videler, M. Kreulen, M.J.P.F. Ritt

Hand therapeutic treatment
Using a training program, we try to break this cycle. We start with learning how to use the correct muscles in the correct way when moving your wrist.

After that we will slowly increase the load on the wrist, and try to optimise the hand and wrist function, often causing a reduction in pain. The total training program takes three months.

 

Complex regional pain syndrome (CRPS), formerly known as Sudeck’s dystrophy or reflex sympathetic dystrophy (RSD). There are two types of CPRS. Type 1, where there is no nerve damage, and type 2, where there is nerve damage. CRPS mostly occurs in the arms and legs.

When you have CRPS, the hand is often swollen, red, hot or cold on touch, and the hand function can be severely restricted. It looks like the hand is inflamed and is accompanied with a lot of pain. CRPS can occur after surgery or after wearing a cast. Sometimes it occurs spontaneously.

Till now it is unknown why someone gets CRPS. It is also not visible on an X-ray or a scan. The diagnosis is made on the basis of symptoms, set by standardised criteria.

Regularly we see symptoms that resemble CRPS, but do not meet the criteria. We then call this vegetative dysregulation; the nervous system is dysregulated.

Hand therapeutic treatment
The hand therapeutic treatment aims at using the hand despite of the pain. We will do this with the help of mirror therapy. If, for example, the left hand is the affected hand, you will look at the mirror image of the right. The right hand looks after all like the healthy left hand, that moves easily and painlessly. With this technique we try to trick your brain into thinking that the affected left hand can be used normally and painlessly. And this will actually ensure that the affected hand to actually feels less painful and more mobile.

We advise you to use DMSO cream. A high dose of Vitamin C has been proven to reduce the risk of CRPS. However, you will have to start treatment immediately on the day of injury/surgery for it to be effective.

CANS is an abbreviation for complaints of arm, neck, and/or shoulder. The complaints can have multiple causes, but usually originate from a disbalance between the load and the load capacity. The complaints have often been preceded by a long period of executing repetitive movements, or maintaining a similar posture for a prolonged period of time. Long stretches of computer work, or long-term use of a smartphone are one of the many examples.

Hand therapeutic treatment
With CANS we will begin with investigating the cause of the complaints. What work or activities aggravate the complaints? Together we will take a look if we can reduce the load. In practice, this is easier said than done. Changing behaviour is incredibly difficult but certainly achievable!

Furthermore, we will also take a look at our load capacity. Is this disrupted and why? Sometimes an orthosis (brace/splint) can help to temporarily provide some rest for the hand or wrist. After which we can start rebuilding the load capacity with exercises.

If you have a skier’s thumb, then the collateral (inner) ligaments of the second joint of the thumb have been strained or ruptured. This joint (the MCP joint) has, just like the knee or ankle, ligaments on the inside and on the outside to stabilise the joint. A skier’s thumb usually (but definitely not always) arises after a skiing accident, hence the name.

Most of the time a skier’s thumb is caused by an acute injury, for instance a fall. It can also be caused by lateral repetitive strain at the tip of the thumb. This causes the ligaments to stretch out, until they reach a point where they do not fully support the joint anymore. This chronic form of skier’s thumb is known as a gamekeeper’s thumb.

You can recognise a skier’s thumb after an acute injury by the swelling around the joint. It will be difficult to encompass objects and perform pressure. For instance, opening a jar will be difficult, making the thumb feel instable.

Hand therapeutic treatment
If you have a skier’s thumb where the ligaments have been partially ruptured you will receive an orthosis (brace/splint), this will make sure that the MCP joint is stabilised (as can be seen on the picture). You will wear this for 4-8 weeks. The duration of the orthosis depends on how quickly the joint recovers, this varies per person. If the instability of the joint is caused by a slowly overstretched ligament, we will evaluate how you can use your thumb without putting too much pressure on the ligaments.

Sometimes the inner collateral band is completely ruptured, or a fragment of bone may have come loose. This is an indication for surgery. After surgery we can help you rehabilitate. You will firstly receive a cast and afterwards an orthosis (brace/splint) to protect the ligament. After approximately 4 weeks you will receive exercises to retrain the strength and flexibility of the thumb.

In the Netherlands there are approximately 10.000 rock climbers , of which 75% have had complaints of their hand, wrist, or arm. Rock climbers burden their hands tremendously, leading promptly to injuries. Common hand injuries amongst rock climbers are:

Partial or complete rupture of a pulley
A pulley is a small band that runs perpendicular over the tendon in the finger, there are multiple of these. When a pulley ruptures in the finger, you will usually feel it snap while you are climbing. After which you will experience pain on the palmar side of the finger. If a pulley ruptures when using an open hand grip the pain usually occurs between the middle and the farthest joint of the finger. When crimping it is usually lower, between the closer and the middle joint of the finger.

Treatment depends on the degree of damage of the pulley, this can be well-visualised on an ultrasound. We can make this ultrasound at SEDN, which is closeby.

Most commonly you will receive a small band or ring that protects the pulley and/or we will teach you a taping technique. When multiple pulleys have ruptured you might need to receive surgery to fix them.

Straining the flexor tendons of the finger
When the tendon sheath gets irritated because it has to deal with a heavy burden, we call this tendovaginitis of the flexor tendons. This is popularly known as climber’s finger.

Contrarily to a pulley rupture these complaints develop gradually. The tendons on the inside of the finger can get enlarged, and making a fist will be painful.  The flexor tendons can also be sensitive or painful to the touch. Inactivity/rest is the best solution, and changing your climbing technique will help with the recovery. Sometimes an anti-inflammatory injection will be given.

When a nodule (knot) develops in the tendon, it may occur that the finger starts to lock. We call this a trigger finger, and you can experience a thickening in the palm of your hand. You can read more about this under the heading: trigger finger.

Rupturing an intrinsic muscle of the hand
When you are hanging on one finger and you feel a little snap, it can be that one of the intrinsic hand muscles has ruptured. We call this a lumbrical tear or shift. This is easily diagnosed on an ultrasound. Your treatment will consist of medical taping and you will not be allowed to do any climbing holds using one finger only for 2-4 months.

Elbow injuries
Even though hand injuries are cause the most problems for climbers, elbow injuries are a strong second. Common are lateral epicondylitis; an injury due to overuse of the extensors of the wrist and fingers, these attach on the lateral (outer) side of the elbow. Medial epicondylitis also occurs often. This is an irritation on the medial (inner) side of the elbow, this is where the flexors of the wrist and fingers attach. When you suffer from elbow complaints, you may always contact us.

A distortion/sprain of the inner and outer ligaments of the finger joints, and fractures, occur commonly in young climbers.