Wrist & Hand Injury in Sports

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1 Wrist & Hand Injury in Sports Jennifer Allen,PT,DPT,OCS,SCS,CHT Return to Play Criteria, Clinical Pearls, & Rehab Considerations PBATS Baseball Medicine Conference 2018

2 Disclosures

3 Wrist & Hand Injury in Sports Agenda: Common Injuries in Baseball & Softball Rehabilitation Considerations Clinical Pearls for Wrist & Hand Return to Play Criteria 3

4 Rehabilitation of the Hand 6 th Edition Upwards of 25% of all Sports Injuries are injuries to the wrist and hand Berger, R. Rehabilitation of the Hand (2010)

5 Epidemiology & Effect of Sliding Injuries in Major and Minor League Baseball 1/336 slides results in injury of some type 25.3% of all injuries Hand/Fingers 31.3% of Hand/Finger Injuries Require Surgery Camp, C., et al. Am Journal Sports Medicine (2017)

6 Baseball & Softball injuries: Elbow, Wrist & Hand *Hook of Hamate Fracture *Thumb UCL Injury Hand/Finger Fracture *Mallet Finger Flexor Tendon Injuries Flexor Pulley Injuries Adductor Pollicis Longus Injury *TFCC Tears Scapholunate Ligament Tear Extensor Carpi Ulnaris Instability Ulnar Head Subluxation Ulnar Impaction Syndrome Digital Ischemia/Microvascular Trauma Bouttonniere Deformity Trehan, S., et al. J Hand Surg Am (April 2015)

7 Hook of Hamate Fracture in Competitive Baseball Players Baseball Cause: - Repetitive Swinging/Batting - Rogue Pitches Main Points: - High rate of non-union with conservative care - Surgical repair with Ulnar Nerve Decompression (Guyon Canal) - Return to play Avg 5.7 wks (Baseball) Bachoura, B., et al. Hand (2013) 7

8 Hook of Hamate Fracture (Surgical Excision) Rehabilitation Considerations: Prognosis: Good for return to pre-injury status with surgical management [Bachoura, A. et al. (Hand 2013)] Timeline: Median Return to play timeline 6wks, full strength 6mos 14% 12wks + return to play 25% incidence of short term postop complications [Bansal, A., et al. J Hand Surg Am (2017)] 8

9 Hook of Hamate Post-op Rehab Surgical Excision of Hook Immobilization Period Immediate Mobilization 2wks Strengthening-RTP 3-6wks - Cast Immobilization days - Physician Dependent - General Conditioning - Cardio - Intensity based on edema/pain - Wrist ROM - Digital ROM - Desensitization - Edema Reduction - Strengthening Progression - Desensitization - Padding for RTP - Sport Specific 6wks 9

10 Clinical Pearls: Hook of Hamate Post Surgery *Early desensitization over scar to decrease hypersensitivity 3min, 3x/day *Scar mobilization and Ulnar Nerve Glides to improve soft tissue mobility *Silicone gel pads, relief foam pads, padded batting gloves for return to activity.

11 Hand Rehabilitation/Hamate Silicone Cupping Hamate Pad Hamate Dry Needling

12 Mallet Finger Rehabilitation Considerations: Non-Op Splinting: Prognosis good with compliance Continuous splinting of DIP in full extension/hyperextension Minimum 6wks, up to 10+wks 12

13 Mallet Finger Post-Op Rehabilitation Considerations: Post-Op Stabilization: Surgery Indicated with 1/3 of articular surface fx Prognosis good for full return ***No difference in long term outcomes noted surgery vs non surg, night splinting vs none Bloom, J., et al. Plastic and Reconstructive Surgery (2013) 13

14 Mallet Finger Progression Non-Op Management Operative Management PROM (Both) Strength/Function - Splinting 6-10wks - No Passive DIP flexion after splinting for additional 4wks - Start AROM with MD approval when splinting ceases - K Wire Fixation/or other - Immobilized up to 6wks - Then follow protocol same as non-operative - Generally started 4 wks after splinting is discontinued - Watch for Extensor Lag - Strength Progression - Goal is Functional ROM and minimal Extensor Lag - Progress timeline with PROM 14

15 Clinical Pearls: Mallet Finger *Skin breakdown is one cause of poor outcomes in treating Mallet Finger. Less skin breakdown with custom splints. (Mallet Mender, Thermoplastic custom) Valdes, K., et al. Journal of Hand Therapy (2015) *Athletes must keep DIP in extension when washing hands, etc. Loss of extension results in restart of the timeline.

16 Hand Rehabilitation- Mallet Finger 16

17 Triangular Fibrocartilage Complex Tears Rehabilitation Considerations: (TFCC) TFCC Components: - TFC Disc (poor healing capability) - Meniscus Homologue - Radioulnar ligaments - Sheath of Extensor Carpi Ulnaris - Ulnar Collateral Ligament - Ulnolunate and Ulnotriquetral ligaments Symptoms: - Ulnar sided Wrist Pain - Clicking/Popping, Instability - Pain with weight bearing 17

18 Triangular Fibrocartilage Complex (TFCC) Tears Rehabilitation Considerations: - Traumatic vs Degenerative - Prognosis: - Trial of Conservative Care is Recommended - Chronic Injuries respond less favorably to conservative care - Surgical repair recommended for high level athletes - Instability DRUJ recommend surgical repair Brownstein, B., et al Cinahl Clinical Review (2018) 18

19 TFCC Management Conservative Care: Surgical Intervention: - For degenerative tears, sedentary patient - Type IA tears (Central Perforation), may heal due to vascularity (Baseball) - Patients without DRUJ instability - Time? In season? - Return to play varied (weeks-months) - Recommended for high level athletes not responding to conservative care - Tear of TFCC with Instability DRUJ - Return to play avg 3.3 months No Baseball Specific outcome comparison studies conservative care vs surgical repair Brownstein, B., et al. Cinahl Clinical Review (2018) 19

20 TFCC Tear Management Conservative RX TFCC Arthroscopic Debrid TFCC Repair Ulnar Shortening - Splint 4-6wks - Modalities - ROM, jt mobilization - Splinting PRN after - Splint 1-2 wks post op - ROM, jt mobilization - Strengthening 4wks+ - Athlete return to sport - Splint 4-8 wks - ROM, edema control, scar management when splint removed - Ulnar Impaction - 1-6wks immobilization - ROM, edema reduction, scar management initial 6wks - Strengthening when pain decreases specific activity 6wks - Strengthening - Athlete return to sport 12wks (avoid impact) week return to activity 20

21 Clinical Pearls: TFCC Rehabilitation *Restore Supination ROM loss in Supination is associated with poor functional outcomes *Start Strengthening first in Supination, Then in wrist Neutral, followed by Pronation. The ulnar sided wrist forces are the least in Supination and the most in the Pronated position. Using this progression will decrease strain in that region as it heals. Brownstein, B., et al. Cinahl Clinical Review (2018)

22 TFCC Clinical Tools:

23 Thumb UCL Injury Rehabilitation Considerations: Grade I Injury- Painful but stable Grade II Injury- Painful with some laxity, possible fracture Grade III Injury- Painful, severe laxity, fracture (it s over) Partial tears- conservative trial Complete tear or Stener Lesion, surgical intervention recommended Stener Lesion: Torn UCL is pulled out from aponeurosis of adductor pollicis and gets trapped 23

24 UCL Thumb Injury Timelines Non Surgical (acute/partial) Surgical Repair Surgical Reconstruction Return to Play - Cast/Functional Splint 2-4wks - Thumb must be stable in flexion for good outcome - Rehab- key pinch first, delay tip pinch and full grip for up to 8wks - Stability is most important - Ligamentous repair of structure then - Splinting x 4wks - Flex/Ext ROM first 4-6wks - Slow strength return with protection of repair - 12 wk return to activity - Recommend splinting for return to activity - Similar to Ligamentous repair - Indicated for Chronic Tears - Palmaris/Plantaris grafts - Slow strength/function progression - Taping - Splinting- short thumb spica - Soft splints available - Slow return- stability most important, avoid early stressors 24

25 Clinical Pearls: Thumb UCL Injury *In rehabilitation of the Thumb UCL injury, ligament protection and joint stability are #1 Priority. * Start with Key Pinch Strengthening first, then slowly progress to Tip pinch and full grip strengthening around weeks Splinting recommended for return to play. Tsiouri, C., et al. Hand(2009)

26 Key Pinch

27 Isolated Extension 27

28 Intrinsic Strengthening 28

29 Intrinsic Strengthening 29

30 Tendon Gliding Exercises (Edema & Mobility) 30

31 Hand Rehabilitation 31

32 Grip Testing- Jamar Technique Matters: - 90/90 position - Position Number 2 gives most consistent results - Max grip strength - Age/Sex Normative Data Available -Trampisch, U., et al. J Hand Surgery (2012) 32

33 Functional ROM in affected Digit/Joints Healing Timeline/Structure Dependent Grip Strength 20psi needed for ADLS Pinch Strength- 5-7psi Needed for ADLS Hand & Wrist Return to Play Criteria Grip Strength: Goal <15% R vs L, Return to sport at 25% Pain Tolerance (Splinting, taping, padding) Psychological Factors, Fear Sport Demands Specific to Athlete s Injury 33

34 Contact Info Jen Allen,PT,DPT,OCS,SCS,CHT Bodycentral PT Ultimate Sports Asylum 1991 E Ajo Way, Ste 149 Tucson, AZ 85713

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