What We Do

Trigger finger / thumb

Trigger finger (or trigger thumb) occurs when the tendons that bend the finger become thickened or develop a nodule and can no longer glide smoothly through the pulley system. Often there is a painful ‘locking’ of the finger in flexion, and movement can be limited.

The goal of therapy is to reduce the swelling and locking, allowing full, painless movement of the finger or thumb. Conservative treatment may include splinting, activity modification and anti- inflammatory medication.

Trigger thumb, although less common, occurs in babies and young children. In these cases referral to a paediatric hand surgeon is often required. Your therapist can assist you with this process.

Fractures

The bones of the hand are commonly broken from falls, direct sporting injuries, crush injuries or twisting forces. Many people think that a fracture is different from a break, but they are the same although there can be different variations and severities of a fracture.

Symptoms of a broken hand can include pain and tenderness, severe swelling, stiffness or difficulty moving the hand, and deformities.

X-rays are usually needed to diagnose the fracture and determine the treatment. Depending on the type of fracture, your doctor may recommend one of several treatment methods.

Some unstable fractures, in which the bone has moved, may need surgery with pins, plates or screws to hold he fracture in place.

Stable fractures can be managed in a thermoplastic splint. Your hand therapist can fabricate required splints / plasters and fiberglass casts and will provide you with a rehabilitation program to ensure you get the best possible functional outcome.

Carpal tunnel

Carpal tunnel syndrome is compression of the median nerve within the wrist. There is a space in the wrist called the carpal tunnel where the median nerve and nine tendons pass from the forearm into the hand. Carpal tunnel syndrome happens when there is pressure on this nerve within the tunnel.

Pressure on the nerve can be caused by swelling of the tendons, joint injuries or fractures, arthritis changes and even fluid build-up during pregnancy. Thyroid conditions, rheumatoid arthritis and diabetes can also be associated with carpal tunnel syndrome.

Compression of the median nerve can cause pain, numbness or tingling of the thumb and index and middle fingers, weak grip with a tendency to drop things.

The symptoms are usually noticed at night often waking the patient, but may also be noticed during daily.

The compression of the nerve is made worse at night by sleeping with the wrist in a bent position. Thermoplastic wrist splints can prevent this and in some cases alleviate pressure on the nerve.

Severe cases and those that do not respond to therapy may require surgery to make more room for the nerve. Hand therapy post-surgery is recommended to ensure optimal recovery of hand function.

Wounds / scar management

Everyone can heal differently and sometimes scars can be sensitive to touch, stuck down to structures underneath, or may thicken.

Therapists at Melbourne Hand Therapy have additional training in the area of wound and scar management. Treatment may help to soften the scar, improve the function and also the appearance of the scar.

Some people may develop keloid or hypertrophic scars.

What is a keloid scar or hypertrophic scar?

Keloids are the result of an overgrowth of scar tissue that usually develops after healing of a skin injury. The tissue extends beyond the borders of the original wound, does not usually resolve spontaneously, and tends to recur after its surgical removal.

In contrast, hypertrophic scars are characterized by raised lesions that typically do not expand beyond the boundaries of the initial injury and may partially settle. Hypertrophic scars are common after thermal injuries and other injuries that involve the deep dermis.

What causes a keloid or hypertrophic scar?

The exact cause of keloid and hypertrophic scars continue to be unknown as no specific gene has been identified. Trauma to the skin, both physical (eg, earlobe piercing, surgery) and pathological (eg, acne, chickenpox), is the primary cause identified for the development of keloids. The presence of foreign material, infection, hematoma, or increased skin tension can also lead to keloid or hypertrophic scar formation in susceptible individuals.

What are the signs and symptoms of a keloid or hypertrophic scar?

pressure earrings 2The cosmetic appearance of the scar is the main reason why people seek medical attention, rather than the symptoms which may include scar tenderness or itchiness. The appearance of a keloid scar is often a red, raised, thick scar which has grown beyond the original boundary of wound.

A hypertrophic scar is a widened scar that does not extend beyond the original boundaries of the wound.

Scar treatment is specifically tailored to the individual patient. It may be through pressure earrings, silicone gel treatment or specific advice aimed at softening the scar and improving the cosmetic appearance of the scar.

Nerve injuries and compressions

The team at Melbourne Hand Therapy are skilled in the evaluation and treatment of nerve injuries and compression syndromes.

Common symptoms may include pain, numbness and muscle weakness. Compression of a nerve can occur at some point over its course in the upper limb resulting in altered function of sensory nerve endings and weakness in muscles supplied by the nerve.

Evaluation:

Hand Therapists perform manual muscle tests and use grip and pinch strength equipment to evaluate muscle weakness. Cutaneous sensation is evaluated with non invasive tests such as Semmes Weinstein monofilament test and 2 point discrimination.

Treatment:

Some compression syndromes can be treated with conservative management such as manual techniques, activity modification and splinting. Compression syndromes that respond well to conservative management include carpal tunnel, cubital tunnel and radial tunnel syndrome. When surgery is required to repair or release a compressed nerve your therapist may involve a Surgeon in your care for the best management of your problem. 

Surgeons may also refer you to hand therapy postoperatively for specific treatment including exercises , scar management, desensitization and strengthening.

Tendon injuries

Tendons attach muscles to bone to transmit muscle force required for movement. Tendons can be injured in various ways including lacerations, ruptures and over use injuries. The tendons on the front of your hand are called flexor tendons and these bend the fingers and thumb. The tendons on the back of the hand are the extensor tendons and these straighten the fingers and thumb. The tendons lie just beneath the skin and as a result are vulnerable to laceration.

An injury to the tendons on either the back or front of the hand can make it impossible to move the fingers normally and and as a result impair hand function. Divided tendons can not heal until the two ends are brought together. This usually requires surgery and a period of protection in a thermoplastic splint. Your hand therapist will fabricate you a custom fit splint and advise in a hand therapy program to ensure you get the the best possible result. Your rehabilitation requires a balance between protecting the healing tendons whilst restoring tendon function. It usually takes up to 3 months to return to full duties and sport following a tendon repair.

Tennis elbow and golfer's elbow

tennis elbowTennis elbow and golfer's elbow are both conditions resulting from injury to the muscles of the forearm responsible for moving your fingers and wrist. Pain, however is felt with these conditions at the boney points of the elbow where the muscles attach. Pain associated with tennis elbow, often referred to as lateral epicondylitis, is felt on the lateral, or outside of the elbow whereas the pain from golfer's elbow is felt on the medial, or inside boney prominence of the elbow. This pain is a result of the tendon, the structure which attaches your forearm muscles to the bone, becoming inflamed in the early stages due to repetitive use of the muscle and the subsequent development of small tears. Overtime this may become chronic and it may become painful to grip or hold things, at rest or during activity, at this point there is no evidence to suggest the condition is inflammatory.

Both of these conditions are more often a result of overuse and/or degeneration of the tendon and not always linked to playing tennis or golf but can be from a range of activities from computer use to gardening. Management of these conditions is a fine balance between rest from aggravating activities and loading the damaged tendon to ensure adequate blood flow and repair of the damage. Therapy for both of these conditions aims to reduce pain and gradually increase the tolerable load and therefore function by a combination of modalities including massage, ultrasound, loading, strengthening and mobilisation.

Surgical review is indicated in certain cases. Your therapist will be able to guide you when and if a referral to a surgeon is required.

Dupuytren's disease

Dupuytrens DiseaseDupuytren’s contracture (named after French surgeon Baron Dupuytren) is a progressive hand condition that causes thickening of the tissue in the palm. Dupuytren’s affects the layer of tissue just under the skin and it develops an abnormal build up of collagen. This build up presents as a ‘cord’ or ‘nodule’. Over time the cord tightens and causes the finger/s to bend towards the palm and you will not be able to straighten them. The rate of progression can be different for everyone. The ring finger and little finger are most commonly affected, however any part of the hand can be affected. There is little evidence that dupuytren’s can be improved with conservative therapy and treatment options include surgical excision of the tissue called a ‘fasciectomy’, an enzyme injection (Ziaflex) which breaks down the cord or a needle fasciectomy which involves a small needle to cut through the cord. Following all treatment options, a period of hand therapy is normally required.

De quervains syndrome

DeQuervains SyndromeDe Quervain’s syndrome (or first dorsal compartment tendonitis) is a condition brought on by irritation or inflammation of two tendons of the thumb: Extensor Pollicis Brevis (EPB) and Abductor Pollicis Longus (APL). The inflammation causes the compartment around the tendon to swell and enlarge, making thumb and wrist movement painful. De Quervain’s can be the result of performing repetitive activity over time, sudden activity or direct trauma. It is a condition very commonly associated with new mothers caring for their baby. The main sign and symptom of De Quervain’s is pain over the thumb side of the wrist which can radiate up the forearm or down the thumb. Treatment for De Quervain’s includes splinting, education on activity modification and gradual resumption of regular activities. If symptoms do not improve, a corticosteroid injection or surgery may be recommended followed by a period of hand therapy.

Joint instabilities / dislocations

There are many joints in the hand and wrist. Each joint is made up of two or more bones that connect the skeleton together and allow movement to occur. They are lined with smooth cartilage to enable the bones to glide over each other and are supported by a number of ligaments. These ligaments help hold the bones together and prevent too much movement. When damaged, they do not stabilise the joint adequately therefore making the joint at risk of moving too far. If this happens, the joint is considered unstable. If the joint moves so far out of alignment, it is dislocated.
Joints that are dislocated often move back into alignment without help, however if this does not happen, a medical professional may need to correct this. Either way, the joint is now at risk of dislocating again as the soft tissue surrounding the joint (ligaments) have been damaged and need time to heal. Your hand therapist may need to make a thermoplastic splint or use buddy straps to help support the joint. Often an exercise program can be commenced immediately and will be customised for your particular needs. Once the joint is considered stable, a strengthening program will be commenced under the guidance of your hand therapist.
During your recovery, you will have regular appointments with your hand therapist who will monitor your progress and upgrade your program. They will also provide advice on when it is safe to return to activities such as sport and work.

Wrist Fractures

wrist fracturesThe wrist is actually made up of two joints; the distal radio-ulnar joint and the radio carpal joint. These two joints work together to ensure proper function of your hand.

Common fractures of the wrist come from a fall on outstretched hand (or FOOSH). The first thing you do when you fall is stick your hand out to catch yourself!

The most commonly broken bones in the wrist that break in a fall are the radius, the scaphoid and the ulna. Other bones in the wrist can also be fractured but this is less common.

Radius fractures are managed in two ways: conservatively or operatively.

Surgery involves an open reduction of the fracture (where the surgeon correctly positions the bones back to their normal position) and internal fixation (plates and screws to fix the bones in place while they heal) This procedure is known as an ORIF (Open Reduction, Internal Fixation). This is done in certain fractures where conservative management (position the bones under xray and put in a cast) might not be possible. An orthopaedic surgeon will usually make the decision to operate or not.

In many cases of distal radius fractures there is a small fracture through the tip of the ulna. If this is in a good position it is often left alone as it will heal well without surgery due to the strong ligaments and muscles that will hold it in place to allow it to heal.

Scaphoid fractures.

Scaphoid fracturesThe scaphoid is a little peanut shaped (use your imagination here!) bone which is in the unfortunate position of being the main weight transfer point from the hand into the forearm. Consequently it is commonly fractured in falls. In an interesting quirk of anatomy, the blood supply comes from the ‘wrong end’ from the bone to what you would expect. This means that the blood supply to the scaphoid can be very easily damaged in a relatively simple fracture. Getting an accurate xray of this small bone is sometimes difficult and a CT or MRI is not uncommon to check for difficult to spot fractures.

Surgery is a little less common in scaphoid fractures but involve a similar procedure to distal radius fractures, a screw or pin is used to maintain the fracture position to allow healing in a good position.
Hand therapy is always recommended following a wrist fracture regardless of surgical or non-surgical management. After your fracture, you will be immobilised in a cast for anywhere from 2 weeks to 6 months. This is all determined by the complexity of the fracture, the rate of healing and the surgeon’s orders (if you had surgery).

Once your period of immobilisation is over you will be very stiff. Don’t worry, this is normal! Hand therapists will initially give you exercises to regain your range of motion and then strengthening exercises that become more and more tailored to you and your needs.

Elbow dislocations or fractures

elbow fracturesOften when you see an orthopaedic doctor they use all manner or jargon that makes sense to us but can be very confusing at times. This little piece will make sure the next time your clinician starts talking about your minimally displaced, intra articular, medial epicondyle humeral fracture with metaphyseal involvement you’ll know exactly what they are talking about!

The elbow is actually composed of two joints each of which has particular movement associated with it:

  • The humero-ulnar joint - elbow flexion and extension (bending and straightening the elbow)
  • The proximal radioulnar joint - forearm pronation and supination (turning your hand so the the palm is up or down)

The most common place that an adult fractures their elbow is at the head and neck of the radius and the most common way to injure it is by Falling On an Outstretched Hand (FOOSH for short). This usually causes difficulty with rotation of your forearm.

Treatment for any fracture involves putting the ends of the fracture back next to each other (reduction) and then making sure they don’t move (fixation). This can be done surgically (pins, screws and plates) or conservatively (a cast and sling).

With either treatment option, early follow-up therapy is very important especially as the elbow is one of those joints that tends to stiffen up quite easily! Make sure to talk to your surgeon or doctor about what their rehabilitation plan is. If you’re unsure, just give us a call!

Dislocations

Dislocations are far less common in the elbow as it is a very stable joint where the bones fit together with a tight fit. In more high trauma accidents (such as car accidents or high impact sports) the head of the radius is the most commonly dislocated bone. Early physio is critical regardless of either a surgical or conservative intervention!

Amputations

Amputations can involve single digits or the entire hand. Amputations can be caused by trauma or elective surgery to manage disease. Loss of the tip of the finger is the most common type of amputation on the hand. These injuries usually have a very favourable outcome, although can initially be sensitive.

The fingers are sensory organs and we use touch to explore our environment. Grasp and fine motor movements are essential to manipulate our environment. Loss of even 1 digit can cause major functional loss, with the thumb, index and middle fingers being the most important to function.

Where possible the surgeons will attempt re-plantation and in some cases reconstruction procedures may be considered. The aim of hand therapy following amputation, re plantation or reconstruction is to regain movement and function as soon as possible and to assist the process of desensitisation.

Complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a chronic pain condition, which typically begins in the first 6 weeks to 6 months from the date of injury. It can arise from either, a minor trauma (type 1) or is associated with nerve damage (type 2).
The primary symptom of CRPS is producing high pain levels that are out of proportion to the stimulus that provoked it, or the initial injury. The pain often spreads throughout the affected limb and remains constant. The exaggerated pain levels CRPS produces has been described as an intense burning, pins and needles, squeezing, hot/cold and sharp pain.
Frequently accompanied with CRPS are visible changes to the surrounding soft tissue. There can be significant swelling or a glossiness to the skin, changes in skin color, blotching, skin atrophy and changes to the hair or nails. Due to the excessive pain there is usually a loss of motion, co-ordination and strength as the CRPS progresses.
Treatment for CRPS is often multidisciplinary and involves a combination of physical therapy, medications and psychological therapy to provide the individual with the best overall outcome.
Preventing CRPS is far easier than a cure, so don’t hesitate to book a consultation if you are concerned.

Shoulder instability

The shoulder is a very complex joint from a mechanical perspective. There are at least 15 muscles that act around it, as well as ligaments and 3 joints involved in stability around it! This complexity allows us to move our shoulder in almost every direction with excellent strength (forward, overhead and sideways). However if there is damage to the supporting ligaments in the shoulder (due to trauma or sometimes genetic pre-disposition) the shoulder can become unstable. This can manifest as something as simple as 'feeling unstable/weak' around the shoulder to repeated subluxations (popping in and out) or dislocations (popping out and staying out).

Management of shoulder instability consists of 6-12 weeks of strengthening of the shoulder muscles which are often weakened due to the instability around the shoulder. If this program is not successful we will give you advice regarding consulting with our excellent surgeons who we work closely with. The surgeon will then advise you on potential interventions to assist your shoulder stability.

Bursitis

BursitisBursa are small structures that exist all over the body where tendons are in close proximity to bones. They act as a protective buffer to prevent the bones from wearing away the tendon like sandpaper on a piece of wood. Bursa become injured most commonly due to a change in biomechanics around a joint that place more strain than usual on them. The sub-acromial bursa is the most commonly injured bursa in the shoulder.

Management of sub-acromial bursitis involves retraining the muscles of the shoulder girdle (the shoulder blade and its muscles) to off-load or rest the bursa as well as manual therapy for symptom relief. Additional interventions such as cortico-steroid injections may be indicated for symptoms management but are becoming less common now as newer research evidence has shown that their long term efficacy is limited.

Rotator Cuff Injuries

Rotator Cuff InjuriesThe shoulder joint gains movement and stability from the Rotator Cuff muscles. The Rotator Cuff comprises of four tendons (supraspinatus, infraspinatus, subscapularis and teres minor)

The Rotator cuff can be injured in a variety of ways:

  • tendinopathy
  • partial tendon tears
  • full thickness tendon tears

Physiotherapy for rotator cuff injuries aims at reducing pain, and gradually restoring function by optimising range of motion, and strengthening.

Physiotherapy input is indicated for tendinopathy and partial thickness tears, however surgery is often required for full thickness tears with post operative physiotherapy input.

AC Joint injuries

The AC compromises of the acromium (hook of shoulder blade) and clavicle (collar bone). Injuries to the AC joint are often caused by acute trauma such as a fall directly onto the side of the shoulder, or alternatively can be caused by overuse, such as excessive lifting (particularly overhead).

Mild to moderate sprains of the AC joint can be effectively managed by your physiotherapist. If multi-directional instability of the AC joint or complete dislocation of the AC joint has occurred then surgical stabilisation may be required. Your physiotherapist would therefore refer you to an orthopaedic shoulder specialist for opinion and management.

Adhesive Capsulitis (Frozen Shoulder)

Adhesive Capsulitis (commonly known as frozen shoulder) is a condition that often results in high levels of pain and reduced shoulder movement. This is caused by inflammation, scarring and tightening of the shoulder joint capsule.

Physiotherapy treatment of adhesive capsulitis often consists of a personalised exercise program in conjunction with hands on manual techniques if indicated. Your physiotherapist may refer you to an orthopaedic shoulder specialist if your symptoms are not progressing. Additional treatment options they may recommend include hydrodilitation, arthroscopic surgery, or manipulation under anaesthetic.