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Joint Mobilization of the Wrist

 

Athletes as well as non-athletes depend on their hands, wrists and fingers for proper strength, grip and range of motion for athletic performance.  For non-athletes who use their hands and wrists frequently such as computer programmers, writers, artists, quilters and machinist, wrist flexibility and proper biomechanics are an integral part of preventing secondary inflammation from the shearing forces of the tendons moving across malaligned bony structures.

The wrist anatomy is studied in medical school and therapy schools, however the importance of this anatomy has never been emphasized in the therapist’s practice. Presently, we are relying on too many modalities such as ice, heat and ultra sound, as well as, manual therapy techniques to mobilize the wrist joint back to functional flexibility.

Additionally, medications are over utilized for pain in these extremities. These medications are utilized in hopes of reaching areas of poor blood supply as noted in joint physiology.

Bracing, including wrist supports, only conforms to postural abnormalities and led to further tightness that result in capsulitis, tendinosis, loss of flexibility and function.

For golfers having strength in the fourth and fifth fingers allows for proper tension in the grip. Weakness of the last two tendons creates an over tightening of the grip in the index/middle finger/thumb complex.

Baseball pitchers require full flexibility of the wrists in accelerating the ball in the overhand throwing mechanism. Balanced strength across all tendons is important for proper control as velocity is increased.

In baseball hitting, the wrist movement has to be quick and non-restricted allowing tendons full flexibility to be an effective hitter. Any malalignments of the tendons across the wrists lead to greater strains across the elbow commonly termed medial and lateral epicondylitis or more commonly known as tennis and golfer’s elbow.

Musicians, such as drummers, who rely on the fourth and fifth finger’s strength to play the drums as well as guitarists who strum with all five fingers, need to have a very flexible wrist aligned across the proper biomechanics through the movements.

Most athletic activities require the use of holding an instrument or releasing an object. 

To perform these tasks, the athlete needs to have optimal wrist mechanics, flexibility, grip and finger strength.

In 2003, my 14-year-old son was a promising young golfer who was in the process of developing his swing mechanics. He was being taught by a professional PGA instructor, who noted my son's potential and was pleased with his progress.

At the time, he was undergoing growth spurts and he was provided with sessions of myofascial release to promote flexibility during the growth stages. Flexibility was important to reduce secondary tendonitis and tightness that are normally associated with the growth process.

Unfortunately, one day my son went to a roller blade arena for a party and a small child lost his balance near him causing my son to lose his balance and he fell backward with his left arm extended. There was a loud audible crack as he landed on the floor with immediate pain.

He was immediately taken to an emergency room where it was revealed that he had a spiral fracture of the two large bones of his forearm, the radius ulna with an additional small fracture of the distal tip of ulnar-styloid process. Fortunately, due to having full wrist flexibility prior to the fall, my son sustained only spiral fractures that were non-displaced and recovery was ensured.

If his flexibility was not optimal, this traumatic fall would have pulled the tendon at the bony attachment possibly causing a displaced fracture or even a compound fracture. Again, flexibility cannot be underestimated in preventing secondary injuries or extension towards more devastating injuries.

In the emergency room, my son was casted from the proximal forearm through the carpal bones of the wrist including the first proximal knuckles of his fingers. This allowed for movement only of his fingertips. Every two weeks he underwent x-rays that showed excellent healing.

Finally, after seven weeks, the x-rays revealed that full healing had occurred. As the cast was removed, I was very optimistic for a 100% recovery until my son looked at me and said, “ My wrist doesn’t move”, and showed me only a 10-degree range of motion through the wrist joint, of the expected 90 degrees.

At first, I was not dismayed at the lack of range of motion. I rationalized that this secondary tightness that could be corrected through aggressive physical therapy. Therefore, my son underwent traditional physical therapy, including myofascial release, flexibility, icing with some improvement in range of motion but only to 30% of expected normal.

I accompanied him to various medical specialists, who after examining him and reviewing the x-rays found no structural abnormalities.  Again, everyone reassured us that with continued physical therapy and force outcomes would be obtained.

Unfortunately, weeks went by with no significant improvement with a lot of discomfort for my son. As he tried to grab the gold club, his mechanics changed immediately, as well as, with any impact of the golf club was painful causing him to drop the golf club..

Having exhausted all the available resources of therapy, physicians and medications, I chose to review my anatomy studying books dating back to the 1930’s, which focused on kinesiology of movement and the physics of the wrist bone and movement.

I found that there were many tests identifying shifting of bones causing malalignments. Various researcher names were attached to these tests. Diagrams of lines and vectors showing which way the wrist bone moved held promise that there was some opportunity to influence these bones and reset them such that the tendons would glide better and full motion could be obtained.

Day after day I approached my son with experimental joint mobilization movements, most of which seemed barbaric to him and painful. This continued for a few weeks to the point that may son was putting his hands in his pockets to discourage me from further experimentation.

Finally, after weeks of study, preparation, and experimentation, I was at a point of frustration and concern. 

Approximately three months after the broken wrist, my son was having his cousins for a sleepover and the music was too loud at 2:30 in the morning. Angry that I was awakened, I got out of bed in order to reprimand them for playing the music so loud.

As I came upstairs, my son noted my eminent anger and as a compromise he willingly extended his wrist, hoping to pacify me with further experimentation. He offered his wrist and asked that I try his wrist mobilization again.

At this point, I closed my eyes reflecting back on the anatomy and the vectors that were shown to me in the various books and taking a deep breath tried to visualize this in my mind. After multiple movements similar to manipulating a Rubik’s cube, I stopped and my son cheerfully said, “Look dad, you fixed my wrist”, showing me that he had 95% range of motion restored to him. Additionally, he remarked that the pain that was tight across his wrist had subsided considerably.

At once I recognized that a gift was given to me for all my efforts of study. I tried as best as I could to memorize what I had done. I started writing some notes to myself regarding the joint mobilization and the next morning I awoke with renewed enthusiasm of the gained knowledge. 

Over the course of the next few months I perfected my technique of joint mobilization in repositioning the carpal bones to their proper anatomical position.

This technique has allowed me access to multiple professional athletes within the PGA, Major League Baseball, National Football League, National Hockey League, tennis as well as well-known entertainers who were drummers and guitarists.

I have applied this technique to individuals who previously did not experience any wrist pain; however, I was able to identify malalignments through a screening process. Recently, I was able to change the performance of baseball pitchers at a high school and college level for improved control and velocity in the pitching mechanics.

To summarize the technique of wrist mobilization, first one has to understand the wrist and hand anatomy. Two large bones, proximal to the wrist are the radius and ulna.

In 40% of individuals the radius is slightly longer than the ulna although that has no bearing on wrist mobilization. The distal end of the ulna does not connect or articulate with any of the wrist bones, and has been shown that surgical removal at the distal end did not impair wrist motion.

Normal wrist motions are noted as 0-80 degrees of flexion, 0-70 degrees of extension, 0-30 degrees of ulnar abduction and 0-20 of radial abduction. The difference in radial and ulnar abduction and flexion of 10 degrees are attributed to ligaments being more slack on the dorsal side than the palmer side. Remembering functional anatomy, the palm of the hand needs to be more stable than the dorsum or the extensors of the hand, which are much more flexible.

The wrist also rotates in the form of pronation and supination. This rotation occurs at the proximal radial ulnar joint. With the elbow flexed, 0-90 degrees of pronation and 0-90 degrees of supination are expected.

Out of the eight carpal bones in the wrist, there is only one muscle that inserts into them and that is the flexor carpi ulnaris muscle inserting into a small carpal bone, the pisiform.

The radius and ulna are connected by a cartilage. The radius has two shallow indentations at its distal end to which the two carpal bones articulate being the lunate and scaphoid. The ulna does not have any facets therefore there are not any carpal bones that attach to the ulna.


The carpal bones or wrist bones glide like a carnival ship. The capsule is elastic; the ligaments are somewhat laxed to allow for gliding back and forth. Collateral ligaments limit the movements of ulnar and radial deviation. 

Rotation, supination and pronation are limited by tightening of the palmer and dorsal ligament. Of all the bones in the wrists, only the second and third metacarpals are fixed to their base almost to the point of immobility.

The carpal or wrist bones are divided into two rows-proximal and distal. The more proximal row starting from the thumb to the little finger includes the scaphoid, lunate, triquetrum and pisiform.

The distal bones of the wrist joint starting from the thumb to the little finger are the trapezium, trapezoid, capitate and hamate.

Of all the proximal and distal carpal bones only the lunate dislocates posteriorly or palmarly. The rest of the bones dislocate dorsally. The scaphoid bone has the greatest mobility, up to one centimeter in movement.

There is a large thick band of fibrous tissue, called the flexor retinaculum that extends from the scaphoid to the pisiform in the proximal row.  This band encases multiple tendons, ligaments, blood and nerve supply to the hand through this tunnel called the carpal tunnel.  Any inflammation of structures under this retinacular band can lead to impingement and result in a condition termed carpal tunnel syndrome.

To assess alignment of the carpal bones, one examines the distal flexor digit attachments of each finger. In the fifth finger or the little finger, opposition of thumb to the little finger at the distal interphalangeal joint is done successfully with proper alignment of the triquetrum and pisiform bones.

Weakness in ring finger’s opposition to the thumb results from malalignment of triquetrum and lunate.  Weakness in the third finger’s opposition to the thumb indicated a malalignment of the scaphoid and lunate combination; whereas, weakness of the index finger’s opposition to the thumb is a malalignment of the scaphoid bone. The proximal row has greater movement by malalignment than the distal row.

To evaluate these oppositional weaknesses resulting from malaligned carpal bones, the examiner asks the person to position one fingertip to oppose the thumb tip.  The examiner positions their little finger in the area made by this opposition and the palm of the hand. 

The examiner gradually pulls his little finger to break the circle made by finger opposition.  If through moderate pulling, the examiner is able to break this circle of opposition, then this suggests a high clinical suspicion for malaligned

Another examination technique is to have the palm and fingers in neutral position, then flex only the distal digits onto the palm crease. This should be done where the tip of the finger is placed flat against the palm.

Any space between the fingertip and palm can be directly attributable to malalignment or secondary tightness of the extensor tendons. This is commonly seen in individuals who have used their knuckles and wrist with excessive force such as boxers and football players.

A test for malalignment can be done with the distal digits flexed against the palm is done.   With the examiner pulling away at the distal digits forcibly and with little or moderate strength, malaligned tendons and bones cause weakness and separation of the distal tip of the finger away from the palm is accomplished.

The third evaluation is to look at flexor and extensor range of motion through the wrist. This motion is dictated by the radial carpal joint and mid carpal joint. Wrist dorsi-flexion occurs at the mid-carpal joint first and then the radial carpal joint. Wrist palmar-flexion is centers primarily through the radial-carpal joint.  Any subluxations or malalignments can lead to loss of full flexibility.

The following is an approach of joint mobilization that I found to be successful.

Have the person hold their arm palms down in a neutral position that the fingers, wrist and forearms are in a neutral plane. Ask the person to relax while you stabilize the forearm.  Place your thumb and index finger just distal to the radius and ulna on to flexor and extensor retinaculum.

The first joint to be mobilized is the lunate by bringing pressure between the radius and ulna towards the middle finger. Then continue with applying pressure between the radius and scaphoid and then going laterally towards the ulnar triquetrum to relieving the tightness and allows to bring the proximal carpal row towards the distal row.

Once the ligaments have been mobilized and the lunate repositioned back to place, pronate the hand towards 90 degrees with the thumb upwards and put pressure at the trapezium and scaphoid while retracting the thumb towards yourself.

At the same time, put pressure downward to reposition the trapezium and scaphoid back under the thumb. Usually, when repositioning of bones occurs, one can hear an audible pop, which represents tension being and bones repositioned.

Once the proximal row has been mobilized and manipulated successfully from the thumb to the index, middle, ring and fifth finger, retract on the metacarpal phalangeal joint in a neutral position with slight force to separate the metacarpals from the distal row. This release allows the distal row to realign itself as the proximal row has already been repositioned.

Once the metacarpals have been adjusted then the proximal and distal phalanges can be retracted to a neutral position similar to what a child does when he pulls his fingers and causes his joints to “pop”.

The next step is to recheck whether the carpal rows are gliding without resistance.  Grasp the hand as if you were shaking hands. Ask the patient to relax while you glide his hand in abduction of the radius then abduction of the ulna swinging it up and down to see if there is proper gliding.

Should any resistance be encountered, it may indicate that further mobilization of the proximal row needs to be repeated.  The scaphoid-trapezium complex more often is much more difficult than the triquetrum-pisiform complex.

Again, return back to the proximal row and retract the proximal row starting with the lunate, scaphoid and triquetrum. Then using your index and thumb grab the triquetrum moving it gently up and down in a palmar-dorsal movement to try to loosen the ligaments and create a fluid movement without resistance in this proximal carpal row.

The same can be done by grasping the scaphoid/trapezium complex, mobilizing it palmarly and dorsally until a glide can be established without resistance.

Complete this repositioning by releasing the metacarpal phalangeals and distal phalangeals. Finalize with the handshake abduction motion of the radius and ulna to ensure that these proximal carpals are properly repositioned.

Checking the success of the joint mobilization, one must have functional flexion-extension flexibility of the wrist as well as strength in opposition of the thumb against the index, middle, ring and little finger against moderate resistance one should not be able to break this finger opposition against moderate pull.

Finally, one can  also assess the success of mobilization in the distal flexors of the fingertips. Placing the palm and fingers in a neutral position where the tips of the digits should touch the palm at the palmer creases and any attempt by the examiner to forced resistance to the pull the distal digits away becomes difficult against moderate pulling.   Return of strength of the distal flexors occurs in response to proper repositioning of the carpal bones.

This technique should be done without any trauma or excessive force. In my experience, there have been no adverse consequences as a result of this of joint mobilization technique. This technique can easily be taught and can be successful in a duration of less than two minutes.

 

Should you have any further questions regarding this article, please direct your questions or comments to "Ask the Doctor" section.

 

Copyright © 2004 - 2012Taras V. Kochno, M.D.  All Rights Reserved
Board Certified in Physical Medicine and Rehabilitation

 

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