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