By Julia Guthart OTR, CHT
Mallet finger refers to a condition in which the end joint of a finger bends but will not straighten by itself. In this situation, the joint can be pushed straight, but will not hold that position on its own. This condition is also known as baseball finger because it most often occurs when a ball or other object strikes the tip of a straight finger. It can also occur from jamming the finger into an object or when the fingertip is forcibly pushed down while the person is trying to straighten their finger. When this occurs the tendon which pulls on the end bone to straighten the finger (extensor tendon) pulls one way, and the force on the end of the fingertip pulls the other way, and something comes apart in between. This is accompanied by swelling, pain, redness, and/or bruising in addition to the drooping fingertip.
Many people just ignore this injury and shrug it off to a jammed finger and believe that it will get better when the swelling subsides. However, this is a myth which often leads to permanent deformity and discomfort. Without proper treatment, the appearance and ability to
straighten the end joint of the finger will not improve. The first step in treating a mallet finger is to apply ice to the finger immediately after injury and continue for about 15 minutes every two hours for the first few days. The hand with the injured finger should also be elevated above the heart to minimize swelling. It is highly recommended that X-rays and medical advice be obtained within a week of injuring the finger to determine whether the finger is fractured or out of alignment. In certain instances, surgery is needed to reattach bone or realign the joint.
Most mallet fingers can be treated by simply splinting the fingertip in extension and leaving it in this position for 6-8 weeks. This is so the extensor tendon can fully heal back to the bone but this can only occur with continuous splint wear. The splint may be removed for hygiene purposes daily, but during this time the fingertip must be supported in full extension to protect the healing tendon. Hand therapy is indicated in some situations where the finger becomes stiff after the tendon has healed.
Why is Physical Therapy Important to Your Recovery
You have just seen your orthopaedic specialist for your physical problem and the doctor has prescribed physical therapy as part of your treatment plan. The first thing you should do is call to schedule an appointment for a physical therapy evaluation as soon as possible. The reasons to start physical therapy are three fold:
- The quicker your physical injury is addressed and treatment started, the faster your recovery should progress. Just like with your automobile you wouldn’t delay seeing a mechanic for an engine problem and the chance of it getting worse.
- Your doctor has placed a high priority that physical therapy will help with your problem.
- Your doctor has a high expectation that the course of physical therapy prescribed will be completed upon your follow up appointment. This will help make decisions on your further care.
What to Expect of Your First Physical Therapy Visit?
Your first visit will range in time, but plan for about an hour for your evaluation with a licensed physical or occupational therapist. Remember to wear or bring clothes that will permit the therapist to visually see the involved area. The first step will be a short discussion of your injury from the first day to the present. Your verbal account is a huge plus to be able to formulate what may be your problem. Most injuries or pathologies follow a certain pattern or response and the ability of the patient and the clinician to communicate this is a great help to the physical part of the evaluation.
Next, your clinician will perform the physical part of your evaluation. This will consist of visual observation, movement of the affected area, testing
your strength, stability, etc. This is done to zero in on what your active problem is and how together we are going to facilitate your recovery. After your evaluation, a discussion between yourself and the clinician will answer your questions as to what is wrong and the type of treatment that will take care of your problem. An explanation on what to expect and the probable timeframe of recovery will also be discussed. Think of it as a team effort between you, your doctor, and your therapist to reach your rehab goals.
Every treatment plan is tailored to the individual patient to include instruction on exercises and activities to be done at home. Remember each session builds on itself with advancement of your treatment program and that is why it is of great importance to attend physical therapy for the duration as determined by your evaluation.
One Last Word Most physical problems don’t get better on their own. Delaying your therapy or choosing not to attend, only adds time to your normal recovery. The most common reasons that people begin physical therapy at JOI Rehabilitation are:
- Multiple sites to cover a large geographic area close to your home or work for your convenience.
- Hours Monday-Saturday, with both early morning and late evening hours available.
- An experienced staff of orthopaedic therapists that commonly treat your problem.
- Close communications and access to your referring doctor
Adhesive Capsulitis (Frozen Shoulder)
Adhesive Capsulitis is a painful restriction of active and passive movement of the shoulder. Adhesions form in the capsule and limit overall joint space. There is a higher incidence in females between the ages 40-60 years old. The onset of idiopathic frozen shoulder is associated with extended immobilization, mild trauma and surgical trauma (breast or chest wall procedures). Diabetes, hyperthyroidism, inflammatory arthritis and ischemic heart disease are medical conditions associated with adhesive capsulitis. The most significant association is with insulindependent diabetes. There is a 10% chance of adhesive capsulitis affecting both arms. Adhesive capsulitis is characterized by three stages.
The first stage is the freezing phase. This stage typically lasts 3-6 months. An onset of aching pain in the shoulder begins, with pain being more severe at night and with activities. Pain at rest is common during this stage. The pain often radiates down the outside of the arm. Holding your arm close to your body is the most comfortable position although it worsens the freezing process.
The second stage is the frozen phase. This phase can last 3-18 months. Activities of daily living such as reaching in your back pocket, fastening your bra, grooming your hair and washing the opposite shoulder become severely restricted and painful. Sharp pain will accompany these movements. Pain at rest usually diminishes during this stage.
The final stage is the thawing phase. The stage is characterized by a slow recovery of motion. This stage can last 3-6 months. Adhesive capsulitis is thought to be a “self limiting” process which can be severely disabling for months to years. Aggressive treatment is necessary once the diagnosis is made. Physical therapy helps regain shoulder motion, decrease pain and inflammation. Anti-inflammatory medications, corticosteroid injections and other modalities are used to decrease pain and inflammation. The focus for regaining shoulder motion is stretching at range of motion limits. Stretching exercises should be performed three to five times per day with a sustained stretch of 15-30 seconds at the end range of motion. Strengthening is initiated when the shoulder motion and pain are improved.
Manual Therapy in Orthopaedic Rehabilitation
When most people think of physical therapy, they think of stretching and strengthening exercises, ultrasound, electrical stimulation, etc. Physical Therapy may also include manual treatment to augment a patient’s care. Manual therapy is any treatment that requires the practitioner to use their hands on the involved area of the body to aide or accelerate the healing process. Studies indicate that the addition of manual therapy to a therapeutic exercise program significantly increases the recovery rate of patients when compared to patients treated strictly with therapeutic exercise. The type of manual therapy incorporated in the rehabilitation of orthopaedic and sport injuries may include any of the following:
- Soft Tissue Mobilization – to break up scar tissue and increase muscle, tendon or ligament pliability
- Massage – to decrease pain and swelling in the involved area
- Manual Traction – to separate involved joint surfaces and decrease pain and swelling
- Manual Stretching – to increase the length of muscles and tendons
- Joint Mobilization/Manipulation – to decrease pain in irritated joints and increase the mobility of stiff joints
For injuries that require more specialized manual treatment, JOI offers therapists with post-professional certification in orthopeadic manual therapy. Certification requires approximately two years of training followed by a comprehensive examination. Manual therapy is an important part of a comprehensive rehabilitation program. Ask your therapist how manual therapy can help you.
Injuries Related to Instrumental Musicians
Professional musicians require the extremes of coordination and endurance… much like professional athletes. Musicians are required to practice for hours and hours a day followed by peak performances. Many of these performances are outdoors and not in the best environment (think cold Christmas concerts or air conditioned music halls). Musicians are at risk for developing overuse injuries, nerve entrapment syndromes and ganglion cysts.
An overuse injury is a condition when any body tissue is physically stressed beyond it’s physiologic limits. It may be acute (after a specific event) or chronic ( the onset of symptoms gets worse over time). Musician’s overuse injuries are classified in five levels. Grade 1 means pain at one body site only while playing an instrument; Grade 2 means pain at multiple body sites; Grade 3 means pain that persists long after musician has stopped playing. With Grade 4 the musician experiences pain during specific activities of daily living (such as opening jars or brushing teeth). With Grade 5 all activities of daily living cause pain if using the involved upper limb.
Common diagnoses of overuse injuries include: trigger finger or trigger thumb, tendonitis, bursitis, DeQuervain’s tendonitis. Musicians experiencing the above symptoms should seek medical advice from their physician. A referral to a Certified Hand Therapist or an Occupational Therapist is often beneficial.
This professional can apply modalities to decrease inflammation and for pain relief. Recovery is more complete and quicker if addressed while in Grade 1 to 3. Pain avoidance or rest is the most important phase. Splinting helps rest the injured area; and the splint can be removed for stretching exercises to avoid stiffness. Biofeedback while playing the instrument is often helpful to assess areas of over activity. Also, video feedback assists with posture and technique awareness.
In my experience, musicians are also at risk for developing nerve entrapment syndromes such as carpal tunnel syndrome, cubital tunnel syndrome, digital nerve compression, thoracic outlet syndrome and Temporo-mandibular Joint disorder (TMJ). A nerve conduction velocity and/or an eletromyelogram test is often ordered to determine the site where the nerve is pinched or if there are multiple sites of compression of the nerve involved ( “double crush”). Again, I believe treatment may involve splinting to avoid positions of compression, biofeedback to assess playing techniques, video feedback and medications. Musicians are at risk for developing ganglion cysts on the back (dorsum) of the wrist due to extreme wrist flexion required for certain instruments. These cysts need to be diagnosed and treated by a physician.
The professional musician should be aware of the risk factors for developing the above problems. Risk factors include: training errors, a change in instrument, change in teacher or style, quality of instrument, inadequate rehabilitation of prior injuries, improper body mechanics, non-musical activities (especially excessive computer use), environmental factors and anatomic variations in individuals. If a musician is experiencing any of the above problems, he or she should evaluate if any of the risk factors has occurred. Professional musicians train and perform much like professional athletes. Their bodies are required to perform extreme feats of coordination and endurance. If they are experiencing a nagging pain, it should not be ignored. In conclusion, musicians should be aware of all of these risk factors in their hands and fingers.
- To schedule a new patient or follow up patient appointment with your MD, please call (904)JOI-2000 or read more here about our orthopedic telemedicine providers.
- To schedule an appointment for physical or occupational therapy, call 904-858-7045 or call any of the 12 area JOI Rehab Centers.
JOI Fracture and Injury Care
JOI Physicians are currently offering ASAP Fracture care. Make an appointment by calling (904)JOI-2000. This is a new option for patients who would like to avoid the emergency room if they have suffered a fracture or soft tissue injury. To learn more about this service, read this article about fracture and injury care.