Nerve entrapments, wrist, and hand conditions

Nerve entrapments at the elbow and forearm

These entrapments occur at the elbow and forearm. Baseline care is acetaminophen or NSAIDs and phase-appropriate physical therapy, and the entries below note only what differs.

• Nerve entrapments
  • Median nerve entrapment
    • Tightness of the pronator teres muscle and under the superficial head of the flexor digitorum superficialis secondary to repetitive gripping activities
    • Symptoms
      • Pain, numbness, tingling, and weakness in the median nerve distribution in the forearm and below
    • Diagnosis
      • Clinical presentation
      • Manual muscle test of forearm muscles
      • Positive Tinel’s over the pronator teres
  • Radial nerve entrapment
    • Entrapment of the posterior interosseous nerve within the radial tunnel as a result of overhead activities and throwing
    • Symptoms
      • Aching over the lateral/dorsal proximal forearm, which can mimic lateral epicondylalgia
      • Radial tunnel syndrome causes pain without true motor weakness; weakness of finger and thumb extension (wrist extension relatively spared) means posterior interosseous nerve syndrome, a more severe compression
      • Typically no numbness or tingling, because the posterior interosseous nerve is a motor nerve
    • Diagnosis
      • Clinical presentation
      • Manual muscle test of forearm muscles
      • Positive Tinel’s over the radial tunnel
  • Wartenberg syndrome (cheiralgia paresthetica)
    • A purely sensory neuropathy from compression of the superficial branch of the radial nerve at the distal forearm or wrist
    • Symptoms
      • Pain, numbness, or paresthesia over the dorsoradial hand
  • Ulnar nerve entrapment
    • Compression or trauma at the cubital tunnel, thickened retinaculum, or hypertrophy of the flexor carpi ulnaris muscle
    • Symptoms
      • Medial elbow pain
      • Pain, numbness, tingling, and weakness in the ulnar nerve distribution in the forearm and below
    • Diagnosis
      • Clinical presentation
      • Manual muscle test of forearm muscles
      • Positive Tinel’s over the cubital tunnel
  • Ulnar tunnel (Guyon canal) syndrome
    • Entrapment of the ulnar nerve at the wrist
    • Symptoms
      • Sensory loss is usually limited to the palmar side of the ring (half) and little fingers, with numbness in the little finger and half of the ring finger
      • Weakness or atrophy of the small hand muscles, which can progress to clawing of the fourth and fifth digits
    • Diagnosis
      • Froment’s sign tests the ulnar-innervated adductor pollicis: the patient pinches a sheet of paper between thumb and index finger, and thumb interphalangeal flexion (the median-innervated flexor pollicis longus substituting) indicates ulnar nerve weakness
      • The Allen test only checks radial and ulnar artery patency and does not test this nerve
  • Physical therapy management for all nerve entrapments
    • Early interventions - rest, modalities to reduce inflammation/pain
    • Nerve glides matched to the entrapped nerve (median, radial, or ulnar), progressing tension gradually along the nerve’s pathway
    • Night splinting as appropriate
    • Functional training
    • Patient education

PTA role: collect objective findings (Tinel’s, manual muscle testing, sensation) rather than diagnosing, and report new or worsening neural signs to the supervising PT. Stop nerve glides and report if a patient develops increased or lasting paresthesia during or after treatment.

Contrasting conditions of wrist and hand

Carpal tunnel syndrome

Compression of the median nerve at the carpal tunnel at the wrist due to swelling of the finger flexor tendons that share the tunnel or inflammation of the median nerve. Caused by repetitive wrist motions; other causes may be pregnancy, diabetes, or rheumatoid arthritis.

• Symptoms
  • Numbness and tingling in the thumb, index, and middle fingers
  • Early carpal tunnel syndrome typically causes nighttime numbness and tingling, often relieved by shaking the hand, because many people sleep with the wrist bent; weakness and wasting of the thenar muscles at the base of the thumb signals severe, advanced compression
  • Pain, often described as burning, aching, or electric shock-like
  • Sensitivity to cold or touch
  • Weakness in the hand, especially when gripping or making fine movements
  • Clumsiness or difficulty with tasks like buttoning clothes or writing
  • Dropping objects
• Diagnosis
  • Clinical presentation
    • Special tests
      • Tinel’s
      • Phalen’s
  • Electrodiagnostic testing - tests if a nerve signal is moving and its speed
• Physical therapy management
  • Range of motion, strengthening
  • Corrections of biomechanical causes
  • Functional exercises
  • Wrist splint in neutral, especially at night (first-line for all patients, including during pregnancy); median nerve and tendon glides

Distinguishing carpal tunnel syndrome from pronator teres syndrome (median nerve entrapment at the forearm): both compress the median nerve and can cause similar hand numbness, but the location of the entrapment changes the clinical picture. Carpal tunnel syndrome entraps the nerve at the wrist - Tinel’s and Phalen’s are positive there, palm sensation is usually spared (the palmar cutaneous branch splits off before the carpal tunnel), and symptoms often wake the patient at night. Pronator teres syndrome entraps the nerve in the proximal forearm - Tinel’s is positive over the pronator teres, numbness can include the thenar eminence and palm, symptoms worsen with resisted pronation, Phalen’s is usually negative, and night waking is uncommon. The distinction matters for treatment: carpal tunnel syndrome responds to a wrist splint, while pronator teres syndrome calls for addressing forearm/pronator mechanics instead.

De Quervain’s tenosynovitis

Inflammation of the extensor pollicis brevis and abductor pollicis longus due to repetitive microtrauma or pregnancy.

• Symptoms
  • Pain at the base of the thumb that radiates into the forearm.
  • Swelling and tenderness on the thumb side of the wrist.
  • A feeling of catching or snapping when moving the thumb or wrist.
  • Pain or stiffness when grasping, pinching, or extending the thumb.
  • Difficulty gripping or holding objects.
  • Occasionally, numbness or tingling on the back of the thumb from irritation of the nearby superficial radial nerve; palm-side numbness of the thumb, index, and middle fingers points to carpal tunnel syndrome instead.
• Diagnosis
  • Clinical presentation
    • Special tests
      • Finkelstein’s test
  • MRI is rarely needed; it’s reserved for atypical presentations, since this is usually a clinical diagnosis
• Physical therapy management
  • Range of motion, strengthening
  • Corrections of biomechanical causes
  • Functional exercises
  • Thumb spica splint (first-line, including during pregnancy)

Intersection syndrome

Intersection syndrome is an inflammatory tenosynovitis where the first and second dorsal compartments cross, with pain approximately 4 to 6 cm proximal to Lister tubercle; de Quervain tenosynovitis is more distal, with tenderness at the radial styloid.

Colles fracture

Fracture causing posterior displacement of the distal radius with radial shift of the wrist and hand. Most common fracture from falling on an outstretched hand with the wrist in extension and radial deviation. Can cause median nerve damage if edema is unmanaged.

• Symptoms
  • Sharp, immediate pain, especially when bending or gripping the wrist.
  • Pronounced swelling and bruising around the wrist.
  • The wrist may appear bent or crooked, often resembling a “dinner fork”.
• Diagnosis
  • Clinical presentation
  • X-ray
• Medical management
  • Immobilization for 5-8 weeks in a position opposite the injury, wrist flexion and ulnar deviation
• Physical therapy management
  • After removal of the cast
    • Range of motion, gaining wrist extension is most important before strengthening
    • Pain, edema control
    • Use of modalities as appropriate
    • Functional exercises

Stop and report to the supervising PT: new or increasing median nerve numbness or tingling, or disproportionate pain, color or temperature change, or swelling - these can signal complex regional pain syndrome.

Scaphoid fracture

Due to falling onto an outstretched hand. This is the most common fractured carpal bone.

• Symptoms
  • Pain located in the anatomical snuff box and weakness on the thumb side of the wrist, especially when gripping or pinching objects.
• Diagnosis
  • Clinical presentation
    • Initial X-ray may be negative; snuffbox tenderness is treated as a presumed fracture (thumb spica) with repeat imaging
  • X-ray
• Medical management
  • Immobilization for 6-8 weeks due to poor blood supply to this bone
  • The scaphoid’s retrograde blood supply puts the proximal pole at risk of avascular necrosis and nonunion
• Physical therapy management
  • Before cast removal
    • Range of motion of the joints proximal and distal to the immobilized wrist/thumb (shoulder, elbow, fingers) to maintain pre-injury flexibility
  • After removal of the cast
    • Range of motion, strengthening
    • Pain, edema control
    • Use of modalities as appropriate
    • Functional exercises

Dupuytren’s contracture

Contracture of the palmar fascia leading to flexion of the digits towards the palm. Common in the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the fourth and fifth digits in non-diabetic patients and the third and fourth digits in diabetic patients.

• Symptoms
  • Small, hard lumps in the palm, often near the base of the ring or little finger.
  • Thickened bands of tissue that run from the nodules to the fingers.
  • The affected fingers are gradually pulled into a bent position, making it difficult to straighten them out.
• Diagnosis
  • Clinical presentation
• Medical management
  • Wound care may be indicated
  • Surgery may be indicated
• Physical therapy management
  • Splinting
  • Flexibility exercises
  • Restoration of normal hand function

Boutonnière deformity

Rupture of the central tendon slip of the extensor hood. Commonly occurs after trauma to the hand or with the diagnosis of rheumatoid arthritis. Deformity noted is flexion of the PIP with hyperextension of the DIP (the MCP is usually neutral or hyperextended).

• Symptoms
  • Deformity as noted above
• Diagnosis
  • Clinical presentation
• Medical management
  • Management of rheumatoid arthritis
• Physical therapy management
  • Splinting
  • Taping
  • Flexibility exercises

Swan neck deformity

Contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons. Commonly occurs after trauma to the hand or with the diagnosis of rheumatoid arthritis. Deformity noted is MCP neutral or flexed, PIP hyperextended, and DIP flexed.

• Symptoms
  • Deformity as noted above
• Diagnosis
  • Clinical presentation
  • Possibly x-ray imaging (rarely used)
  • Intrinsic tightness (Bunnell-Littler) test: passive PIP flexion is compared with the MCP joint extended and then flexed; intrinsic muscle tightness limits PIP flexion with the MCP extended and improves when the MCP is flexed, while extrinsic extensor tightness shows the reverse (PIP flexion improves with the MCP extended and worsens when it is flexed); no change with MCP position suggests capsular restriction at the PIP joint
• Medical management
  • Management of rheumatoid arthritis
• Physical therapy management
  • Splinting
  • Taping
  • Flexibility exercises

Mallet finger

Rupture or avulsion of the extensor tendon at its insertion into the distal phalanx digit. Commonly occurs after trauma, forcing the distal phalanx into a flexed position. Deformity noted is flexion of the DIP.

• Symptoms
  • Deformity as noted above
• Diagnosis
  • Clinical presentation
  • X-ray to check for a bony avulsion fragment of the distal phalanx or joint misalignment, either of which can change management (MRI is rarely needed)
• Physical therapy management
  • Continuous splinting of the DIP in extension (or slight hyperextension) for about 6-8 weeks; the DIP must not flex during this period, including when the splint is removed for skin care
  • Active range of motion of the uninvolved PIP and MCP joints to prevent stiffness
  • Night splinting and gradual DIP motion after the continuous-splinting period

Ape hand deformity

Median nerve dysfunction causes thenar muscle weakness with the first digit moving dorsally until it becomes aligned with the second digit.

• Symptoms
  • Inability to move the thumb in and out of the palm
  • Inability to oppose the thumb
  • Weak flexion at the base of the thumb (flexor pollicis brevis, a thenar muscle); thumb extension is spared, because the thumb extensors (extensor pollicis longus and brevis) are supplied by the radial nerve
  • Sensory loss or tingling in the thumb
  • With a high (elbow-level or above) median nerve lesion only: weakened forearm pronation, finger flexion, and bending of the thumb tip (flexor pollicis longus)
• Diagnosis
  • Clinical presentation
  • Electrodiagnostics
• Physical therapy management
  • Splinting
  • Taping
  • Flexibility exercises
  • Functional strengthening and coordination activities

Lunotriquetral dissociation

The lunotriquetral ballottement test holds the lunate still while the examiner moves the triquetrum volarly and dorsally; pain or more motion than the uninjured wrist suggests lunotriquetral dissociation.

Extensor carpi ulnaris (ECU) tendon subluxation

ECU tendon subluxation causes a painful snap or click on the ulnar side of the wrist as the tendon slips out of the ulnar groove with forearm supination, wrist flexion and ulnar deviation; it is a different problem from the radial-side scaphoid instability that the Watson test checks.