What body part has 27 bones, 33 muscles and 30 joints and can fit in your pocket? If you answered the hand, you are right! The hand is one of the most important parts of our body for survival. It is one of the factors that make us “human” and different from other animal species. Often, we don’t think about the hand and its integral role in daily life. However, once you are injured, you realize how essential hands are to perform daily routines including eating, drinking, writing, dressing, opening up containers, etc. We strengthen our core, shoulders and legs, but we may not think about strengthening the hand and wrist for function and in the prevention of repetitive stress injuries. Yet, hand strengthening is a necessity, especially as one ages.
Hand and wrist anatomy is complex. Eight carpal bones and two forearm bones called the radius and ulna make up the wrist. The radius is often broken in falls on an outstretched hand, which is called a distal Radius Fracture or Colles Fracture. Wrist motions include wrist extension/flexion (bending the wrist up/down) supination/pronation (turning the palm up/down) and radial/ulnar deviation (turning the wrist towards and away from the body with the palm down). Normal use and function of the hands depend on the muscles acting on the wrist along with the fingers. Grasp is weaker with wrist flexion than with wrist extension. One must use the wrist extensors on the dorsal side of the hand to hold objects securely. Thus, the wrist extensors need strengthening for hand stability and skilled handling. In addition, radial/ulnar deviation and pronation/supination contribute to many functional tasks including opening jars, eating soup, driving and applying make up. We should not neglect strengthening these motions via the use of weights, bands, putty or grippers.
There are many factors that contribute to the increased incidence of hand and wrist injuries as we age. Prolonged rest leads to muscle atrophy and decreased joint mobility, which can cause debilitation as we age. Also, we subject our hands to more stress and strain over the years than we realize. Repetition, vibration, forceful exertions, localized contact stress, eccentric overload to muscles, low temperatures, specific postures and poor technique all contribute to heightened risk. Since skeletal muscle and nerve structures begin to deteriorate between 50 and 60 years of age, many hand conditions and repetitive stress injuries become more prevalent as we age. These conditions include Carpal Tunnel Syndrome, trigger fingers, DeQuervains Disease and Medial/Lateral Epicondylitis. (To read Alex Allan's excellent overview of Lateral Epicondylitis, click on "related articles" at right.) In addition, as we age, our grip strength as well as our dexterity and fine motor coordination decreases. This is why grip strengthening is so important. By learning about these conditions, you can help to prevent them and maximize your clients' ability to function in daily life. Adding specific wrist and hand exercises to workouts is important as we need 20 pounds of grip strength to perform daily tasks and five to seven pounds of pinch strength to function. Having more strength is always an asset. Here is a brief description of each of the conditions I just mentioned.
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome is a repetitive stress injury resulting from compression of the median nerve as it passes through the carpal tunnel. The Carpal Tunnel is located in the palm by the wrist. It is highly sensitive, as many nerves and tendons run throughout it which control hand sensation and motor function of the small muscles in the hand. When it is compressed through constant bending, numbness and tingling are experienced in the thumb, index, middle and part of the ring fingers. Examples of people at risk for this condition include restaurant servers who carry trays with extended wrists, people who do repetitive work at computers or women who knit. Clients may complain of weakness and dropping objects. It is important to avoid sustained abnormal postures such as wrist flexion with ulnar deviation and wrist hyperextension to prevent this condition. However, it can also develop along with post traumatic changes such as a wrist fracture or systemic changes such as diabetes, pregnancy or thyroid imbalances. It is important to note how your clients hold weights or grasp equipment handles when doing cardiovascular exercise. They should be held in a neutral posture with about 20 degrees of wrist extension.
Lateral Epicondylitis is more commonly known as tennis elbow. It is a condition involving a lesion in the extensor structures which originate at the lateral epicondyle, resulting from dynamic overload of the musculotendinous unit. The extensor tendons extend the wrist and fingers. The muscle most affected is the extensor carpi radialis brevis, but secondary muscles may include the extensor digitorum communis and extensor carpi radialis longus, which extend the wrist and fingers. Activities such as turning door knobs, lifting groceries or suitcases, pouring from a pitcher, using a screwdriver or hammer or ironing can be causative factors. It is characterized by pain and tenderness by the lateral epicondyle of the elbow. Sometimes forearm pain is presented along with pain in the ring and long fingers. Risk factors include age and hormonal imbalances as well as inadequate strength, endurance and flexibility of the extensor muscles. Although tennis elbow is associated with racquet sports such as tennis, the condition can result from other sports such as swimming, fencing and baseball.
Medial Epicondylitis is a less common condition that refers to inflammation on the opposite side of the elbow where the flexor tendons arise. Also commonly known as Golfers Elbow, it is caused by repeated strain from overuse of the flexor/pronator muscles including the flexor carpi radialis and pronator teres. Forceful pronation and wrist flexion combined through activities such as swinging a golf club can be causative factors.
Trigger finger is also a repetitive stress injury which results from gripping objects too tightly in the palm of the hand. Inflammation is felt in the palm and may cause a locking of the fingers with an inability to extend them. Direct, severe and multiple trauma to the flexor portion of the fingers (palm) are factors. The thumb, long and ring fingers are most commonly effected. There may be pain with grasp.
De Quervains Disease
De Quervains Disease is an inflammation of the long tendons that originate in the elbow lateral epicondyle and abduct the thumb. Pain and swelling is felt where these tendons cross the wrist to go to the thumb at the wrist radial styloid. Again, this condition is related to repetitive activities of the thumb including twisting and pinching activities such as wringing out a towel. Electronic device assembly or grocery scanning requires pinching and ulnar deviation of the wrist, which can contribute to this condition.
Fitness professionals can play a role in preventing these conditions by recognizing risk factors during exercise sessions, noting any complaints of symptoms and referring clients to medical providers. In addition, you can be involved by strengthening the wrist and hand musculature on a regular basis.
Tips to Help Clients
- The further the arm is away from the body, the greater the stress to the arm, creating significant biomechanical disadvantage. Bring the work closer to you. This especially includes lifting free weights. That is why stable strengthening equipment can be safer at times.
- Temperature extremes increase vulnerability to cumulative trauma. Therefore, adequate aerobic warm-ups of three to five minutes are extremely important before doing outdoor activities and working in cold weather. Outdoor workers should wear anti-vibration gloves if working with vibratory equipment.
- Strengthen the shoulder external rotators and scapular muscles including the supraspinatus, infraspinatus, teres minor, rhomboids and middle trapezius musculature. Proximal stability comes before distal control, meaning you must strengthen the muscles supporting the arm at the shoulder. This does not mean ignoring the wrist and hand. Equally strengthen all muscle groups of the upper extremity. However, focus needs to be placed on the small muscles of the wrist and hand for forearm pronation/supination, wrist flexion/extension, wrist radial/ulnar deviation and finger and hand strengthening.
- When seated at a desk, clients should have the head directly over the shoulders, with the shoulders down and chest open. The natural curve in the back should be maintained. Elbows should be held in a relaxed posture at about 90 degrees with the wrists in neutral. Feet should be firmly planted on the floor. Computer screens should be at eye level and the keyboard flat. When sleeping, place hands elevated on a small pillow to prevent a flexed wrist posture.
- Avoid sustained pinch/grip, particularly pinching with wrist flexion.
- Use a power grip when possible. For example, hold a weight with all fingers and thumb tucked under. Be sure to keep the wrist in neutral.
- When lifting heavy objects, bend with both knees, keeping objects close to the body and holding with palms up.
- Watch for correct posture. Make sure clients are seated with hips and knees at 90 degrees and ears aligned above the shoulders when performing wrist and hand exercises.
- If a client has been discharged from occupational or physical therapy, start with light weights in a gravity eliminated position if pain is still an issue. Consult with his therapist to find appropriate exercises to transition from therapy to exercise programs.
- Refer clients to medical professionals if you note symptoms that worsen.
- Avoid repetitive use of the wrist and encourage clients to take frequent breaks and stretch tightened muscles including the pectoralis major/minor, latissmus dorsi, wrist flexion/extensors and the hand.
- Incorporate more of the arm - which is stronger when turning nuts and bolts - to avoid strain.
- General conditioning can have a positive effect on mental attitude as well as increasing cardiovascular conditioning. Also, it increases systemic blood flow, promoting healing, strengthening uninjured muscles and increasing lower extremity and trunk endurance, which can be a contributor to the condition (relying too heavily on the upper body for power and control). Options can include stationary bikes, stair climbing, treadmills or cross trainers.
Fitness professionals can be a great asset to clients in both recognizing the risk factors for many of these conditions and implementing fitness regimens that are preventative in nature.
- Hand Care 2000: Hand Therapy in the New Millennium. Indianapolis, Indiana.
- Hunter, J. Rehabilitation of the Hand: Surgery and Therapy (1995). St. Louis, Missouri.
- King, C and Gonzalez-King, Z (1999) Orthopedic Assessment and Review of Common Upper Extremity Pathologies Advanced Rehabilitation Services Inc. Marietta, Georgia.