| Hand osteoarthritis |
> Background
Hand osteoarthritis (MA) is a highly prevalent condition that can affect multiple joints, affecting the quality of life of a significant portion of the population. It is more common in women than in men and its prevalence increases with age. It experiences a typically slow progression but can be debilitating. AM is a degenerative joint disease. As for the role of inflammation, it remains controversial.
> Clinical characteristics
Symptoms of AM typically include pain, stiffness, and decreased range of motion. Although heterogeneous, AM usually involves the carpometacarpal joint of the thumb. In patients with AM, it is common to find firm nodules and swelling on the dorsal aspects of the distal interphalangeal joints (Heberden’s nodes) or proximal interphalangeal joints (Bouchard’s nodes).
There is often pain at the base of the thumb that usually worsens with activity. As the disease progresses, pain appears when opening jars, turning doorknobs, or performing fine motor activities. Patients may also lose grip strength. In the presence of prominent Bouchard or Heberden nodules there may be pain at these sites and the patient often complains of aesthetic dissatisfaction with the appearance of their hands.
> Physical examination
Physical examination findings depend on the severity and stage of the disease. At first, the exam may be relatively benign, with normal range of motion. As the disease progresses, the range of motion of the thumb (or other joints) decreases. The grind test can also be useful in determining the presence of arthritis of the carpometacarpal joint.
It is performed by holding the metacarpal bone of the thumb and moving the thumb in a circle while applying gentle axial pressure. The test is positive when sudden, sharp pain appears. The examiner may also feel crepitus during the maneuver. Grip strength may also be reduced, compared to the contralateral side. A deformity with enlargement of the base of the thumb can also be visualized.
> Diagnostic tests
The diagnosis of AM can be made on the basis of history and physical examination, without imaging, but x-rays are likely to show joint space narrowing, osteophyte formation, subchondral sclerosis, and subchondral cyst formation.
Ultrasound or MRI have no role in the standard workup of AM unless the presentation is atypical. Previous trauma, prolonged morning stiffness that worsens rapidly, or swelling evident on physical examination may indicate alternative diagnoses that require further investigation.
> Treatment
Patients should be educated about the essentials, regardless of the severity of the disease. This education should include resources that describe the nature and course of the disease, along with self-care guidelines.
It is important to apply a multidisciplinary approach, especially for severe cases. Targeted physical therapy and exercises can help, although it is unclear how much relief is achieved compared to other osteoarthritic joints.
Splinting may also be considered. Pharmacologic analgesic options include oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs), capsaicin, or acetaminophen.
Intra-articular injection of corticosteroids is also an option, especially in those who have ≥2 joints causing their morbidity. Surgery is an option for some patients with refractory disease.
Clinical care points
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| Carpal tunnel syndrome |
> Background
Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. The nerve is damaged at the site of its passage through narrow spaces. In the case of CTS, the median nerve is compressed as it passes through the carpal tunnel, which is made up of the wrist bones, transverse carpal ligament, median nerve, and digital flexor tendons.
The overall prevalence is unknown, but some estimate that 10% of the general population will develop CTS at some point in their lives. There is a strong female predominance of the disease and the risk increases with age.
Risk factors for CTS include diabetes, menopause, pregnancy, hypothyroidism, obesity, and repetitive wrist activities, including the use of vibrating tools.
When evaluating patients with hand numbness as a chief complaint, providers should rely on history and physical examination to distinguish between localized nerve entrapment corresponding to STCF, a polyneuropathy (due to an alternative cause such as vitamin B12 deficiency, or diabetes) and cervical radiculopathy.
> Clinical characteristics
Initially, patients with CTS report intermittent nocturnal symptoms that include some or all of the following: pain, numbness, tingling, and paresthesias. As the disease progresses, the frequency of these episodes increases and they begin to occur during the day. Finally, there is loss of sensation, muscle weakness and atrophy.
Usually, discomfort is felt in the area of the hand innervated by the median nerve, palmar aspect of the thumb, index finger, middle finger, and the radial half of the fourth finger. In practice, symptoms can vary in location and include the entire hand, be located at the wrist, or radiate proximally to the forearm, upper arm, and even the shoulder. Patients may wake up with symptoms that force them to reach for relief. This sign is 93% sensitive and 96% specific for CTS.
> Physical examination
Before focusing on the hand and wrist, it is important to evaluate other causes of neuropathic symptoms, including examination of other peripheral nerves, the entire upper extremity, and the neck. The Spurling test is performed by rotating the head and extending the neck.
An axial load is then applied to the head. If it causes a shock-like sensation, it suggests radicular syndrome and not CTS. This alternative diagnosis may be supported by decreased or absent deep tendon reflexes.
In severe cases of CTS, inspection of the palm may reveal thenar atrophy. There are several provocative maneuvers that can be used to evaluate the presence of CTS. Performing more than one maneuver increases the precision of the evaluation.
All maneuvers attempt to temporarily exacerbate the entrapment and are positive if the symptoms reproduce. Carpal tunnel percussion is called the Tinel test. The Phalen test is passive palmar flexion of the wrist while extending the elbow for 1 minute. The wrist compression test is done by passively flexing the wrist while direct pressure is applied to the carpal tunnel. This test appears to have the highest sensitivity and specificity.
> Diagnosis
The diagnosis of typical CTS can be made clinically without additional testing. When the diagnosis is in doubt or alternative diagnoses are suspected, nerve conduction studies may be helpful. Although electrophysiological evaluation is relatively sensitive, it may be negative in up to one-third of patients with mild entrapment, even if the symptoms are severe.
Ultrasound is a study that is increasingly used for diagnosis. This modality can be used to measure nerve cross-sectional area, which has been closely related to disease severity (a measurement >9 mm2 is both sensitive and specific for CTS).
> Treatment
Management of CTS depends on the severity of the disease. In mild to moderate cases, where there has been no impact on muscle strength, it is reasonable to apply conservative, non-invasive measures.
First, the least invasive and lowest risk intervention is to educate the patient about the cause of their illness and advise them to limit repetitive wrist movements, reduce heavy work activities, and adopt ergonomically friendly habits. Other non-invasive measures include splinting the wrist to reduce flexion and extension. This splinting limits the increase in pressure in the carpal tunnel. Initially, a splint can be worn all the time (as it may improve symptoms more quickly), but it can lead to muscle weakness secondary to disuse, and dependence on the splint.
Steroid injection is a non-surgical alternative. This procedure can be performed under ultrasound guidance and reduce symptoms and surgery rate at 1 year compared to placebo, although the majority of patients in this study underwent surgery (73% vs 92%). Other non-surgical alternatives, such as laser therapy and therapeutic ultrasound, are available, but more studies are needed to demonstrate their effectiveness.
For severe disease, surgical decompression is recommended. Before referral for surgical evaluation, nerve conduction testing is recommended. Referral to a specialist is indicated when a patient with severe CTS presents with muscle weakness and/or atrophy or has persistent symptoms despite conservative management for 6 weeks.
Clinical care points
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| Ganglion cysts |
> Background
A common, benign cause of nodules on the hand or wrist is ganglion cysts. They usually occur in people between 20-40 years old with a female predominance. These cysts are usually located adjacent to the tendons or joints, being more common on the dorsal aspect of the wrist (70%) than on the volar aspect (20%). The cysts are filled with thick fluid and there is usually a communication between the cysts and the tendon sheath or joint, through a stalk.
> Clinical manifestations
Most patients consult about the cyst after it has existed for months or years. They are usually asymptomatic, although they can sometimes cause discomfort, depending on the location and size. Cyst size typically fluctuates and may be related to activity. It is unusual for a cyst to continue to grow in size.
> Physical examination
It is not uncommon for a patient to report a mass that is not evident to the examiner at the time of presentation due to size fluctuations. It may become more prominent with wrist flexion or extension. When present, the cyst is usually uniform, smooth, firm, painless, and translucent to light. It is also minimally mobile.
> Diagnosis
The diagnosis of a ganglion cyst is made clinically. X-rays are only necessary if an underlying bone condition is suspected. Other imaging, such as MRI or ultrasound, should be reserved for patients with unusual history (continuous growth, trauma, or constant pain) or atypical semiology (unusual location, multilobular, masses).
> Treatment
The previous practice of direct trauma to induce rupture is now obsolete. Since most cysts are asymptomatic, reassuring the patient is usually sufficient. There is a relatively high rate of spontaneous resolution (40%–58%) within 6 years of diagnosis. Therefore, if there is discomfort, conservative management with immobilization and oral analgesia will be done, which can offer relief until the cyst decreases in size or resolves. For persistent symptoms, aspiration alone or aspiration with corticosteroid injection may offer relief, although there are high recurrence rates. It should be noted that since the liquid is usually quite viscous, it is recommended to use a large gauge needle. Another possibility for these patients is surgical excision in the hands of an experienced surgeon. This approach is associated with a low recurrence rate.
| Points of clinical attention Ganglion cysts are usually asymptomatic nodules that fluctuate in size and are found on the dorsal aspect of the wrist. Imaging is not needed for diagnosis unless the cyst is continuously growing or multilobulated. It is important to reassure the patient since many cysts resolve spontaneously. |
| plantar fasciitis |
> Background
Plantar fasciitis is the most common cause of heel pain and is present at some point in the lives of 10% of the general population. Risk factors include a body mass index >27, running, or prolonged standing. It is considered an overuse injury, causing degenerative changes, including micro-tears in the contracted fascia. Therefore, the name is a misnomer because inflammation is low.
> Clinical characteristics
Patients complain of pain in the anteromedial part of the heel. It is characterized by being acute, with worsening upon initiation of ambulation, after a period of rest (such as upon waking up in the morning or after sitting for a long time). The pain gradually improves with activity. It is usually preceded by changes in your walking routine, such as starting a new exercise regimen or wearing new shoes. Numbness or paresthesias are unusual symptoms.
> Physical examination
On physical examination, patients are tender to palpation on the medial side of the calcaneus. Forced dorsiflexion of the toes at the metatarsophalangeal joints while the ankle is stabilized may also cause pain. The grind test can also help with diagnosis. This maneuver is insensitive but specific. The physical examination should be aimed at seeking an alternative diagnosis, such as a stress fracture of the calcaneus. Squeezing the posterior third of the calcaneus, between the thumb and index finger, (calcaneal compression test) should not cause pain and may help rule out a stress fracture of the calcaneus.
> Diagnosis
Plantar fasciitis is a clinical diagnosis. Imaging is reserved for patients who do not improve or who have an atypical history or semiologic signs indicating a possible underlying bone condition, such as a stress fracture.
Treatment
It is important to emphasize to the patient that there is no quick fix. Treatment is usually prolonged and the symptoms take months to disappear. In the vast majority (80%) of patients, symptoms resolve with conservative treatment, using analgesics and exercises. It is important to identify and modify behavior that may have contributed to the condition.
Patients should avoid walking barefoot, including showering, for which they can use folded washcloths to maintain the arch. Basic stretching can be accomplished at home. A simple way is to roll a tennis ball under the arch of your foot. For patients who do not improve, the benefit of more invasive interventions is unclear.
A Cochrane review found that corticosteroid injection may provide minimal relief for 1 month, but there is no difference in the long term. As for other degenerative conditions, treatment with platelet-rich plasma (PRP) injections has been proposed. A recent review of 15 studies comparing PRP and corticosteroid injection showed that PRP was effective in reducing pain at 6 and 12 months.
In the short term, there was no difference between the 2 groups. If the symptoms are severe and affect daily activities or the patient is opposed to conservative treatments, after a few months they should be referred to a foot and ankle specialist. If neurological symptoms or signs, numbness, or paresthesia are present, additional imaging or other studies should be performed. The same criteria are used if there is a pathological bone condition, such as a suspected calcaneal stress fracture.
Clinical care points
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| Onychomycosis |
> Background
Onychomycosis is a common toenail disorder that has an estimated prevalence of 6%-14% in the general population, with higher prevalence in warm, humid climates. It is caused by an infection of the toenail by dermatophytes, non-dermatophyte molds or yeasts. There is a greater prevalence of onychomycosis in older age or when there is a family history of oychomycosis, immunosuppression, diabetes, peripheral vascular disease, tinea pedis , and smoking. The use of occlusive footwear also contributes to the development of the condition.
> Clinical characteristics
Patients with onychomycosis have toenails that are discolored (yellow, white, or brown), thick, brittle, and separated from the nail bed (onycholysis). The infection is usually limited and primarily a cosmetic condition, but can occasionally cause pain and even affect the ability to ambulate.
> Diagnosis
The characteristic appearance of the toenails raises clinical suspicion of onychomycosis. Most experts recommend confirming the diagnosis with bedside testing with potassium hydroxide (KOH) preparation microscopy of the nail clipping followed by culture of the fungus. Other techniques are also available, such as histopathology, polymerase chain reaction, and flow cytometry. Confirmation of the diagnosis can help tailor treatment and evaluate other alternative diagnoses, such as nail psoriasis, trauma, and lichen planus. It is noted that onychomycosis can coexist with the aforementioned disorders, while positive tests for infection do not exclude an alternative diagnosis.
> Treatment
Toenails grow almost 1-2 mm/month. Therefore, it is important to inform patients that treating onychomycosis takes time. There are several treatments for onychomycosis. Opinions about who should be treated vary widely. Over-the-counter topical solutions are not effective. Prescription topical medications have significantly lower cure rates than systemic oral antifungal agents. Even systemic agents have a 20%-25% recurrence rate.
It has been suggested to use systemic medications if the nails have been affected for more than 4 nails or if the involvement is proximal subungual, or if there are factors that favor a poor prognosis, such as immunosuppression. Both terbinafine and itraconazole are approved medications for onychomycosis. Terbinafine is generally preferred due to higher cure rates and fewer drug interactions. The author believes that if the impact is minimal for the patient, reassurance and follow-up are acceptable.
If onychomycosis is associated with pain, the patient can be referred to a specialist (podiatry or dermatology) in order to eliminate the thickening and painful part of the nail. On the other hand, if the diagnostic tests are negative, the patient should be referred to a specialist to help elucidate the cause of the nail disorders.
Clinical care points
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| Morton’s interdigital neuroma |
> Background
Interdigital neuroma is a common cause of pain in the sole of the foot. It is observed as a protuberance of the interdigital nerve, proximal to the bifurcation of the digital nerves. The cause of neuroma formation is not completely known, but there are several theories, including chronic traction damage, chronic inflammation from bursitis, chronic compression, and ischemia.
Interdigital neuromas are much more common in women than in men and usually appear in middle-aged people. In a fifth of patients, the neuroma is bilateral. In two-thirds of patients, the most frequent location is in the third interdigital space (between the third and fourth distal metatarsals), followed by the second space. It is rare for there to be a neuroma in several interdigital spaces.
> Clinical characteristics
Patients with Morton’s neuroma complain of burning, sharp, or blow-like pain on the plantar surface between the metatarsal heads. This pain may radiate distally or proximally to the 2 adjacent fingers. The pain worsens with tight shoes or high heels. Patients sometimes also complain of numbness in the same area.
> Physical examination
Direct palpation of the affected interdigital space can reproduce the pain. Palpation of the web space while simultaneously compressing the metatarsal joints (Mulder’s sign) may reveal a clicking sound accompanying the pain. This maneuver has been shown to be 61%-98% sensitive. It is essential to confirm that palpation of the metatarsal head is not tender. This finding would be inconsistent with a Morton neuroma and should lead to further evaluation.
> Diagnosis
The clinical history and semiology compatible with the diagnosis of an interdigital neuroma are sufficient to state it. If Mulder’s sign is negative, it is recommended to confirm the diagnosis by injecting a local anesthetic. If this drug does not relieve pain, alternative diagnoses should be considered.
The image is usually of little use for the diagnosis and management of the condition. Specifically, MRI is neither sensitive nor specific. For patients with atypical features, such as cases in which more than 1 interdigital fold is involved, the imaging modality of choice is ultrasound. Thickening of the fascia and hypogenicity can be observed.
> Treatment
The most reasonable thing is to do staggered management. Conservative treatment, such as the use of plantar orthoses to unload the metatarsal and the use of wider shoes, improves symptoms in 32% of patients. Corticosteroid injection relieves symptoms in one-third of patients, most of whom achieve resolution of symptoms without recurrence.
Botulinum toxin A injection appears to be more effective than corticosteroid injection. Alcohol injections have an even higher response rate, but are accompanied by an increase in relapses. For those who failed to improve with the non-surgical approach, surgical resection of the neuroma showed a success rate of almost 90%. If patients do not respond to conservative treatment, referral to a specialist for more invasive interventions is suggested.
Clinical care points
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