Maggie Shao MTCM LAc
March 2015

OVERVIEW

57-year-old female presents with hand tingling and severe wrist pain that began 9 months prior to visiting the clinic. Both wrists are affected. Patient reports pain began first in right wrist, but currently feels more pain in her left wrist. The western diagnosis for this patient is De Quervain’s syndrome, caused by repetitive stress injury. After 7 treatments with NSAIDs, acupuncture, moxibustion, topical pain ointment and electro-stimulation, patient reports 75% reduction in pain.

Subjective

Patient is a 57-year-old female presenting with bilateral wrist pain. Pain began with the right wrist, and now her left wrist is more painful. Patient points to bony prominences on both wrists, near radial styloid, and reports chronic pain for the last 9 months. Patient reports that pain is worse with cold and damp weather. She comes to the clinic with no prior intervention or treatment for this wrist pain. 

Objective

Patient appears in good health with weight proportional to height, and luster in facial complexion, hair and skin. Blood pressure is 120/80 and blood glucose is 101 mg/dL. Tongue is pale with white coat. Pulses are thin and weak. When palpating both right and left wrists at the location of the radial styloid, near acupuncture point Lung 7, patient reports sharp pain. She tests positive when performing Phalen’s test, reporting numbness and pain after holding hands in prayer position for several seconds. Noticeable prominence on both wrists at the radial styloid is evident. Patient tests positive with Finkelstein test, reporting severe pain with thumb flexed across the palm, enclosing fingers around thumb in a fist and deviating and rotating the fist toward the ulna. DTRs (deep tendon reflex) for brachioradialis, biceps and triceps are normal.

Assessment

DX: De Quervain’s tenosynovitis 

De Quervain’s syndrome is stenosing tenosynovitis of the short extensor (extensor pollicis brevis) and the long abductor tendon (abductor pollicis longus) of the thumb with the first extensor compartment. Inflammation of the tendons, and subsequent fibrosis over the radial styloid of the first digit dorsal compartment causes this area to become thickened and bone-hard, raising the skin and creating a prominence that is tender and painful. De Quervain’s tenosynovitis is most commonly due to the repetitive stress injury involving repetitive hyperextension of thumb. Diagnosis is based on the major symptom of aching pain at the wrist and thumb, aggravated by motion. Physical testing is the Finkelstein test as described above. 

Considerations for differentiating include: 

• Dorsal ganglion of wrist – Cysts are fluid filled with clear high viscosity fluid. This patient’s swellings are bony and hard, more consistent with De Quervain’s tenosynovitis.

• Carpal tunnel syndrome (median nerve compression within wrist) – This is diagnosed with a positive Phalen’s test of elicited numbness and tingling along median nerve pathway, which includes the second finger. Further testing with patient shows no numbness in second or third finger, ruling out CTS.

• RA (rheumatoid arthritis) – A blood test for RA factor is useful for this diagnosis. Usually, there is symmetric involvement of multiple joints that are inflamed, with redness and warmth. RA symptoms often include symptoms of malaise and fatigue. Patient does not show any characteristic redness or warmth in swelling, or signs of fatigue.

• Cervical radiculopathy of C5 or C6 nerve root – Sensory abnormalities in a distribution involving the dermatome; Patient tests normal for deep tendon reflexes, ruling out cervical radiculopathy.

• Scaphoid fracture in wrist – Can test using tuning fork on scaphoid bone; If fractured, patient will report pain. Patient does not report any accident occurring with onset of pain. Pain first occurred in right wrist and then left wrist. This is more consistent with repetitive stress injury from hyperextension of thumb.

TCM DX: Cold-damp bi syndrome with local channel blockage of Lung and Large Intestine channel. Pain in wrist is less when stick moxa is applied to area. Condition is worse with cold and damp weather. Bi syndrome is characterized by the obstruction of qi and blood in the channels due to the invasion of pathogens of wind, cold or damp, as well as heat or blood stasis. Cold bi is characterized by severe stabbing arthralgia with fixed location, alleviated by warmth and aggravated by cold with white fur on the tongue and tight pulse. Damp bi is characterized by soreness and fixed pain in the joints with local swelling and numbness, aggravated on cloudy and rainy days, with white and greasy tongue coat, and soft or slow pulse. 

PROGNOSIS: Fair; Inflammation of tendons can take several months to heal completely. Reduction of pain is expected through the use of NSAIDS and acupuncture. Plan is to reduce pain by 50% over 7 treatments.

Plan

Treatment Principle: Move qi, remove meridian blockages with warmth and resolve dampness.

Treatment: Patient travels over 4 hours to clinic. Traditionally, any type of tendonitis treatment involves rest, ice, NSAIDS, stretches, modification of activity, possible corticosteroid injection and possibly surgery. Thumb spica splint that immobilizes thumb, preventing hyperextension, may help. 

Rest, or modification of activity, is not likely to be viable components of treatment with this patient, who uses her hands for daily chores. 

Ice is not available in rural Nepal. Both corticosteroid injection and surgery are outside the patient’s parameters for availability and affordability. 

Initial plan includes acupuncture treatment 1 time per week. Placement of the needles are along the Lung and Large Intestine channel that align with the tendons and muscles of extensor pollicis brevis and abductor pollicis longus. The needle direction is toward the bony prominence. Alternating treatments each week with moxa 1 week and electro-stimulation for 20 minutes the following week. Experimenting with a topical NSAID ointment preparation by crushing 2 x 100mg sodium diclofenade tablets and mixing into 83ml container of petroleum jelly. Patient is being treated with oral NSAID of ibuprofen, 400mg TID for 10 days. Patient is instructed to use topical ointment at night after completing chores of the day. Patient is also instructed to wrap thumb with an Ace bandage to prevent hyperextension during the night while sleeping. 

Outcome

During first contact, the respiratory emergency was stabilized and patient’s oxygen levels returned to normal ranges for his disease state. After that time, the patient showed relatively stable oxygen levels, less anxiety and was able to sleep through the night. He began sharing his life story, but was not yet able to discuss his death. 

After 3 weeks, the patient presented with +4 pitting edema in his legs that prevented him from putting weight on his feet. He reported sharp chest pains. He became vocal about his death and stopped smiling and laughing as much.

At 4 weeks, the patient reported lowered anxiety and a feeling of increased relaxation. He asked for more practitioner visits, reporting feeling best on days when we came. 

After nearly 30 patient contacts, the patient’s family reported a respiratory emergency with sharp chest pains. Upon arrival, pulse oximeter readings showed a blood oxygen level of 63% with a pulse of 34 bpm and respiration rate of 28. The patient could not maintain consciousness and at some point, could not recognize family members. Cultural traditions around death were already being performed by the family. He died during the night.

Outcome

Patient was tested at sixth treatment with Finkelstein test and reported no pain on right wrist and only slight pain on left wrist. At the seventh and final treatment, she reported an overall 75% reduction in pain. 

Conclusion

The use of NSAIDs to reduce and limit the pain, and reduce inflammation with acupuncture and moxa, proved very helpful for this patient. The swellings in both wrists were quite small in area, superficial and seemed to respond well to topical NSAID preparation. However, for larger areas or deeper inflammation, the topical application would not be useful. 

Dietary changes, such as using or increasing the dosage of turmeric, may aid in the reduction of inflammation. Initial diagnosis was carpal tunnel syndrome. However, with further testing and interaction with the patient, De Quervain’s syndrome became more likely. Both these syndromes are due to repetitive stress injury. Treatment over time changed to focus more on the hyperextension of thumb and associated tendons and ligaments, and less on the wrist compartment.