Conditions Dr. Desai treats, and the treatments he uses.
Arthritis is a relatively common yet serious condition in which the cartilage of the joints deteriorates and results in direct contact between the bones. In a healthy joint the cartilage allows the interacting bone surfaces to fit together as a set and move smoothly. When the cartilage wears out the fit of the joint becomes irregular with the effect most noticeable in the hands and fingers. Arthritis of the hand and wrist is painful and potentially disabling.
Common symptoms of Arthritis
The most common symptoms are pain, swelling and difficulty using the hand for routine, daily activities. Patients may also notice a deformity as their fingers drift away from the thumb and toward the outside of the hand. These conditions will generally worsen over time and as the disease progresses patients may experience pain even during rest. A loss of strength occurs in the hand, fingers and thumb. In the most severe cases, a bump will develop at the base of the joint where it has moved out of position.
Treatments and Therapies
We have a variety of treatment options depending on the nature and severity of the condition. In less-severe cases, simply changing daily activity or splinting can alleviate the problem. Pain medication and anti-inflammatory drug injections may be recommended. If these treatments do not work surgical repair of the joint may be necessary.
We can reduce and often eliminate pain, realign the position of the thumb and fingers and improve the overall function of the hand using a variety of surgical techniques. Consult with your doctor to decide the best course of treatment.
Medications
Anti-inflammatory drugs such as aspirin may help relieve pain and reduce swelling. However, their actual benefits are unclear since they are generally used in association with other treatments. You should always consult a doctor before taking any medication. We advise against using anti-inflammatory medications when the source of pain is something other than inflammation. Side effects can result from long term use.
Splinting
We splint the wrist and thumb to provide temporary relief from symptoms. Splints allow the arthritic joint to rest and keep it from moving. As a result, inflammation is often decreased and the surrounding area is allowed to heal.
Splints should be worn on a part-time basis during heavy activities that bring on or worsen pain or during flare-ups. Wearing splints full-time, unless prescribed by your hand surgeon, may result in stiffness in the immobilized joint. Ideally, a splint should be custom-fitted.
A wrist splint is not a substitute for good work place design and proper body mechanics. Some experts advise against wearing a wrist splint while working because doing so can strain tendons in the hand.
Cortisone Injections
Cortisone shots are injections of a naturally-occurring steroid that can provide temporary relief from arthritis symptoms. Injections can be administered directly to the affected area, helping to relieve swelling and pain. Side effects are generally minimal. Up to three injections may be given, each providing between a few weeks and a few months of effective pain management. However, individual patient results may vary.
Arthroplasty
Candidates for arthroplasty — hand, wrist or elbow joint replacement — suffer from pain, stiffness and loss of function due to arthritis. However, these procedures are not limited to joints worn out by years of wear-and-tear. Improperly-healed injuries, chronic illnesses and congenital deformities that cause pain and loss of mobility may require surgical replacement.
Surgery is usually considered when other treatments have not provided adequate relief of symptoms. Surgery can be a very effective way to take away the pain of arthritis and regain the use of joints that do not need to bear heavy loads. Joint replacement surgery may restore your mobility while improving your ability to perform daily activities without pain. Results may be superior to bone fusion, another treatment which limits movement in the joint.
In certain scenarios soft tissue arthroplasty is recommended over traditional joint replacement. Soft tissue arthroplasty involves replacing a small support bone with a tendon that acts as a cushion to keep the bones separated. As healing progresses a flexible connection much like a natural joint forms between the bones.
Wrist Arthroscopy
Arthroscopy, which literally means “to look within a joint,” is a surgical procedure used to visualize, diagnose and treat problems inside a joint. In an arthroscopic examination, a small incision is made and a pencil-sized instrument containing a small lens, camera and lighting system is inserted into the joint. Three-dimensional images of the joint are projected on a television monitor, enabling the surgeon to examine the area and identify the condition. The surgeon then uses tiny probes, forceps, knives and shavers to correct many problems at the same time.
Diagnostic arthroscopy may be used if your pain is unresponsive to non-surgical treatment or the cause cannot be identified. Arthroscopy allows detailed anatomic inspection and results in a more accurate diagnosis. Several conditions can be diagnosed and treated using arthroscopic surgery including ligament injuries, ganglion cysts and fractures. Arthroscopy may also be used to smooth the bone surfaces and remove inflamed tissue.
After surgery it is important to keep the area around the incision clean and dry to prevent infection. The joint will need to be elevated for the first few days. Rehabilitation exercises will be taught to regain range of motion, rebuild strength and reduce swelling. Applying ice will also help prevent swelling.
Basal joint arthritis is a condition that irritates or destroys the joint at the base of the thumb. The cartilage that normally covers the ends of the bones begins to deteriorate, allowing the bones to rub against each other. The result is significant damage that can cause severe pain and drastically limit thumb movement. Common activities such as opening jars, turning door knobs or buttoning clothing can become difficult or impossible if the condition continues to worsen.
Treatment for Arthritis
Diagnosis of arthritis at the base of the thumb is based upon a carefully performed physical examination and review of medical history with confirmation by X-rays. This allows us to stage the arthritis as early, mild, moderate or severe.
In early stages, splinting and medications may be beneficial while more severe cases may require surgery. The goal of surgery is to eliminate the pain at the base of the thumb by creating a new joint. The procedure can improve the position of the thumb, its range of motion and the hand’s strength for pinching and grasping.
Two types of surgery are currently available to us to maintain motion. The traditional surgery, useful for patients with advanced disease, involves removing the entire trapezium bone and then using a tendon from the forearm to suspend the thumb and to act as an interposition material. This is referred to a “Ligament Reconstruction Tendon Interposition” Arthroplasty (LRTI).
In some cases it is possible to undergo arthroscopic surgery to remove bone spurs and place interpositional material to decrease pain and improve function.
Arthritis of the wrist results in pain, swelling around the joint and difficulty in gripping. Patients with acute inflammation or bone spurs can experience tingling and numbness of the fingers caused by irritation of the nerves surrounding the joint (see carpal tunnel syndrome). A major cause of pain and decrease in wrist function is rheumatoid arthritis, a chronic disease that leads to inflammation of the joints and surrounding tissues. Rheumatoid arthritis sufferers commonly have inflammation of the finger joints as well as arthritis of the wrist.
Treatment for Wrist Arthritis
Our wrist arthritis treatments range from lifestyle modifications, splinting, heat applications, anti-inflammatory medications and cortisone injections that treat inflammation.
Surgery is not a typical option, but can be performed in severe cases in which other treatments do not provide relief, surgical procedures include:
In Wrist Fusion, we secure the bones of the forearm to those of the wrist and hand. The loss of motion can preclude some activities but provides predictable relief from pain. The preferred procedure is a partial wrist fusion, which allows some movement of the wrist. If all the joints of the wrist are affected, however, a total wrist fusion may be the only option.
Proximal Row Carpectomy removes three small bones from the wrist joint to diminish pain while allowing some motion. This procedure is only an option for some types of wrist arthritis.
Wrist Replacement, a procedure that replaces damaged bone with a metal and plastic implant, is used in situations in which the entire wrist is compromised by advanced arthritis. Pain relief with motion is the desired outcome. This option is best in individuals who do not undertake heavy labor or sports.
Arthritis of the elbow is the result of damage or wear to the cartilage surfaces on the ends of the bones that join in the elbow joint. When normal, these bone surfaces move smoothly together. Cartilage in arthritic elbows is damaged and worn, with common symptoms of pain and loss of range of motion, although both do not necessarily occur at the same time.
Patients usually complain of “grating” or “locking” in the elbow. The grating is caused by the rough and irregular surfaces in the joint that result from cartilage damage or wear. Locking occurs when fragments of cartilage or bone lodge in the joint and impede motion. As arthritis progresses, joints may also swell and, in advanced stages, cause numbness in the ring and pinky fingers.
One of the leading cause of arthritis of the elbow is rheumatoid arthritis, a long-term disease that leads to inflammation of the joints and surrounding tissues. The condition is also caused by previous elbow injury, such as a fracture or a dislocation, or the result of degeneration of cartilage in the elbow joint from aging or long term overwork. Elbow arthritis without previous injury is more common in men. While the condition typically occurs in patients age 50 or older, some can experience symptoms earlier.
We usually diagnose arthritis of the elbow based on symptoms and X-rays which show the arthritic changes. Advanced diagnostic imaging, such as CT (computed tomography) or MRI (magnetic resonance imaging), is typically not needed to diagnose arthritis of the elbow.
Treatment for Elbow Arthritis
We commonly treat early-stage arthritis of the elbow with pain medication, physical therapy and by modifying activity. Corticosteroid injections can provide significant pain relief. An alternative to steroids is viscosupplementation which uses hyaluronic acid to increase the fluid to cushion the diseased cartilage in the joint.
When nonsurgical treatment cannot control symptoms, surgery may be needed. If wear or damage to the elbow cartilage is limited, arthroscopy offers a minimally invasive treatment option. The procedure removes loose fragments or inflammatory/degenerative tissue in the joint while also smoothing out irregular surfaces. By using multiple small incisions, we are able to do this as an outpatient procedure with relatively rapid recovery for most patients.
Joint replacement surgery becomes necessary when the joint surface has worn away completely and no other option can provide relief. There are several types of elbow joint replacement available.
In appropriately-selected patients the improvement in pain and function can be dramatic. With an experienced surgeon, the results for elbow joint replacement are typically as good as those for hip replacement and knee replacement. Young patients or those too active for prosthetic joint replacement can benefit from other surgical options. If loss of motion is the primary symptom, we can release the contracture and smooth the joint surface. Also, a new surface can be made from the patient’s tissues.
Carpal Tunnel Syndrome (CTS) is one of the most commonly reported upper extremity problems in the United States, and one of the most common ailments we treat here at our Parham Rd office in Richmond. Typical symptoms of Carpal Tunnel Syndrome include nighttime numbness and pain, numbness while driving or talking on the phone. The problem arises when swelling pinches the median nerve, which provides sensation to the palm side of the thumb, index finger, middle finger and to the inside half of the ring finger. The median nerve also provides strength to the thumb muscles.
The resulting symptoms are often described as numbness, weakness and pain in the fingers, thumb, palm or the forearm. If the condition is not treated, permanent deterioration of the muscle and nerve can occur.
Most experts believe that typing does not cause Carpal Tunnel Syndrome. Some known conditions associated with CTS include a low thyroid hormone level, diabetes, obesity, and lack of aerobic fitness. Smoking is also an increased risk factor in this condition.
Carpal Tunnel Treatment
We base our diagnosis on an evaluation of your medical history, physical exam and nerve conduction testing. Initial treatment can involve rest, splinting and steroid injection. Sometimes an x-ray of the hand and wrist may be taken. Hand therapy has not been shown to have much benefit in improving the symptoms of Carpal Tunnel Syndrome. When patients are unable to get relief from the CTS symptoms by non-surgical means, surgical treatment sometimes becomes necessary.
Endoscopic Hand Surgeon
Fortunately, most patients can undergo endoscopic surgery through a very limited incision and relatively rapid recovery. Most of the time we use skin glue to close the incision so no stitches need to be removed. The endoscope divides the tight ligament that restricts the nerve. Once the ligament is divided the nerve has more room and is no longer under pressure. The surgery is typically done under regional or general anesthesia on an outpatient basis.
There is no cast after surgery, just a soft bandage that is removed after 48 hours. Light activities such as eating, dressing and using the bathroom commence immediately after surgery. Keyboarding and heavier gripping and lifting are allowed after a few weeks. It is very rare to need hand therapy after this type of surgery. Patients are given a sheet of exercises that they start after 2 weeks. If you are in need of hand treatment for Carpal Tunnel Syndrome and are in Richmond, VA or the surrounding areas, please contact Dr. Desai to set up an appointment.
Dupuytren’s disease is an abnormal thickening and shrinking of the tissue beneath the skin of the palm. This condition is thought to be hereditary and is more frequent in people of Northern European ancestry. It can cause lumps or dimples in the skin surface, limit movement of the fingers and draw the fingers toward the palm in a permanently contracted position. Dupuytren’s disease is usually painless, but in severe cases can make everyday activities difficult or impossible.
Treatment for Dupuytren’s Disease
We diagnose this disease following a physical examination and discussion of medical history. Usually Dupuytren’s is evident as a small lump in the palm located near the base of the ring and little fingers. Over time a thick, fibrous cord may become noticeable between the palm and the fingers. Most patients seek medical treatment for Dupuytren’s disease when the palm can no longer lay flat on an even surface.
While there is no known cure, surgery is typically the most effective treatment option. The goal of surgery is to release the contracture and restore the use of the fingers and hand. Even with successful surgery, thickened palm tissue may redevelop and require additional procedures.
A newer technique to correct Dupuytren’s – an office procedure called “needle aponeurotomy” — has recently gained popularity in the US. In this minimally–invasive procedure done under local anesthesia, we weaken the cord at multiple locations with the tip of a small needle. Once the cord is sufficiently weakened it is “popped,” resulting in a straighter digit. No stitches are necessary. While not everyone with Dupuytren’s disease is a candidate for needle aponeurotomy, we can generally make a determination based on the initial office visit. Complications of this procedure include nerve injury, recurrence of the contracture and skin tears.
Ganglion cysts are common swellings or masses that develop within the hand and wrist. A ganglion is an accumulation of jelly-like fluid in a tissue sheath that grows out of a joint, like a balloon on a stalk.
These non-cancerous cysts grow in the wrist, at the end joint or base of a finger.
Ganglia are often pea-sized, but can grow due to increased movement of the affected joint or disappear completely without warning. Most ganglion cysts cause some degree of discomfort, although they are often painless. The mass can consist of one large cyst or many smaller ones. Multiple small cysts can appear to be one cyst, but they are usually connected by a common stalk in the deeper tissue.
Though the specific causes of ganglion cysts are unknown, several factors seem to influence their formation. The cysts occur more frequently in women and in individuals whose occupational or leisure activities apply repeated stress to the wrist.
Treatment for Ganglion Cysts
As ganglion cysts are harmless, the first course of treatment is often non-surgical. However, if the symptoms are not adequately relieved or the cyst remains unsightly a number of minimally-invasive surgical options can be recommended. Arthroscopic treatment of wrist ganglions has been demonstrated to be highly effective, with a faster post-operative recovery in most cases. The most common complication of any form of treatment is recurrence of the cyst.
Pain on the inside of the elbow made worse with gripping is generally due to a condition called golfer’s elbow, or medial epicondylosis. Golfer’s elbow results from tearing of the tendon attachment (the connection between the tendon and the bone). Most cases are due to a combination of degeneration of the tendon and overuse. You can be at risk from golf as well as tennis and weight lifting.
Treatment for Golfer’s Elbow
The most important treatment we recommend is simply to stop the activity, although stretching exercises, therapy and steroid injections can sometimes help this condition. For those who are not improved by these measures, surgical removal of the torn portion of the tendon and reattachment is sometimes recommended. Recovery can take 6-12 weeks after surgery.
In today’s technological age, the world is at your fingertips. However, modern technology could also be what is causing pain in your arms, wrists, and hands. Typing, scrolling, and swiping require movements that put stress on several small muscles, tendons, and nerves in our fingers and wrists. For example, typing on a Blackberry, smartphone, or another handheld device requires repetitive thumb motion that may lead to a variety of conditions, including tendinitis.
The pain usually forms around the knuckle, and frequent handheld device users may even experience a clicking sound while bending the thumb. Some smartphone users may be at risk of developing arthritis, which can also result from activities that require similar repetitive thumb motions, such as text messaging and playing video games. These repetitive motions can lead to inflammation, pain, and even surgery for severe cases.
Treatment for Smartphone Thumb
In most circumstances, the best treatment simply involves resting the thumb. If you know you’ve been on your phone or other devices for most of the day, put it down periodically. Avoid sending long or frequent messages with the devices and use a computer with an ergonomic keyboard designed to limit strains on the hand instead. You might try switching the hand in which you hold your device. Another effective treatment is placing your device on a tabletop rather than holding it. Don’t forget about voice messaging either, as it can help alleviate the stress altogether. If the problem persists, it might be time to take an anti-inflammatory or consult your doctor. He or she may recommend steroid injections or surgery. Luckily, these procedures are minimally invasive and can be done in under 20 minutes with a recovery timeframe of just two to four weeks.
Tennis elbow is a common disorder of the tendons attached to the outside of the elbow. The condition begins with small tears or scar tissue developing under the tendons, with wear-and- tear of the elbow joint or irritation and inflammation of nerves in the elbow region. These tendons degenerate with repeated stress or overuse, resulting in painful tendinitis.
Frequently occurring between age 30 and 50, tennis elbow is linked to frequent twisting movements of the hand, wrist and forearm. However, the condition is not exclusive to players of racquet sports. Other known causes include everyday motions such as using a screwdriver or digging in a garden as well as direct blows to the area.
The most common symptom is discomfort in the outer region of the elbow. The affected area may be tender to the touch or become significantly painful during gripping, twisting or lifting motions. Pain can range from mild to severe and can radiate up to the forearm, though there is usually no outward sign of redness or swelling.
Treatment for Tennis Elbow
Tennis elbow is most often diagnosed during a physical exam and assessment of your daily activities and medical history. We may use imaging tests to diagnose a potential bone problem.
Typically, we begin treatment with conservative rehabilitation techniques. There is also a promising new, non-invasive treatment called Sonocur which uses sound waves to allow the tendons to heal. Surgical treatment is sometimes necessary if symptoms cannot be eliminated by other means or if the condition has been present for over a year. The procedure involves releasing the tendon, removing the damaged tissue and reattaching the tendon to the bone.
Trigger finger is an often painful condition caused by the narrowing of the tendon sheath in the finger. Normally the tendons glide easily through the sheath as the finger moves. When the sheath becomes irritated or swollen, the tendon can become temporarily stuck in the tight space. This can cause pain or a popping and catching sensation leading to further inflammation. As the problem worsens, the finger can become locked and may be difficult to straighten or bend.
Causes of trigger finger are not always clear but the condition is more common in women than men and occurs most often in patients between age 40 and 60. Medical conditions such as diabetes, gout and rheumatoid arthritis may be associated with the symptoms of trigger finger. People whose work or hobbies require repetitive gripping actions also seem to be most susceptible to this condition. In rare cases trigger finger can also be caused by a congenital defect that forms a nodule in the tendon.
Treatment for Trigger Finger
Depending on the severity of the condition, we treat trigger finger with rest, splinting or a steroid injection. The goal of treatment is to reduce the swelling of the tendons and tendon sheath, thereby eliminating the problematic catching or locking and allowing for a full and painless range of motion.
Newer minimally-invasive techniques are available to release the narrowing causes trigger finger. These procedures can often be done in the office without the need for a surgical incision or stitches. Surgery can eliminate symptoms associated with this condition, generally as an outpatient procedure that in most cases enables rapid recovery.
If non-surgical forms of treatment do not improve symptoms or your condition is more severe, surgery may be recommended. The goal of surgery is to widen the tendon sheath to relieve the catching caused by the narrowed passage way.
Ulnar nerve compression occurs when the ulnar nerve, a main nerve in the arm, becomes irritated due to injury or pressure. Symptoms include a tingling in the ring and little fingers, pain on the inside of the elbow and difficulty moving the fingers or grasping objects.
The exact cause of ulnar nerve compression is unknown. Factors that influence the chance of developing symptoms are: prior injuries, including fractures of the elbow; bone spurs; swelling of the elbow joint or cysts. Certain medical conditions may also increase the risk of developing ulnar nerve compression including rheumatoid arthritis, obesity and diabetes.
Treatment for Ulnar Nerve Compression
Screening for ulnar nerve compression begins with a detailed examination of medical history and physical health. Numbness in the fingers, evidence of muscle atrophy and weakness in the hand and forearm are all signs that further testing is needed for a complete diagnosis.
Surgery may be recommended If non-surgical treatments are not improve your symptoms, or you have a severe case of nerve compression or muscular atrophy.
The newest technique for addressing Ulnar nerve compression at the elbow is Endoscopic Ulnar Nerve Release. The technique, which was pioneered in Germany, was introduced in Virginia by Dr. Desai in 2006 and has been a highly successful part of his practice. Pressure on the nerve at the elbow can be relieved through a one-inch incision. Recovery can be measured in days or a few weeks as compared to months for the significantly more invasive, open technique.
A healthy tendon moves unhindered through a protective sheath that allows it to travel around joints and across other tendons. Someone with tendinitis experiences thickening of the tendon sheath, which restricts the tendon’s movement. The area generally becomes inflamed, making joint movement painful and more difficult.
While wrist tendinitis may occur anywhere along a tendon, it is most commonly seen at a point of contact with bone or with another tendon. One frequent example of wrist tendinitis, especially in new mothers, is called DeQuervain’s tenosynovitis. This inflammation of the tendon is found at the base of the thumb.
There are some underlying factors that may make you prone to tendinitis, including age, poor wrist posture, poorly aligned joints, injury, or diabetes. Tendinitis can also stem from repetitive daily activities. For example, using a mouse or keyboard, texting, playing video games, or consistently writing with a pen or pencil could be causing your wrist to feel pain, become swollen, or lose flexibility.
Treatment for Wrist Tendinitis
Treatment options for wrist tendinitis vary depending on the severity of the case. Start by avoiding any activities that could be causing stress to your wrist. If your wrist begins to hurt or becomes swollen, apply ice to reduce inflammation. However, if the problems persist, you should see a doctor to receive proper treatment.
As a first step, we often use a splint, which allows the tendon to rest by limiting its movement. In less serious cases, this decreases swelling and allows the pain to subside. While you’re home, intermittent icing is also recommended.
If this approach is ineffective in reducing pain and swelling, another option is to use non-steroidal, anti-inflammatory medication. This includes over-the-counter medications such as ibuprofen or prescriptions provided by your doctor. This should at least allow for temporary relief.
For severe cases, a cortisone injection applied directly to the site of inflammation may ease the symptoms. Cortisone injections are considered safe but may weaken the tendons of the area over time if injections are done repeatedly. Our final option is surgery, which is highly effective and can frequently be done in the office under local anesthesia with sedation. The surgery requires a small incision in the wrist to locate the damaged tendon to release the sheath surrounding it. Ultimately, more space is created for the tendon to move by widening the tunnel and removing inflammatory tissue. Your wrist will feel as good as new in just a few weeks.