Upper Limb Overload

Patient Profile:
64 year old female, on the taller side of average and healthier side. Sedentary lifestyle. Right dominant

Complains: 
1. Pain at small joints of hands, wrist, forearm & shoulder of Right upper limb- 4-5 months. Severe enough to disturb her sleep. She is able to use the hand for activites of daily living (ADL) with great difficulty.
2. Pain with gross restriction in mobility of left shoulder- 8-12 months
3. Tingling numbness right hand especially in the night with difficulty in sleeping on right side

Patient had undergone a CABG (bypass) surgery 5-6 years back and was better for the next 2-3 years. But is incapacitated since last few months due to reduced ability to use the right hand and wrist. There is difficulty in forming a wrist and grasping objects. She has the maximum difficulty in the early morning.
Her left shoulder is painful with progressive restriction in overhead movements.

Observations:
Right hand & Wrist: Swelling ++++, tenderness at small joints & wrist, Wrist Movement: grossly restricted. Movement of the small joints restricted and painful. Signs suggestive of Carpal Tunnel Syndrome

Left Shoulder: tenderness ++++, ROM restricted in forward flexion, horizontal abduction, cross-body adduction, abduction with external rotation and adduction with internal rotation (reaching the back).

Mechanical Overload Component: 
A detailed history revealed that that the patient has been using her both upper limbs to rise from the sitting surfaces on a regular basis. She has maximum difficulty in rising after bathing & loads her both upper limbs for that purpose. Previously she used the left, affecting the shoulder and once that became painful used the right more, damaging them. She has no difficulty in rising from her commode as that is of appropriate height for her.

This overloading activity undertaken multiple times in a day seems to be the mechanical overload component compromising the function of the muscles and joints. This aspect has to be taken into consideration while managing such a patient. She has been asked to follow-up after a week for reassessment and further management protocol.

Management: 
Patient has been suggested to give a trial for a week of the following:
  1. Sitting at an appropriate height such that she does not require to load the upper limbs.
  2. Cock-up splint to provide rest to the right wrist
  3. To take frequent breaks when sitting for prolonged duration.
  4. To start working and use her hands in the functional zone.
  5. Analgesics and anti-inflammatory medications

Follow-up: Will update.

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