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Pain in the forearm, wrist and hand

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Abstract

Pain in the forearm, wrist or hand may arise from one of several discrete rheumatic disorders of soft tissues, such as tenosynovitis, or from a non-specific regional pain syndrome. Symptoms are prevalent in the general population and both patterns of illness are well represented. Many epidemiological investigations of prevalence, incidence, causal risk factors, management and prevention exist, although surveys have used a wide variety of case definitions, hampering comparisons. Improved standardized approaches to classification are in prospect and these are described. A synthesis is also attempted of the main findings of existing surveys. A growing body of evidence now links distal arm pain with physical risk factors in the workplace (e.g. repetition, force, duration, short cycle time and awkwardness of posture); some possible ergonomic solutions to occupational arm pain are discussed. But occupational and psychosocial factors are also linked with symptom reporting and disability, and their role in pathogenesis may be important in primary prevention and the management of recalcitrant cases. Some key research questions are proposed aimed at preventing chronicity and disablement from arm pain.

Section snippets

Tenosynovitis and tendinitis

In a pathoanatomical sense, tendinitis is defined as inflammation of one or more tendons, and tenosynovitis as inflammation of the synovial sheath of one or more tendons. Some authors also draw a distinction between these and inflammation of the paratendon at the muscle–tendon junction further up the arm (peritendinitis). But histological evidence of inflammatory change is rarely obtained in the diagnosis of soft-tissue disorders, and so these terms, which rely on clinical findings suggestive

State-compensated and reportable disorders in workers

In many countries upper limb disorders (ULDs) are compensated by state welfare benefit for insured workers who develop illness because of their occupation. In Britain, for example, provisions have existed to cover occupational accidents since 1897 and occupationally related diseases since 1906. Tenosynovitis, CTS (in users of vibratory tools), beat hand and cramp arm are compensatable; and trends, although affected by rule changes, can be monitored over time (Figure 1).13 However, only willing,

Case definitions in epidemiology and research

Epidemiological research focuses on large groups of people rather than on individuals. So the case definitions employed in epidemiological surveys are necessarily cruder than those used in clinical practice, or to assess patients seeking compensation. Frequently the determination of ‘caseness’ is based solely on self-report of pain, but the definition may be refined by reference to an anatomical site, time period, duration, severity, or impact on daily activities. Many surveys have employed the

Hand–wrist pain

The estimated prevalence of distal upper limb pain varies, depending on the time period, severity, and the duration of symptoms for which enquiry is made (Table 3)24., 25., 26., 27., 28., 29.; but by any measure, such symptoms are common. For example, persistent pain in the hand or wrist had a prevalence of 3–7% in a large American population survey24 and 9–17% in one rural area of Sweden.29 More recently, two British surveys26., 28. have found a prevalence of hand or wrist pain preventing

Physical risk factors

Many investigations of hand–wrist complaints have been conducted in the occupational setting, as it is assumed that symptoms and disorders in the region are most often caused or aggravated by physical activities at work.

To investigate, researchers have generally compared the prevalence of pain (Table 5) or tendinitis (Table 6) in cross-sectional surveys of workers whose jobs entail contrasting degrees of repetitiveness, force, awkwardness and duration.51., 52., 53., 54., 55., 56., 57., 58., 59.

Pathogenesis of hand–wrist pain and hand–wrist disorders

Various models of causation for WRULD have been proposed. Generally speaking, the mechanical model of pathogenesis assumes a passage through the steps of activity, biomechanical stress, temporal loading (as some function of duration and repetitiveness), tissue strain, tissue response (injury and attempted repair), and pathology.72

For some outcomes this model is supported by the finding of gross pathological changes in the tendons at necropsy or surgery, consistent with a process of wear and

Prevention and management of hand–wrist disorders

Preventive measures in the occupational setting, assuming a mechanical basis of occurrence, may include

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    job rotation or job enlargement, to provide respite from work that requires repetitive monotonous use of the same muscles and tendons;

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    rest breaks;

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    task optimization – better design of tools and equipment, and a better work lay-out make the task easier to perform;

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    training, to ensure better working practices;

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    an induction period, to allow new employees to start out at a slower pace;

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    a

Conclusions and future research needs

Pain in the distal upper limb is a common symptom in the general population. It often exists in the absence of discernible pathology, but sometimes arises from discrete upper limb rheumatic disorders such as tenosynovitis and CTS. A growing body of evidence, summarized in several large reviews89., 90., 91., now links the symptom and its associated disorders with physical risk factors which may be avoidable if good ergonomic practices are followed. Control of mechanical risk factors in the

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