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Diagnosing DeQeurvain
850 Plays1 year ago
Josh and Miranda cover all the special tests for DeQeurvain's and bring clarification to the special tests used for diagnosis.
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Transcript
Introduction to Hand Therapy Academy
00:00:06
Speaker
Hi, I'm Josh McDonald.
00:00:07
Speaker
And I'm Miranda Matiri, and we are Hand Therapy Academy.
Provocative Testing for Hand Conditions
00:00:12
Speaker
All right, so we're going to talk today about some provocative testing, specifically for tenor vaginitis or tenor sinovitis, a first dorsal compartment, also known as decoir veins. There's a whole bunch of tests that are available, like all these diagnoses that have way more provocative tests than maybe we even need. But there's some wisdom in knowing which tests to use. And then how many total do I need to use when I'm testing somebody?
Clarifying Misidentified Maneuvers
00:00:37
Speaker
Yeah, and I feel like this is one that everybody knows about Finkelstein's or Finkelstein's, right? You get students that come out and you say, what's the special test for D quervains? And they all say Finkelstein's. But we know that there's more to this. And then how we define Finkelstein's is different as well, right? So sometimes students will show us and you're like, oh, that's not really how we do
00:00:55
Speaker
Finkelstein's are the correct way that it's stated in research. So I think for the purpose of this, we want to give clarity to our audience the difference between these special tests and which ones have better sensitivity and specificity if it's reported.
00:01:11
Speaker
So let's talk first about Finkelstein's. That's the one that everybody spouts off first. That's when students know right off the bat. When I have a patient who has pain there, I want to test the tension and I want to gently load that APL and EPB in the first dorsal compartment.
00:01:26
Speaker
So, when we tell patients to hold their thumb within the second through fifth digits and then only deviate, I'm doing it here in a different position, but basically you're doing the forearm in neutral and I tell them to only deviate, that is not Finkelstein's. That is an ICOF test, E-I-C-H-O-F-F is the name of the doctor that discovered that as a provocative maneuver.
00:01:51
Speaker
That's the Eichhoff maneuver. Having them do it actively is Eichhoff.
Introduction to the WHAT Test
00:01:56
Speaker
When I do it to them passively, where I put their thumb into flexion and adduction, and I only deviate their wrist passively, that's Finkelstein's.
00:02:08
Speaker
Yeah, so the big difference and the big takeaway is the therapist doing the maneuver for them or the patient actively doing it. So I think most of the students think when the patient actively does that, that's Finkelstein's and that is not the case. That's Eikos. And it matters because of the balance of muscles happening.
00:02:26
Speaker
and think about the provocative testing of the shoulder. If I do an empty can test and they're holding a can and they dump it upside down and then pull themselves up, if I do that passively, certain muscles aren't firing and I'm not stabilizing and co-contracting. So if I have that patient do it actively versus me doing it passively to them, there's different muscle forces at play. Honestly, the outcomes are relatively similar, but it's good to call things by the right name.
00:02:52
Speaker
Right. And then we're going to talk more about another test that people aren't as familiar with, but one that we use in our clinic probably a lot more frequently than we use ICOS and Finkelsteins. And that's the what or what test. And then Josh and I were saying, well, it's WHAT, right? So that's what we're saying. And so Josh calls it the what, and I call it the what.
00:03:15
Speaker
I think I just pronounce it differently than the word what because I feel like it makes it sound like a different word or something. I don't know. I probably shouldn't call it something different, but it's the what test. WHAT, wrist, hyperflexion, and abducted thumb.
00:03:33
Speaker
And when we do an abducted thumb, specifically in the literature, they don't want the patient just pulling it out. They don't want you pushing it into abduction. They want you pushing into a deduction and the patient holding isometrically abduction. Yeah. So A holding A, just to clarify, ABduction, you're holding the patient, the patient's holding their thumb in ABduction.
00:03:56
Speaker
Yes. So I'll have the patient's owner side of the forum resting on the table. I'll put them into a flexed wrist. I'll position them with an abducted thumb with a thumb that is now an abduction. I'll position them passively into that abducted and that's not painful. I'll say hold it there.
00:04:15
Speaker
Just by me letting go, they are now doing an isometric hold, and that's loading APL and EPB in their first hostel compartment. Sometimes that's a positive enough sign that I don't need to do a resistance against that load. That's painful enough. If it's not and they can hold that, that's not technically a positive enough sign, yet that's not a positive provocative maneuver. I need to try to push them into a deduction while they hold a deduction, an abducted thumb.
00:04:45
Speaker
That's what elicits pain. That's a provocative, a positive test. But if they have pain before you get there because they can't isometrically hold it there, then that's also positive. I don't need to go the next step. I know it's going to be painful. Yeah. And I think my next question is for you. So you're doing, you have a patient that comes in, they're complaining of radiocided wrist pain. What test are you doing first and why?
00:05:09
Speaker
So when we're talking like that physical exam, the first thing I do is just lightly palpate around that area and just get an idea of, is it painful to touch? Because I'm not going to do provocative maneuvers that send them through the roof if absolutely everything about that region is painful.
00:05:27
Speaker
And I know like, hey, if I just put them in reflection extension, I just do some gentle mobilization of that joint and they're screaming through the roof, then anything I do and call it a provocative test is going to be painful if it's not. And they're like, yeah, that's fine. That's fine. That's fine. Then I'll start with the with the what test.
00:05:45
Speaker
and I'll put them in that wrist flexion, put them in an abducted thumb, and then let go and see if they can hold it loading those and then step
Evaluating Test Sensitivity and Specificity
00:05:53
Speaker
it up. I'll start with those. If that's unclear, I will then go to Finklestein or Eikhoff for confirmation, but those have way less sensitivity and specificity than the What Test does.
00:06:06
Speaker
Yeah, so first line for diagnostics or evaluating the patient is looking for pain and the symptoms that are kind of giving you that indication that they may have it, then doing the what test, and then possibly further confirmation with the Finkelsteins.
00:06:22
Speaker
And I think that when we're reporting in the, in our findings, in our notes too, we're also reporting, you know, I think it's easier to report Finkelstein's because more providers know what that is, right? So if a patient sent from their primary care doctor, they're probably like, why aren't they doing the Finkelstein's test, right? So sometimes I just put it in there for communication. Like I know, I know this is probably going to be a little sore, but I know that if it's positive, I'm going to put that in my note as well, even though maybe it's not as
00:06:47
Speaker
you know, likely to be indicated. So I'll put the what test first positive, and then I'll put the Finkelstein's test is being positive if they are positive. Yeah.
Effective Test Selection and Reporting
00:06:54
Speaker
And if I have a patient positive on one test, maybe I do a confirmation or a differential diagnosis provocative test, but I don't need to go through every provocative test that exists for that body part. If nothing else, I'm flaring it up. If they're all positive, I'm making it worse and worse and worse. So I think we, because we have so many provocative tests, it doesn't mean we have to use all of them. You'll find a favorite look for ones that are good with sensitivity, specificity, inter-rater reliability, all of that, but you don't have to keep poking the bear over and over.
00:07:23
Speaker
Right. And I agree with you. And sometimes if you do that test and it's positive, all the other tests are going to be positive, even if they're like differential tests, right? So if you really flare up a patient and you're doing other tests, maybe for intersection, maybe, maybe positive just because you irritated the structures around that area so much. So I think you have to be careful of that too. When you're doing your special tests, do the one that you think is going to really flare it up for the last part of it. So
00:07:47
Speaker
Before you get all those other ones to be positive when they're not they wouldn't necessarily be positive if you would have done them first Right, right and I think it's a good discussion to have to with specifically with this diagnosis
00:08:01
Speaker
If I do, I cough or Finkelstein's on myself. I'm not a particularly mobile person. It doesn't feel fantastic when I do that owner deviation with thumb fisted. It doesn't feel great, but that doesn't mean I have to quervains. And so I think it's good to clarify and help for new grads and students to understand what counts as a positive test. You know, it may not feel comfortable to go into that position or anything like that doesn't feel great, but that doesn't mean it's positive. I'm looking for a clear and distinct response
00:08:27
Speaker
Usually pain depends on what the test is. I'm looking for something clear and distinct. Like if I'm going to do that, it's a sharp pain. It's an event that happens. Not just like, well, it doesn't feel good. Right. Yeah. That's a good reminder for students as well. Cause sometimes you'll have mild discomfort with some of these provocative tests as well. And it doesn't mean that it's positive. It's not a clear positive indication.
00:08:49
Speaker
A lot of that, go ahead. That's okay. That, that muddies the water too with a differential diagnosis of this patient with CMC arthritis. That's not going to feel good on that for CMC joint, but that doesn't mean it's positive for, so you've got to make sure it's like, yeah, that's a definite positive indicator. Yeah. And does it really matter if you know, they have
00:09:06
Speaker
If you're doing a good client or patient interview, a lot of times you'll know what it is before having to do any special tests. And then at the end of the day, it doesn't really matter. You know, if you're doing a good interview, a lot of times the special tests don't really matter as much.
Conclusion and Contact Information
00:09:20
Speaker
Yeah. Yeah. Or if they come in with a diagnosis and we all know what it is, if they come in with a diagnosis of CMC arthritis based on X-rays, I don't need to do a grind test. I didn't need to do the lever test. We know they have it. Let's move on and start doing something productive without just eliciting pain for the sake of testing purposes. Right. Definitely.
00:09:37
Speaker
All right, lots of good information there. Hopefully that helps inform your practice and how you interface with patients during evals and provocative testing. But if you have any questions, feel free to reach out to us at our email info at handtherapyacademy.com or on Instagram or social media at handtherapyacademy.