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Handlebar Palsy
376 Plays26 days ago
Miranda and Josh delve into the topic of ulnar nerve compression at the wrist. They explain what ulnar nerve compression is, its causes, symptoms, and the impact it can have on hand function. Join us as they share their expert insights on diagnosing this condition, effective treatment options, and practical exercises to alleviate symptoms.
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Transcript
Introduction to Ulnar Nerve Compression
00:00:06
joshmacd
i am josh mcdonald
00:00:08
mmateri
And I'm Miranda Materi and we are Hand Therapy Academy. So today we, go ahead Josh.
00:00:12
joshmacd
we're going to talk
00:00:15
joshmacd
Okay, so today we're gonna talk a little bit about an ulnar nerve compression problem. um One of the names for it is handlebar palsy, comes from when guys riding or people riding like 10 speed bikes, road bikes, bicycles, the handlebars that curve down, if you lean on those too much, it can cause some compression of the ulnar nerve on the hypothenar eminence around about Guillain's
Causes of Ulnar Nerve Compression
00:00:40
joshmacd
canal. So let's talk about some of the implications with all that.
00:00:43
mmateri
yeah and I just want to add in it really i've seen this from many different types of handlebars so it could be I mean it's more prominent, I think, in the curved ones as well, but I think you know it wouldn't be unnecessarily um strange if you had it from a different type of handlebar as well so.
00:01:00
joshmacd
Yeah, and and it's certainly like tennis elbows, not only for tennis players. We see this with people who are resting their hand on their desk all the time while they're mousing. All kinds of different things. It's just the location there. Got
Zones of Ulnar Nerve Compression
00:01:11
joshmacd
its name from that. but um So there's a couple of different zones of it. When we think of a cubital tunnel, a carpal tunnel compression, it's this whole global thing because the compression there. But this one actually has some zones, depending on where the compression is. So we've got three different zones. Guillain's Canal runs between the PZ form and the hook of the hamate, and so if it is proximal to the hook of the hamate, it's zone one, and we have both motor and sensory problems.
00:01:37
joshmacd
on that distal aspect, if it's on the medial or radial side, it's go its zone two, and it's gonna be mostly, if not only motor ah motor symptoms. And if it's lateral or on the owner side of that hook of the hamate, then we're looking at almost exclusively sensory symptoms.
Differentiating from Other Conditions
00:01:54
joshmacd
And a lot of times these can be like, it's not exactly, it's kind of overlaps a couple. If it's mostly motor, then maybe it's more towards zone one, so it kind of can can have some blending of those zones.
00:02:06
mmateri
Yeah, it can definitely vary. And how do you distinguish this, say, from ah compression at the elbow, say, cubital tunnel? How are you differentiating the two?
00:02:14
joshmacd
So I'll do, yeah, I'll do a ah version of different like provocative testings. I'll do tenelles along the pathway of the nerve starting at cubital tunnel and working distal. I like to work distal because if I flare that up proximal and then work up, it can be hard to differentiate. like Is that a new tingling or tingling that's left over from five taps ago? So I'll start proximal and work distal, see if I can elicit some positive sign with tenelles. I'll do sensory testing down the lateral forearm, down in the hand. And then a compression where I'm actually like pressing on, almost like Durkin's of the median nerve. I'll just push on Guillain's canal over top of that. And then I'll also do like an elbow flexion test for tension to the ulnar nerve through cubital tongue to differentiate that.
Early Symptoms and Initial Treatments
00:02:58
mmateri
Yeah, that's very helpful. And I think we always know if it's just motor, then you can always be like, oh yeah, that's, I'm pretty sure it's that geons canal. But when they have the motor and sensory component, then it's like, well, how do we know it's not cute little tunnel? And that's far more common.
00:03:12
joshmacd
Yeah. And sometimes we catch patients early enough that the motor problem hasn't really developed much yet, that the early symptoms are just the tingling. And so it's like, well, it really bothers me, but they haven't like the the motor weakness hasn't set in yet. They maybe have lost some coordination, but we don't expect a lot of coordination on that side of the hand kind of to begin with. So it's not until we start testing more complicated things that maybe you would find that motor component if it is very early on.
00:03:39
mmateri
Yeah, definitely. Okay, so we now they have the diagnosis of a compression at Guillain's Canal. What are we going to do and offer for treatment with these patients?
Treatment Techniques and Lifestyle Changes
00:03:50
joshmacd
my first My first go-to when I've got a nerve compression is to decompress and and change their like whether it's their daily lifestyles, their their mechanics on things, sometimes it's splinting. I want to get tension off that nerve um because nothing can heal until we decompress and protect that nerve. So I'll usually start with making like an ulnar-based wrist support to protect that nerve pathway. um So we're not leaning on it, you're not banging into it, um and then we can keep it from compressing if we're sleeping on it at night in kind of that flexion position.
00:04:23
mmateri
Yeah. One thing I really like to do for these patients is recommend a proper bike fitting. Cause I think a lot of times, you know, people don't get a bike assessment done. And if they're leaning too far forward or those things, I think that can help them, um, make sure they have the proper fitting bike. I mean, unless it's caused from something else, of course, but most commonly I've seen it in bicyclists.
00:04:43
joshmacd
Yeah. and And it's maybe even modifying the equipment they're using, having them wear like writing gloves, padded gloves there, padding the handlebars, getting different grips on there. um Some of those things just to like like a lot of our modifications or or treatments, it's as much adaptive equipment and compensatory strategies, but that equipment can really help.
00:05:04
mmateri
Yeah, definitely. Or sometimes it's as simple as like lowering their seat on their bicycle. You're like, Oh, that was so easy. You know?
00:05:10
joshmacd
Yeah, a positional thing for sure. Then they're not putting as much weight in their hands and it can make a big difference.
00:05:14
mmateri
Yeah. Yeah.
00:05:15
joshmacd
Yeah.
00:05:15
mmateri
Sometimes it's the little things make a huge difference with these types of injuries.
Conservative Treatments and Surgical Options
00:05:20
joshmacd
Yeah. Any other big treatment techniques you like to use for this?
00:05:25
mmateri
um Similar to you, like I try to think you know do activity modification, ergonomics, but then also I'll go into doing nerve glides, things that make the nerve happy. Of course, if it's making their symptoms worse, we might do the nerve glide within a shorter range, anti-inflammatories, contrast baths, anything to get the swelling and inflammation down in that that region, I'll recommend those things as well. Usually, I feel like conservative treatment works pretty well for these patients. I rarely see them needing surgery in my experience. How about you?
00:05:58
joshmacd
Yeah, you can do so much with conservatives. The only time that I think it really warrants a referral to surgery is if it is a very long-standing problem that they've let go for a really long time. And the conservative, after trying it for you know maybe six six weeks or so just to see if it's gonna start to move the needle a little bit, if that's just having no impact and you start to get some atrophy, then we might say, well, maybe we need to go for more EMG testing and and possible surgical, but that's like way far down the road.
00:06:27
mmateri
Yeah, I would say that these respond better to conservative treatment than carpal tunnel does. Um, and I think it's just by doing some simple interventions that usually works pretty well. Another thing is if your monomophilament or your two point testing scores are really outside of the normal range, I might refer them to a surgeon sooner than later as well.
00:06:46
joshmacd
Yeah. Yeah. And
Measuring Progress and Medication Impact
00:06:47
joshmacd
so that's one of the reasons why it's so important to have lots of good objective measures on the front end, provocative testing, sensory testing, manual muscle testing, um all those things so that you can both identify where they're at at the beginning, how big of a deficit is this, and then give objective measures to progress them along so you can justify to them, to a doctor, to an insurance company, the effectiveness of what you're doing. You got to have that evidence to support.
00:07:10
mmateri
Yeah. If they're, yeah, if they're getting better fine. If not, I would definitely refer them, refer them out for further testing. And then what they do surgically, I know sometimes they'll do a cortisone injection or sometimes they'll just release the canal as well.
00:07:17
joshmacd
yeah
00:07:23
mmateri
I think depending on the severity of an injury and also, um, I want to bring up another thing is if they have a fracture in there, like sometimes you can have an undiagnosed like hamate fracture that they may not be aware of. So I would look for like point tenderness, um, in that region as well.
00:07:39
joshmacd
Yeah, yeah. The nerve compression should not result in specific point tenderness um with like like um pressing on it. That's a positive sign for for fracture indicators. So yeah, that's definitely a ah warning sign.
00:07:53
mmateri
kinds of fractures, yeah. tender there You could also have like a tendinopathy in that region that could have some tenderness, but ah so I would check, you know, just differential diagnoses and testing.
00:07:55
joshmacd
Yeah.
00:08:03
mmateri
I would test resisted um like ulnar deviation and ulnar fasciid flexion. I would test those two just to see if that recreates in on their symptoms because they could have a little tendinopathy as well.
00:08:14
joshmacd
Yeah, yeah, all possibilities.
00:08:15
mmateri
That could be making ulnar nerve symptoms worse. so
00:08:19
joshmacd
Yeah. um You mentioned something earlier. I'm curious on your answer to something. If you have a patient with, let's just call it a um distal peripheral nerve compression, cubital tunnel, carpal tunnel, this, how long do you go of treating them before you say, yeah, we're just not making a big enough difference to warrant continued conservative. You need to go see someone else. How long do you give that?
00:08:41
mmateri
So, you know, like most things, is it depends on the severity of it.
00:08:43
joshmacd
Okay.
00:08:45
mmateri
So I would just say with the mild case, if they've had a mild case that's been going on for four to five months, I would probably say, hey, it's been going on four to five months. You've got to give me at least two months to try to see if we're moving this in the right direction. But if it's more severe, we might be doing something for like three, four weeks and see if it's budging at all and then send them out because I don't want them to have prolonged de-innervation to those muscles that could lead to long-term damage. Um, and then if it's an acute case, I would say we should see it moving quickly in that direction within, uh, you know, maybe three to four weeks.
00:09:19
mmateri
So it just depends on how long they've had it going on and the severity of it.
00:09:19
joshmacd
Yeah, yeah.
00:09:23
mmateri
How about you?
00:09:25
joshmacd
That's pretty much where we're at, too. We get a lot of referrals right now from two different neurologists' offices. um And a lot of times, it's a diagnosis of carpal tunnel. And it ends up being this big, ambiguous, on interview and assessment. They're like, oh, I've got peripheral neuropathy. And I've had neck pain for a long time and I've got numbness in both feet and numbness in both hands, the whole thing. So it just kind of becomes this whole thing. And then we've got to decide, like, what is our ability to help this patient? And how long do we go before they, you know, if they say, yeah, this this isn't working.
00:09:56
joshmacd
Well, two weeks in, yeah, you got to give it time. Where's your threshold for at some point? We got to see some tick up and improvement. I may not be able to make it all go away, but I can give them some relief of symptoms. So just a good, good question to to consider.
00:10:09
mmateri
Yeah. Well, and then that's the other thing too. Cause we get a lot from a neurology near us to an early ology office near us. If they have gone to the neurologist and the neurologist gives them the prescription of gabapentin or something like that, you know, and they start taking that at the same time they start therapy. There's then sometimes you're like, well, maybe it's my therapy or maybe it's a gabapentin. So I always ask the patients too, when did they start that? Um, because I think it can impact, you know, we might get some false positives that therapy is helping them. based on that medication response, or vice versa.
00:10:40
joshmacd
Yeah.
00:10:40
mmateri
It might be the therapy helping them and not the medication.
00:10:43
joshmacd
Right, right. I like to try to change one variable at a time, but when patients just want to feel better, they may say, give me everything at once and we'll do whatever works.
00:10:51
mmateri
Yeah, and then maybe they have to wean off the gabapentin later, and I always educate them on that too.
00:10:55
joshmacd
Yeah.
00:10:56
mmateri
You know, I know the neurologist does well, but gabapentin, they're not medications you can just cut off. You usually have to wean them off
Additional Resources and Contact Information
00:11:03
mmateri
too, so.
00:11:03
joshmacd
Yeah. Yeah. All right. Lots of interesting stuff. Um, if you have any questions on this, you can certainly check out a blog post we put up not long ago about a handlebar palsy and talks about some of the zones with a really good image of it. Um, but definitely reach out to us on our email, handtherapyacademy.com, uh, excuse me, info at handtherapyacademy.com or on our social media pages.