Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Saddle Syndrome
506 Plays5 months ago
Miranda and Josh talk about saddle syndrome based on an article that Josh had written and published
Recommended
Transcript
Introduction of Hand Therapy Academy and Published Article
00:00:06
Speaker
I'm Josh McDonald and I'm random material and we are hand therapy Academy. So today we're going to be talking about an article that Josh had published. Um, and I was just asking him a few questions about it. And if he could explain it to, um, our listeners, I think it's a really interesting article about saddle syndrome.
00:00:25
Speaker
Yeah, so back in 2020, after probably a year or two working on it, our mentor Cindy Ivey and I published an article, it's a unique discovery of saddle syndrome after elbow fracture dislocation. It's in the Annals of International Occupational Therapy in 2020. And it's an article kind of giving you an anatomical description and clinical presentation of what happens with saddle syndrome.
Origin and Collaboration on Saddle Syndrome Article
00:00:47
Speaker
This patient fell on an outstretched hand, had an elbow fracture and dislocation, but was having all kinds of hand pain as well. And so clinically, what we found was that he had pain with an intrinsic minus position. And so I'm very new to hand therapy. And Cindy comes over and says, Josh, we should take a look at this. And she says, oh, this would be a great journal article. So we started putting together a case study on things.
Understanding Saddle Syndrome
00:01:09
Speaker
And
00:01:11
Speaker
came to this like final project. Basically, saddle syndrome is when you have adhesions between the palmar, interosseae, and the lumbricles. And when they adhere to each other or adhere to the deep transverse metacarpal ligament, which stretches across all of the metacarpals deep down inside there, you get pain with motion that pulls those adhesions apart. So if the adhesions are to the deep transverse metacarpal ligament,
00:01:39
Speaker
then elongation and doing an intrinsic minus position pulls those scissored adhered muscles away from the deep transverse metacarpal ligament and pull as painful as it's pulling those adhesions off. The opposite is if they've just adhered to each other. So if the pulmonary ostei and the lumbricals adhere to each other alone,
00:02:01
Speaker
Then when I do an intrinsic plus position and I have proximal excursion, then that deep transverse metacarpal ligament serves to separate or like divide those as they proximally advance down. And so that becomes painful as that adhesion tears apart during intrinsic plus. So there's kind of two versions of it that we explained in this article. And they're both called the same thing. You're not calling them like, Saddle Syndrome 1, Saddle Syndrome 4.
00:02:28
Speaker
Correct. Saddle syndrome is adhesions of pulmonary ossi and lumbrical and it can be painful one way or the other. Okay. Got it. Yeah. And then how did you like determine that that patient had that? So we did, um, pain with palpation, um, specifically to that intermetacarpal space, um, that was present in an otherwise non injured hand with fractures, soft tissue injuries. It was because he had this, um, this
00:02:57
Speaker
soft tissue landing and injury and then immobilization for a while that allowed those adhesions to sit in. He had some also pain with abduction of the fingers because that then also pulls the palmitar ossi away from the lumbricals. So that causes more of that shearing tearing of those adhesions.
Challenges in Diagnosing Saddle Syndrome
00:03:16
Speaker
And so what we did was we worked on just different types of the six pack of tendon glides. We worked on abduction, adduction exercises, and we worked on self and passive range of motion to get improved glide and basically breaking up the adhesions that we knew were in there. And then that was successful.
00:03:37
Speaker
Yes, within probably three to four sessions of addressing that specifically, that pain had resolved entirely, which was great. Knowing what I know now, I might, if it was a persistent case and his was not, I might have looked into things like maybe dry needling,
00:03:54
Speaker
or I stim in there to help break up some of those adhesions but it's very very deep so some of those superficial methods would not have been as successful but it was really one of those things that you like if you address it early it can be a really non-issue but if not it can lead to a stiff hand that's stuck or
00:04:12
Speaker
not able to go into one of those two positions and can lead later to a lot of those chronic stiff hands that we see that are, you know, they kind of look like CRPS. It's a fall on a, you know, a distal radius fracture, falling out stretch hand, and they get these stiff, painful fingers. And a lot of times it's a saddle syndrome presentation that then becomes chronic and inflammation spreads and sensitivity increases, all of that.
Identifying and Treating Saddle Syndrome
00:04:37
Speaker
Interesting. What do you think the incidence of this is?
00:04:41
Speaker
We have, we weren't able to find that all that much. Um, there's only been like one or two other articles coming out on saddle syndrome since we kind of like keep an eye on it and see if we're, you know, if we're mentioned in their, um, references or whatnot. Haven't seen an incidence rate, I think a lot of times because it's an overlooked thing. Um, and now it's something I go looking for when we're working on
00:05:02
Speaker
you know we measure abduction and adduction of digits and you know you go to the tendon glides and if they have a particular pain in in a hook fist or a tabletop then that kind of leads me to believe like okay maybe we're having some deep inside pain here we need to address that and just work the soft tissues and and put some effort into that so then when you're like identifying it like say in your current caseload do you have a patient that has that are you saying this patient presents with symptoms associated with saddle syndrome are you like calling it that and doing
00:05:31
Speaker
Yeah. Yeah. So I'll make reference to that and then I'll do a little narrative description because it's not like a type one, type two thing. So I'll say patient presents with symptoms consistent with saddle syndrome with pain during intrinsic minus position, both active, maybe with both active and passable, not typically with passive, but with active range of motion.
00:05:49
Speaker
and has pain, you know, just description of the pain and location and presentation so that it's easier for either another therapist who may not know or if a surgeon is reading this like, oh, okay, that's maybe why they have pain in the palm and it's, you know, there's no injury there and they kind of get gaslighted a little bit about like, oh, your hand is fine, just move in therapy, stretch more aggressively and let's maybe target the structures that are injured.
00:06:12
Speaker
Yeah, and I was thinking when you're talking about it, how you could splint them essentially kind of in the opposite of what right to like free up the adhesion. Yeah, yeah. And so it's I wouldn't necessarily do like
00:06:25
Speaker
all like a like a persistent all-day kind of splint but yeah give them something that's like even like a that soft vel foam strap that they can like work to pull into that tension position to to get distal excursion or if it's into a tabletop position maybe give them something that's like a volar piece and then they can work to pull their fingers down just to give them that stretch that's more than they can just hold for a movie or something.
00:06:48
Speaker
Yeah, I was almost thinking about like when we have patients that maybe just bend at their MCPs but don't flex at their PIPs, right? So a lot of times I'll put them in like, I'll wrap a splinter on their MCP so they're forced to load the PIPs. I was almost thinking something like that.
00:07:04
Speaker
Yeah, absolutely. Almost that CMMS style splint. Yeah. Yeah. And I think that is why sometimes we end up with those chronic stiff hands because we have that saddle syndrome presentation that is this chronic, like they're, they're guarded against that painful movement and then it snowballs into this bigger thing. Well, that's the same splint I would use to treat a saddle syndrome if I want to do a blocking movement.
00:07:28
Speaker
Right. And then they have this weird movement pattern and you're trying to fix that. Yeah. Yeah. So you can't always catch it early, but if I have a distal radius fracture patient and I'm doing the normal, you know, working through all of my eval stuff and I measure fingers and I say, I'm not just doing extension and composite flexion. I'm saying, all right, give me this hook fist position. Give me tabletop just to see how those intrinsics are moving with abduction. If I can see that early, we may be able to preempt all of that other stuff.
00:07:55
Speaker
Right. And the reason why we give so many people tendon glides, right? Because sometimes I have students be like, well, can't we just, you know, have them open and close their hand? And I'm like, well, no, you really need to do the differential gliding, the hook fisting to prevent those type of problems.
00:08:09
Speaker
Yeah, yeah. So just a bit of a quirky little diagnosis, but I learned a ton by doing the article we did while we were in Mayo Clinic and they did some fantastic drawings. They have an anatomy artist on site that does these amazing drawings.
Accessing the Article and Engaging with Audience
00:08:23
Speaker
And so we had long conversations and really cool experience to kind of learn that process. Yeah. Is that an open access journal? Like can people go and find it or is it where you have to?
00:08:43
Speaker
Yeah, yeah. So yeah, I'm not sure, but if you do just a Google Scholar search for it, it's a unique discovery of saddle syndrome after elbow fracture dislocation in the annals of international occupational therapy. If you also do a Google search for just the images of saddle syndrome, I think the images in that article pop up and you can kind of like go to source and it'll show you. So I think those images are now in the algorithm.
00:08:59
Speaker
That's a good question. I have access to it, so I don't know if it's open access or not. I should probably figure that out. I'm not sure exactly.
00:09:08
Speaker
Yeah, that's very cool. Yeah. All right. Well, if you guys have any questions about that, or if you see that in your patients, comment below, give us some idea of what you're seeing with maybe potential saddle syndrome patients, or you can reach out to us on our Instagram at hand therapy academy or email us at info at handtherapyacademy.com.