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Letter: ‘Proof’ about Carpal Tunnel Syndrome Published on Saturday, August 18, 2007 Dear Sir, I would like to respond to Ms Christina Dumal’s letter of August 2, 2007 in which she asked for “proof” of my statement that repetitive activities, such as using a computer keyboard, are not the cause of carpal tunnel syndrome. Her concern allows me to elaborate on certain points which were not addressed in the series, The Truth About Carpal Tunnel Syndrome (CTS) which recently appeared in your newspaper. No, we don’t yet know what causes carpal tunnel syndrome. We don’t know exactly what causes the diffuse tendon sheath thickening in the carpal canal that then compromises the median nerve. However, we do understand the pathophysiology and know that certain medical conditions predispose patients to developing CTS: rheumatoid arthritis, diabetes, thyroid conditions, even menopause. It is entirely possible that future research will determine that in certain patients, obesity, genetics (inherited traits such as the structure of the carpal tunnel canal) and even today’s often poor, high fat diet, or excessive alcohol and caffeine consumption may be contributing factors that produce metabolic changes leading to CTS. We already suspect a strong metabolic connection. I’d like to make the analogous comparison to our knowledge of cancer. We understand the histology, cell types and progression of the disease, but we don’t really know the cause—likely aberrant genes, perhaps triggered by undiscovered viruses or prions—and certainly not some simple activity. Ms. Dumal asked for proof that carpal tunnel syndrome is not “work related” and by that I assume she means caused by jobs that require repetitive motion activities. That proof can be found in findings of numerous scientific studies conducted during the past 15 years, many of which have been published in leading medical journals, including the Journal of the American Medical Association (JAMA). One of the leaders in CTS research is Dr. Peter Nathan of the Portland Hand Surgery and Rehabilitation Center in Portland, Oregon. His landmark 11- year study, involving of hundreds of subjects representing a very diverse range of ages, was one of the first definitive studies that found no relationship between repetitive activity and the compression of the median nerve within the carpal canal. That compression of the nerve is what causes the symptoms of CTS. Another often cited study conducted by Oregon State University’ medical department reinforced this finding, as Dr. Richard Kinston, working with Dr. Nathan confirmed: “In fact, the job studied requiring the most intense repetitive motions, keyboard data entry, actually had a significantly reduced risk for CTS in over 2600 subjects studied. Ongoing studies conducted at the Mayo Clinic in Rochester, MN continue to provide the proof Ms. Dumal seeks. Many of these published findings can be accessed online through university and public library systems, often at no charge. These and other epidemiological studies have demonstrated that so called” repetitive stress injury” has no relationship to compression neuropathies. There are other well-known researchers whose studies have shown that people with repetitive motion jobs don’t experience any more aches or pains in their hands than the population at large. Despite published scientific data that repetitive activity is not the cause of CTS, this mythical link seems impossible to correct. The media, and even members of the medical community, choose to ignore the evidence refuting this fallacy. If in fact, repetitive activities “caused CTS” then every computer user, video game player and typist would develop CTS. Much of the world’s professional work force would be disabled due to such widespread computer use. Not only is this obviously not the case, but many CTS sufferers I have treated have never used a computer or keyboard of any kind, or performed any repetitive activities whatsoever. Ms. Dumal asks why “recurrence is so high (for CTS) when one returns to the same job that involves what many researchers believe contributes to this syndrome, such as repetitive motion…” This is simply not true. Resuming prolonged repetitive activities can aggravate the symptoms of CTS once a patient experiences the onset of those symptoms—this is not a “recurrence of CTS.” Logically, how could you expect to do the same thing and have different results? An important component of conservative treatment advises the patient to change his work habits if the job requires such activities; take breaks from those activities frequently, rest, and stretch. With proper evaluation by a hand specialist and early treatment, the majority of patients experience relief from CTS symptoms. If a patient fails to respond to conservative treatment, then a simple surgical procedure called endoscopic carpal tunnel release, discussed at length in the series, has proved extremely effective in relieving CTS symptoms and those symptoms have a very, very low recurrence rate. I hope that if Ms. Dumall herself is suffering from CTS symptoms she will overcome her suspicion and fear and be evaluated by a hand specialist. I welcome any readers with concerns or questions to contact me through my website, https://www.drbadia.com/. It’s important to understand the medical facts about CTS and know that treatment is not only available to you, but also quite simple. Dr. Alejandro Badia Miami, FL

Traumatic sports Injuries to the fingers and thumb are commonly occurring, occasionally career ending, lesions to the competitive athlete, particularly cricket players.

While often neglected, these injuries can occur in both contact and non-contact sports due to the crucial role the hand plays in many sporting activities. Unfortunately, these rarely receive much attention by the trainer or traditional team doctor, and it is only when the pain, swelling and functional deficit persist that the patient is referred to the hand surgeon specialist. The injury is often given the misnomer “jammed finger”, yet a clear diagnosis is rarely established, and this can have disastrous long term consequences to hand function and consequently, athletic performance.

Digital injuries usually occur via an axial impaction mechanism in ball sports, while twisting injuries are seen more in contact sports. Regardless, the injuries can range from simple collateral ligament sprains, to tendon avulsions, or even complex articular fractures. The exact diagnosis will determine treatment and the time of return to sport. Thumb injuries overwhelmingly occur at the critical MCP joint, with ligamentous injuries requiring careful deliberation if operative intervention is needed. Early assessment will allow for the appropriate type and position of protective immobilization, often allowing continued play. More severe injuries, requiring surgical intervention, are also best treated early as this will lead to the best possible result and then allow faster return to competition. Articular fractures of the PIP joint are good examples, in that delayed recognition will completely alter the treatment options. For example, a complex fracture dislocation may be amenable to dynamic external fixation if assessed within first ten days, but delayed evaluation and treatment may then require a less predictable reconstruction, such as hemi-hamate arthroplasty. Arthroscopy, particularly at the finger or thumb MCP joint, provides a less invasive and more accurate way of assessing chronic pain issues at this joint. Acute injury, such as a bony gamekeeper’s fracture, can also be more optimally treated via arthroscopy, avoiding the scar formation that can delay recovery and return of necessary motion.

Finger injuries are commonly seen in Bahamian cricket athletes and early recognition is key. Team physicians, trainers, coaches and cricket players themselves must learn that optimal long term function depends on early, accurate diagnosis and the hand specialist should be involved from the onset.

Deep persistant pain in the shoulder can affect young and old alike. The causes, however, can be very different and require a thorough diagnostic process to understand the underlying problem and lead to a solution. Young, active patients often feel that there is an overuse syndrome. This may be the case, but it is important to understand why. Current exercise regimens usually emphasize strengthening the deltoid muscles, but the rotator cuff is largely ignored. This leads to an instability syndrome that can cause pain and even worse, a mechanical deficiency of the shoulder joint. If this is a chronic problem, with no history of a single traumatic event, the patient will usually respond to a strengthening therapy protocol that requires diligence on the part of the patient and therapist.

The most common cause of shoulder pain in older people is known as impingement syndrome. Bursitis is often an element of this syndrome and this frequently used term is much more accurate in depicting the problem than the term “arthritis”. Impingement refers to the mechanical process where the overlying bony arch of the shoulder (acromion of scapula and clavicle) is pressing on or rubbing on the underlying rotator cuff tendons and bursa. With age, the blood supply to the rotator cuff is diminished, and small microtears in the tendon leads to tendonitis and bursitis and even larger tears. This situation may respond to conservative treatment including a cortisone injection to reduce the bursitis, and shoulder therapy to improve the strength of the intact rotator cuff.

What does it imply to have a complete rotator cuff tear?

A complete rotator cuff tear implies that the torn tendon has pulled away from the bone and hence, cannot stabilize the head of the humerus against its cup joint (glenoid). The patient will either be unable to physically raise the arm or they can do this only with severe pain. This whole range of impingement problems is characterized by pain with elevation of the arm, pain worse at night, and inability to lie on the side of the affected shoulder. Once the pain is severe enough and does not respond to therapy and other conservative means, then surgery is indicated. Some smaller tears can be repaired through arthroscopic means, but larger tears are usually repaired through a traditional incision. Most repairs require a one month period of immobilization in a sling and several months of post-operative therapy closely directed by the surgeon. Local Barbadian, Karen Meakins, managed to win her 12^th straight squash national singles title barely 6 months after similar arthroscopic rotator cuff repair, and then went on to take 4^th in the world masters championship !! Many other citizens of Barbados also had arthroscopic rotator cuff repairs by Dr. Badia including local prominent physicians and community leaders. Shoulder pain should not be ignored and requires appropriate diagnostic studies and examination by a shoulder specialist. Dr. Alejandro Badia, Hand & Wrist Surgeon Miami, FL

Treatment for injury, inflammation, pain

By ANNE HILTON published of Page 10 of NEWSDAY SECTION B Tuesday, Feb 4, 2014

HAVE you ever stopped to consider what you’d do if you weren’t able to use your hands, if the hand you favour, the right or the left, were injured? I had a wake-up call when I developed “trigger thumb“. In fact I didn’t know it was trigger thumb until I got an email from Newsday’s Features Editor forwarding an email headed “Caribbean Hand Centre Foundation, founded by Dr. Alejandro Badia, celebrates Fifth Year Anniversary” with a request that I interview Dr. Badia…. Click on the article to read what happened next…

Bahamian patients often travel to Miami to undergo endoscopic release of the median nerve since in the Caribbean nations, the procedure is currently done via an open incision with is much more painful, takes longer to recover and may require rehabilitation. We have good relationships with therapists in Nassau, Freeport etc but fortunately, most patients with carpal tunnel release require no formal therapy and have complete relief of their painful numbness. Procedure is done with local anesthesia requires only a 3 day stay in Miami (Doral) and patients can use the hand immediately.

Dr. Alejandro Badia knows hands. He should, he has performed surgery on enough of them. The Florida-based surgeon operates on the hands, fingers, upper limbs or shoulders of about 25 patients a week. He estimates that 30 percent of his patients come from overseas and a majority of those are from the Cayman Islands. On a recent visit to Cayman, the doctor combined follow-up consultations for patients with presentations of some of the latest in surgical techniques that he performs at Badia Hand to Shoulder Center in Doral, Florida. Ian Downing, who injured his arm while weight lifting, visited Dr.Badia in Miami on Tuesday, 16 November. Three days later, on 19 November, when Dr.Badia was in Cayman giving a presentation at A Step Ahead Physiotherapy in Governor’s Square, he got his follow-up consultation. “That’s the thing about minimally invasive surgery, it’s all so quick. I went for my first consultation on Monday, was operated on Tuesday and headed back to Cayman on Wednesday,” Mr. Downing said. He underwent a procedure involving the Platelet Rich Plasma therapy, in which the plasma is injected into the affected area to stimulate and enhance healing. Another patient, Andy Scott, underwent more complicated surgery. He broke his finger when he slipped on stairs, but did not seek medical attention for three weeks because he thought he had merely sprained the finger. His operation, done by Badia last month, entailed having a piece of bone from the back of his hand grafted onto his finger bones. “It’s surprising how injuring just one finger can put you out of commission. Things like tying your shoelace and buttoning your shirt become difficult,” Scott said as he waited for Badia to see him. Badia said it was common for patients, like Scott, to fail to seek medical attention quickly, but this often led to complications. “People need to understand that if they have an injury or problem, you take a big risk when you just assume it’s OK, that it will just get better. You have a window of opportunity. If I had seen [Scott] in the first week, it would have been a totally different operation,” the surgeon said. Badia, who is chief of hand surgery at Baptist Hospital, works on a variety of hand, arm and shoulder problems, including carpal tunnel syndrome, nerve problems, arthritis, acute trauma and work- or sport-related injuries. He said many people do not realise that the pain they put up with on a daily basis can be rectified by treatment. “There are lots of things we can do for people who have ailments they think they have to live with,” the doctor said. The prevalence of Cayman Islands residents among his patients is not because people in Cayman were particularly clumsy or break more hands and arms than people in other places, but because he is often referred by patients in Cayman he has operated on or by doctors who have sent patients to him before. The surgeon explained that he got into the specialised field of upper limbs while studying orthopaedics. “I realised that you could really get people better, you could make the most difference there,” he said. But, he admitted, that when opting for his chosen field, he was probably thinking of his grandmother who suffered from crippling rheumatoid arthritis. He recalled that when he was eight or nine years old, she went to see a hand surgeon in New York City in the 1970s, but because of insurance issues, she could not undergo the joint replacement surgery the surgeon recommended. “I was very close to my grandmother. Somewhere in the back of my mind, I was drawn to this field because of her. She passed away when I was pre-med,” he said. One of the most common injuries the surgeon deals with are wrist fractures, which often happen when a person tries to break their fall by putting their hands out in front of them. Perhaps his most complicated surgery was the “re-re-attachment” of a woman’s arm. “Her arm had been ripped off in a motorcycle accident in Venezuela,” he recalled. The woman’s arm had been initially reattached, but blood flow to the arm had eroded and infection set in, so he had to detach the arm and re-attach it again. “That surgery took 14 hours,” he said. The surgeon insisted that the operations he performs work in tandem with rehabilitation and exercises the patients does after the surgery. “It’s a whole process. It’s a team approach. The physician has to work closely with the therapist, and luckily, there are a lot of good therapists in Cayman,” he said. During his trip to Cayman, Badia met several of the physiotherapists who work with his patients. Download Article » Article Link »