Case Study – 83 Year Old Female

Physiotherapy initial

Client presented with first signs of Dupuytren’s contracture (a condition in which one or more fingers become permanently bent in a flexed position. It usually begins as small hard nodules just under the skin of the palm) on the 3rd finger on right hand, creating dry and pale skin with adhesion’s in the pathway of the 3rd finger flexors tendon limiting its movement. A year ago Norma stated it started affecting the carpal tunnel compressing the median nerve creating paresthesia on 3rd and 4 finger.
Her grip in both hands is weak, but even weaker on her right hand. Things has been falling from her right hand lately as she has been unable to keep grip.
She had a fall two years ago falling on her right arm and fractured T8 to T12.

I believe lack of strength is due to the muscle tension in both shoulders and arms. With her consent, massage to the right hand, forearm, biceps, pectoral and infraspinatus muscles is performed, to free the median nerve and reduce tension throughout the muscle chain.
She feels much better after the massage, feels she has a better grip and the paresthesia is now just on the tip of her 3rd finger.
I showed her mobilisation of the median nerve, and a mild stretch of the pectoral-biceps-forearm-hand to do at home everyday.
Norma agreed to gradually increase the physical activity as well as include a daily soft massage with moisturising cream on her palm.

Follow Up Appointments – 60minutes Sports Massages

During the next 2 appointments we keep working on the same areas until the tension is completely reduced around the shoulders and arms.
Next we focused on keeping the right forearm/hand relaxed and start breaking adhesion’s in the hand/wrist by massage and mobilisations.

Norma noted she started to feel some itchiness during the night on the hand and 3&4th finger.
I suggested a cream and a glove, and a orthosis to keep her wrist straight whilst sleeping.
After following these instructions Norma found the itchiness less intense and it is now only affecting her 3rd finger tip.
As her grip improves she feels more secure, confident and things are not falling any more from her right hand.
I recommend to keep gradually increasing the intensity and amount of activity.
By the end of the process she is feeling secure when grabbing things, and nothing has fallen from her hand lately.

Her grip is now uniform, fast and strong. The skin has improved so much that it is now nearly as good as her good hand (left hand), no dryness, good colour and nearly normal flexibility.
She can fully extend her fingers after the treatment (not yet hyper extension).

30 minutes Sports Massage – Final appointment

In our final appointment I can see the hand is a bit drier because of the cold weather but everything else is good. Norma has not dropped anything for more than 6 weeks now.  The grip is strong but it seems to take 3 seconds or so to achieve full strength.

With Norma’s consent today I performed massage to the right hand to improve circulation and reduce scar tissue. I did a bit of massage on the right rotator cuff muscles which are starting to get a bit tight and are affecting the grip. Plus some massage to the fingers extensors. The grip is now in 1-2 seconds for full power and the skin is much softer.
Tendons are not offering any pathological resistance, fingers now have normal hyper extension except for the proximal interphalangeal joint in 2nd and 3rd fingers in both hands which do not reach full extension, which is most likely caused by mild Osteoarthritis. I showed her exercises to prevent this from worsening.

I recommend she keeps doing the exercises including the shoulder exercises and stretches and include general exercises to create more length on the front torso muscle chain to avoid leaning forwards with the upper body.

These photos show Norma’s hand after the treatments showing full extension of the fingers with skin of good colour and no dryness.

Thank you to Norma for allowing us to document your progress and appointments with Raul.

By Raul Hernandez Girones, Physiotherapist