STIFFNESS

What is stiffness?

There are 2 types of stiffness: it can mean a reduction in the overall range of movement i.e. the extent of the bending or straightening possible in a joint or series of joints; and it can mean a lack of easy flow within that range of movement. They tend to occur together. In particular most joints with a lack of full movement have some stiffness within the movement available. This is not, however, inevitable. Each type of stiffness can be disabling. Both tend to be more marked in cold and wet weather, known as "cold intolerance".

Hand stiffness dueto Rheumatoid arthritis


Why does it occur?

Stiffness can be due to joint problems i.e. the underlying structure is abnormal or it can occur due to soft tissue problems which prevent full movement.
Joint problems: The commonest cause is arthritis in a joint (see information sheet). Essentially the lining of the joint wears and the joint responds by producing more lubricating fluid to help and more bone at the edges to stabilise the joint. These restrict movement and may be painful which causes further limitation of movement. Other causes include joint malalignment due to fractures or very uncommonly bony growths around a joint that block movement.
Soft tissue problems: The soft tissues are any tissues that are not bone.In the hand these include skin, fat, tendon, nerves, arteries and veins and joint capsule (joint capsule problems tend to be thought of as joint problems as that is their main cause). Any of these structures may limit movement: skin contractures occur following injury particularly burns but also severe injuries where skin is lost and sometimes contractures in the skin occur following surgery; fat is very infrequently a cause of loss of movement except in very obese people; tendon problems commonly cause stiffness either due to inflammation around the tendon, a tendon lump catching (trigger finger - see information sheet) or tendon contracture which can follow injury or be secondary to long-term stiffness e.g. Dupuytren's disease (see information sheet) and thus prevent full movement even after the primary problem has been addressed; nerves may become attached to scar tissue following injury or surgery. When the joint is moved the nerve becomes stretched as it cannot glide normallt through the tissues. This is often painful thus limiting movement; arteries and veins rarely cause reduced movement unless either there is a growth associated with thes e.g. a haemangioma (benign blood vessel tumour) or possibly if they are caught up in scar tissue; joint capsule often thickens due to a joint injury such as following an accident or surgery. It also tends to contract if the joint has been held in a stiffened position for some time. The soft tissues cause stiffness through a combination of tightness preventing movement and pain restricting how much a patient wants to move a joint. These occur easily following surgery and hence the importance of careful post-operative care.

What happens if nothing is done?

(This is referred to as the natural history i.e. what happens if Nature runs its own course.) This depends upon the cause. Some conditions will settle on their own (or with treatment - see below). Some conditions will remain static and others will progress. Where the underlying cause is not progressing such as skin contracture following an injury months or more ago or an established joint contracture following injury then the stiffness tends to stay the same. Where the underling cause is progressive such as Dupuytren's disease or joint arthritis the contracture will typically progress. Obviously it is crucial to sort out between these to help guide treatment. Once a patient has any functional limitations they should seek the advice of a Hand specialist for assessment and guidance even if not for any specific treatment.

Hand stiffness dueto Rheumatoid arthritis

Making the diagnosis

The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking at some or all of the neck, elbow, wrists and hands. Individual joints and combined movements will be tested. These may be a little uncomfortable but should not be painful.

Hand stiffness dueto Rheumatoid arthritis

What test(s) might be performed?

Tests (also known medically as Investigations) include X-rays, scans, blood tests and particularly in the hand electrical tests (known as EMGs or Neurophysiology). These may be used to help make or confirm a diagnosis after a patient has described their symptoms and been examined.
In many cases the diagnosis is usually obvious after listening to and examining a patient. If not the commonest tests is an X-ray which shows bone and joint alignment and structure. This will typically be performed on the same day as the consultation. The only other likely test (and that is infrequent) is an MRI scan.
An MRI scanner is usually a short tunnel which the patient's arms and top half of the body go into. Once in the tunnel a loud magnet is spun around and images of the bones and soft tissues created. Some people find the tunnel rather claustrophobic. If any patient doubts whether they would tolerate the scan they are best advised to visit the scanner department in advance. The films will be reported by a radiologist but also reviewed by the Hand specialist who will advise the patient accordingly.


Treatment:
What are the non-operative (non-surgical) treatments?

Treatment should start with non-operative options. These will depend upon the specific diagnoses. In general the steps are to reduce pain and then undertake prolonged gentle stretches to improve the movement.
Pain: The first step is activity modification which the patient may well already have tried. Pain killers (analgesics) particularly anti-inflammatory analgesics, such as Ibuprofen (Nurofen) and Diclofenac (Voltarol) can be very helpful for the pain. These can be applied as a gel, massaging the area, or taken orally, assuming there is no history of indigestion. A splint for certain activities can also be of value. A splint on the end of the finger may prevent it being knocked during certain activities and can rest the joint. If these measures are insufficient then a steroid injection would usually be recommended. An injection is given of a long-acting steroid, such as Depomedrone or Triamcinolone, with some local anaesthetic into the joint at the bottom of the thumb. The body naturally produces steroids to help dampen down inflammation. This appears to be one of the actions at this site. Success cannot be guaranteed but in 70-80% of patients there is some significant benefit. How long this lasts is unpredictable. Some people only have a few weeks or months of benefit. Others may have years or even life-long benefit such that they do not require further treatment, although may still have some mild on-going symptoms. If one injection provides only short term benefit then it may well be repeated. Patients often ask how many injections can be given. There is no set rule about this. Typically, however, a second injection will work a little less well than the first (although this is not inevitable). By the time three injections have been given, if this is over a shortish period, i.e. less than 1 year, then it is unlikely further injections will be successful and most surgeons would recommend an alternative approach. There are risks. The biggest risk is of failure. There are risks of some pain for a few days, although that is usually minimised by taking pain-killers, starting while the area is still numb from the local anaesthetic. In theory there is a risk of infection, but this seems very rare and has not occurred in our Practice in over 10 years. The main other risk is some thinning of the skin. This can present with some pallor and a little less bulk at the site and occasionally an increased tendency to bleeding if the area is knocked. This is not common with this injection but is common with some other injections. If it does occur then that is a relative contra-indication to further injections, i.e. the patient's surgeon would probably decide not to go ahead with further injections because of the risks of further local damage. If these interventions fail then surgery may well be required depending upon the patients symptoms. In general whilst pain persist then efforts to improve movement will have limited success.
Movement: It used to be thought that with efforts to regain movement the patient had to suffer a bit: "no pain no gain". This is probably counter productive in most cases. Rather the ket is long slow gentle stretches. Ideally these should be performed for 5 mins in each direction (feeling the stretch but without pain) once an hour. In practical terms most people mange 5-6 times a day. Stretches can be helped by splints especially for wearing at night where there is an opportunity for prolonged gentle stretching.
Even with optimal non-surgical treatment many patients will require surgical treatment if they are troubled enough.


What are the operative (surgical) options?

The surgical options depend upon the cause (see specific information sheets). In general:
Joint problems: The joints can be "cleaned out" (called debridement) usually with release of any contracted joint capsule/ligaments. Mostly this is done as an open procedure but for the larger joints - wrist and elbow - this can sometimes be performed arthroscopically (key hole surgery). The clean out may not be sufficient and at the same time or later a joint replacement may be performed.
Soft tissue problems: The first step is to address any causes of pain such as inflammation around tendons (tenosynovitis - see under trigger finger) or trapped nerves. This may suffice in allowing return of movement. Otherwise surgery is directed at removing the physical limitation such as a band of Dupuytren's disease or contracted skin. For skin in particular new tissue i.e. new skin may need to be brought into the hand such as with a skin graft.


What are the results of the operation?

The results vary greatly depending upon the cause. With a sensible approach and in particular realistic expectaions then most patients are reasonably satisfied. Plainly the more sever the problem then in general the worst the result. In particular the elbow and the finger PIP joints (middle joints of the fingers) tend to do least well from release of contracture. In some patients the stiffness/contracture may return.


Are there any risks?

All interventions in medicine have risks. In general the larger the operation the greater the risks. In general the risks include:

  • The scar may be tender, in about 20% of patients. This usually improves with scar massage, over 3 months.
  • Aching for several moths particularly for carpal tunnel releases. Grip strength can also take some months to return to normal.
  • Increased stiffness may occur in particular in the fingers. This is usually short-term and only infrequently requires physiotherapy. But it is very important that it is resolved quickly to avoid permanent stiffness. This occurs rarely but can do associated with CRPS (see below) 
  • Numbness can occur around the scar but this rarely causes any functional problems.
  • Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
  • If a joint replacement is undertaken then this can fail long-term and may need a reoperation. 
  • Chronic Regional Pain Syndrome "CRPS". This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand "over-react", causing swelling, pain, discolouration and stiffness, which very slowly improve.
  • Any operation can have unforeseen consequences and leave a patient worse than before surgery.
 
 

The Hand to Elbow Clinic
29a James Street West
Bath BA1 2BT

Tel 01225 316895
Fax 01225 484949
info@handtoelbow.com
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