Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused by elevated pressure in the “carpal tunnel,” which is a space at the base of the wrist through which pass nine tendons that flex (bend toward the palm) the fingers, along with the median nerve. It can be caused for a number of reasons, which include forceful, repetitive use of the wrist. The pressure causes the median nerve to have diminished function, which leads to the signs and symptoms. These include pain, numbness, tingling, and/or burning sensation on the palm side of the thumb, index finger, middle finger, and thumb side of the fourth finger. The “pinkie” side of the fourth finger and fifth finger are spared, as they are serviced by the ulnar nerve, which lies outside the carpal tunnel. Treatment is to avoid the offending activity and to splint the wrist in a “neutral” position of function (see page 73), both night and day if possible. A nonsteroidal antiinflammatory drug may be helpful. If the case is severe, a physician may prescribe oral steroids or inject steroids into the carpal tunnel. Medical evidence does not support the use of vitamin B₆. If carpal tunnel syndrome persists and the victim shows loss of nerve function or muscle wasting at the base of the thumb, surgery may be advised to decrease the pressure.

Cyclist’s Palsy

If a cyclist leans on the handlebars for an extended period of time, he may compress the ulnar nerve as it passes through the wrist. Symptoms include numbness and tingling of the fifth finger and the outside half of the fourth finger. Treat with a wrist splint and administration of a nonsteroidal antiinflammatory drug, such as ibuprofen. On rare occasion, steroid injection or surgical decompression of the nerve is necessary.

Muscle Fatigue

Simple fatigue, with depletion of energy stores within the muscle, is manifested as weakness, pain on exertion, soreness to the touch, and cramping. In many cases, this is compounded by dehydration, deficiencies of electrolytes (usually sodium and/or potassium), lack of sufficient caloric intake, or a specific injury. The sufferer has been informed by his body that it is time to rest. Sufficient time should be allowed to remove waste products, restore energy sources, correct dehydration, and regenerate muscle tissue. The victim should avoid vigorous physical activity for 12 to 24 hours, and should eat and drink amply. For overuse syndromes, pharmaceutical muscle relaxants are of little value, and pain medication is generally not necessary. Massage of the involved muscle groups is relaxing, although it probably does not hasten recovery.

Shin Splints

Shin splints is the term used to describe a painful disorder generated by excessive walking, running, or hiking. The sufferer has irritated the thin membrane that connects his two lower leg bones along the longitudinal axes where the membrane attaches to the bones. With every footstep, there is further irritation of the membrane, so that it can become impossible to walk rapidly. The victim should attempt to curtail running or vigorous walking activity, and may benefit from the administration of aspirin or a nonsteroidal antiinflammatory drug (such as ibuprofen or naproxen). A shoe that is well cushioned (particularly its ball and heel) is very important for prevention and recovery. More complex orthotics may be required.

Plantar Fasciitis

Plantar fasciitis is inflammation of the fascia (tough connective sheath tissue) that encloses the muscles and tendons that traverse the bottom of the foot. It is a syndrome of overuse, caused by excessive walking or running, particularly associated with repetitive impact on the bottom of a foot that is improperly cushioned or without appropriate arch support. Symptoms include pain in the bottom of the foot (ball, arch, and/or heel), worsened by repetitive weight bearing. The pain is often worse with the first steps in the morning or after a period of inactivity. It occurs commonly in athletes and long-distance hikers, particularly if they wear poorly fitting shoes or boots. When examining the foot, pain may be elicited by applying pressure to the forward-inside area of the heel.

Treatment consists of rest, elevation of the foot with cold (ice packs) applied to the tender areas at the end of the hiking day, wearing orthotics, gentle stretching (e.g., pulling back the toes and front part of the foot), and administration of an oral nonsteroidal antiinflammatory drug, such as ibuprofen. Worn at night, a splint that holds the foot in neutral position—thus keeping the plantar fascia slightly stretched—may help, as may avoiding walking barefoot or in flat-soled shoes.

If the victim must continue to walk on the painful foot, it can be taped to provide arch support; this can do much to reduce pain. It is accomplished as follows: Apply a thin layer of benzoin or spray tape adhesive onto the bottom of the foot. Fix an anchor strip of ¾ in (1.9 cm) adhesive tape in a U shape around the heel from just under the malleoli (prominences of the ankle) up to just behind the level of the “knuckles” of the toes (Figure 169, A). Next, lay fairly tight cross-strips of ½ in (1.3 cm) tape across the bottom of the foot, with their ends torn to lay on the anchor strip (Figure 169, B). This creates a “sling” of tape under the foot for support. Finally, apply another U-shaped piece of tape around the heel that crosses under the center of the arch and locks down the crosspieces (Figure 169, C).

Figure 169 Taping for arch support. A, Fix an anchor strip under the heel. B, Attach strips across the bottom of the foot. C, Lock the crosspieces.

Torn Muscle

A torn muscle (“pulled” muscle) is recognized as sudden pain in a muscle group associated with a particular vigorous exertion, such as sprinting or lifting a heavy object. Depending on the severity of the injury, there may be associated bruising, swelling, loss of mobility, and/or weakness. For instance, a small tear in the deltoid muscle of the shoulder may cause minor discomfort on lifting the arm over the head, while a complete separation of the quadriceps group in the anterior thigh will cause inability to straighten the leg at the knee, extreme local pain, blue discoloration of the knee, and a defect in the shape of the muscles above the knee that is easily felt and seen.

In general, a minor muscle injury can be distinguished from a bone injury by evaluating active and passive range of motion. Active range of motion is the range of normal activity the victim can manage without rescuer assistance; this will be painful with both muscle and bone injuries. Passive motion is movement of a body part performed only with the aid of the rescuer; no effort is provided by the victim, who should attempt to relax the muscle completely. If there is no pain on passive (assisted) motion, but pain is present on active motion, the injury is most likely muscular, because an injured bone will hurt no matter how it is moved. If there is pain on passive motion, with or without pain on active motion, suspect a bone injury.

Minor muscle injuries should be treated in the first 24 hours with immobilization, the application of cold (insulated ice packs or chemical cold packs, for example; do not apply ice directly to the skin) for 30 to 45 minutes every 2 to 3 hours, and elevation. After 48 to 72 hours, the application of heat (warm water or a heating pad, not ointments) and gentle movement should be started. If a significant injury is suspected (for example, complete tear of the biceps muscle or quadriceps muscle group), the injury should be immobilized as for a fracture (see page 74) and the victim transported to a physician.

The best way to prevent a pulled muscle is to stretch and warm up adequately. This allows the local blood flow to increase and minimizes the risk for small tears that can cause spasm, which in turn leads to decreased flexibility.

Sprains and Strains

Sprains and strains are injuries to ligaments (which attach one bone to another) and tendons (which attach muscle to bone) that are incurred by twisting, direct blunt trauma, or overexertion. Symptoms include pain, swelling and/or deformity, decreased range of motion secondary to pain, and bruising. The treatment is the same as for a suspected fracture. The injured part should be elevated, immobilized (see page 74), and treated with cold applications for the first 24 to 48 hours (“RICE”: rest, ice, compression, and elevation). After 72 hours, heat may be applied. It is important to prevent reinjury (ankles are notorious) by proper wrapping or the application of a splint. Because the injured joint is immediately weakened, it should not be relied on for great exertion.

The most common sprain is of an ankle. If the injury is minor (no chance of a fracture) and/or if the victim needs to put weight on the ankle to seek help, the ankle may be wrapped snugly with an elastic wrap in a figure-of-eight method (Figure 170) or taped in a crisscross weave (Figure 171). During the wrapping or taping, have the victim point his toes and ankle upward by passing a slender rope or strap around the ball of the foot and pulling toward the body (Figure 172). This allows the ankle to be strapped with the foot perpendicular to the leg and the ankle ligaments in the shortened position in which they best heal. A splint can be fashioned from a SAM Splint (see Figures 91 and 92) to provide additional support. If the sprain is severe, splint the ankle as for a fracture. An Aircast Air-Stirrup ankle brace is excellent for in-shoe support.

Figure 170 Wrapping the ankle with a figure-of-eight bandage. A, Start above the ankle and (B) wrap down under the foot. C, Cross back and forth over the top of the foot and (D) continue in a figure-of-eight pattern to secure the ankle.

Figure 171 Taping a sprained ankle. A, Strips of adhesive tape are placed perpendicular to each other to (B) lock the ankle with a tight weave. C, The tape edges are covered to prevent peeling.

Figure 172 Pulling up on the toes to attain proper ankle position for wrapping.

The Achilles tendon, which runs from the heel into the lower calf, may become irritated or inflamed due to recurrent impact or repetitive stretching, particularly if the heel is not well padded. An inflamed Achilles tendon that is painful should be protected against further irritation by limiting vigorous exercise and using a heel cup or extra padding underneath the heel to reduce stretch forces on the tendon. Achilles tendon rupture is usually caused by a sudden forceful impact on the foot that is “flexed,” with toes pointed down, commonly during a jumping activity. There is pain and a sensation that something has torn or “popped.” The victim has difficulty walking and pushing down with the forefoot. A simple test that can detect a complete Achilles tendon rupture is to have the victim lie face down with the leg bent at the knee. Squeeze his calf and see if the foot moves in such a way that the toes point downward. If there is no motion (in comparison to the uninjured side), the tendon may be ruptured. For treatment, splint the foot and ankle with the toes pointed slightly downward, and try to eliminate weight bearing.

Knee sprain is discussed on page 105.