Case report
Manual labor metacarpophalangeal arthropathy in a truck driver: a case report

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Abstract

Objective

The purpose of this study is to present an unusual and rarely described case of occupational hand arthropathy involving the metacarpophalangeal (MCP) joints.

Clinical Features

A 62-year-old male truck driver (of 35 years) presented to a chiropractic clinic with pain and stiffness along the third metacarpal and MCP joint of the left hand. Examination revealed severe pain and limited flexion at the third MCP joint. Bilateral radiographs demonstrated severe osteoarthritis (OA) of this joint in the left (nondominant) hand and mild-to-moderate (asymptomatic) OA in the same joint on the right. Results of laboratory blood tests were unremarkable for metabolic, inflammatory, or infectious joint disease.

Intervention and Outcome

The patient was diagnosed with bilateral, third MCP joint OA associated with manual labor. He was treated unsuccessfully with a short course of low-level laser therapy, MCP joint mobilization, and hand-stretching exercises. After 3½ years, the patient continues to work despite ongoing and worsening symptoms. Three serial left hand radiographs are presented, highlighting the progressive nature of this arthropathy.

Conclusion

The differential diagnosis in patients presenting with manual labor MCP joint OA should include hemochromatosis and calcium pyrophosphate dihydrate crystal deposition disease. Because of the increased risk of serious systemic disease, it is imperative that these latter 2 disorders are ruled out before the former is diagnosed.

Introduction

Osteoarthritis (OA) is the most common form of arthritis and often affects the knees, hips, hands, feet, and spine.1, 2 In the United States, the incidence of radiographic OA for those aged at least 26 years (including data of the hands, knees, and hips) ranges from 13.8% to 37.4%.3 The incidence of symptomatic OA is lower, however, ranging from 4.9% to 16.7%. In general, OA becomes more prevalent with age, affecting the hands and knees of women more frequently than men, especially in those aged at least 50 years. Clinically, OA often presents with pain, morning stiffness, crepitus, deformity, and joint swelling or enlargement.4 Multiple factors interact to cause this disorder (Fig 1). Osteoarthritis is normally diagnosed through patient consultation and examination, whereas radiographs (if taken) can provide further objective evidence of the disease (Fig 2).

Traditional medical management of OA may include patient education about its natural and progressive course, lifestyle modifications, exercise prescription, pharmacologic treatment, and/or surgery (if necessary).4 Common pharmacologic agents used are acetaminophen, nonsteroidal anti-inflammatory drugs, aspirin, and cyclooxygenase-2 inhibitors. Intraarticular steroid injections are another treatment option, but should be used sparingly.5 Commonly used alternative therapies may include herbs, supplements (eg, glucosamine), ointments or topical rubs, and other nonpharmacologic modalities such as exercise, physical therapy (or chiropractic), acupuncture, electromagnets, transcutaneous electrical nerve stimulation, ultrasound, and low-level laser therapy (LLLT).6, 7, 8, 9 Because of the prevalence of OA in the general population and because chiropractic practice often involves the treatment of musculoskeletal disorders, chiropractic physicians are bound to encounter many patients with OA. In a recent cross-sectional study of arthritis patients (in North Carolina), 7 more than 20% of those with OA reported seeing a chiropractic doctor for treatment.

In the hand, the distal interphalangeal and proximal interphalangeal finger joints, and the first carpometacarpal joint of the thumb, are most often affected by OA; the metacarpophalangeal (MCP) joints are less commonly involved.10 Secondary OA involving the MCP joints is common, however, in hemochromatosis and calcium pyrophosphate dihydrate (CPPD) crystal deposition disease.10, 11, 12, 13 Hand OA in both disorders usually involves the second and third MCP joints, bilaterally. The “iron salute” (of hemochromatosis) can be used by clinicians as an efficient screening tool for MCP arthropathy (Fig 3).14

An occupational OA involving the MCP joints has also been described in manual laborers.15, 16, 17 This disorder—thought to be from heavy work involving sustained gripping with both hands—has been termed the Missouri metacarpal syndrome.15 Presented here is the first such case to be described in the chiropractic literature. A discussion on the importance of making this diagnosis and ruling out its differentials is also included in this report.

Section snippets

Case report

A 62-year-old white man presented with a 5-year history of insidious and progressive pain and stiffness in his left hand. The pain was located along the dorsal aspect of the third metacarpal and MCP joint. It was described as a dull ache, with an intermittent throbbing quality, and graded with a severity of 4 on a numeric rating scale of 10. Acetaminophen medication and rest were typically palliative, whereas repetitive use (eg, gripping) was provocative. The patient had worked for more than 35

Discussion

The patient in this case did not benefit from 6 sessions (over 3 weeks) of LLLT and mobilization to the third MCP joint of the left hand. A discussion on the effectiveness (or lack thereof) of LLLT in treating OA, however, is beyond the scope of this article. Other authors have written more extensively on this topic.9, 18, 19 The primary purpose of this article was to present a case of MCP joint OA associated with a manual labor occupation and, in doing so, familiarize chiropractors with the

Conclusion

Presented here was an unusual case of severe, symptomatic third MCP joint OA in the left (nondominant) hand of a truck driver, along with mild-to-moderate (asymptomatic) OA in the same joint on the right. It is possible that truck driving for more than 35 years, repeatedly using a handgrip exerciser, and gripping the steering wheel on a daily basis (particularly with the left hand) may have led to this atypical pattern of hand OA. Patients with higher handgrip strength, combined with years of

Funding sources and potential conflicts of interest

No funding sources or conflicts of interest were reported for this study.

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Cited by (1)

  • Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: A systematic review

    2013, Journal of Manipulative and Physiological Therapeutics
    Citation Excerpt :

    A few additional MMT case series, reports and other types of MMT studies have been added to this review revisiting shoulder conditions as noted in the previous systematic review including, in regards to RCIDs or similar, the blinded diagnostic study of Trigger Points and increased pain pressure threshold (PPT) in patients with shoulder impingement syndrome (more trigger points and an increase in PPTs was found in those with RCID as compared to controls) in Hidalgo-Lozano et al; in a case report of 2 patients Krenner described MMT of 2 shoulder patients each with a combination of RCID and SCDP diagnoses with thoracic and cervical spine MMT, glenohumeral MMT and the use of a specialized myofascial MMT that was used along with exercise and rehabilitation with apparently good outcomes for both subjects. Similarly we have included the case report of Caldwell et al (for RCID and SCDP); a case report of a patient with combined SCDP and NSP by Haddick; a case series by Gemmell et al of shoulder patients with a combination of SCDP and MPDS; Wies case series of FS; and the FS case series of 50 consecutive patients by Murphy et al which appears supportive of the work of Bergman et al in the treatment of SCDP3,115,134; a look at chiropractic management of a shoulder condition called the Parsonage-Turner syndrome (that appears to be a combination NSP and MPDS); a case report of a shoulder patient with cervical radiculopathy and MFPD in the shoulder by Daub; additionally added were case series, reports and other studies looking at MMT applied to a variety of elbow, wrist, hand, finger and upper quadrant TMJ/TMD disorders.106,116-119,122,124-126,130-133,135-137,139-142,147,148,151,154,155,160,242-245 Almost without exception all of these upper extremity or upper quadrant disorders and conditions in both the RCT, CT, case series and reports sections were treated by a combination of MMT and multimodal care or rehabilitation (MMT and multimodal care = mobilization, manipulation, soft tissue or myofascial therapy; and exercise, stretching, advice, education and/or in an interdisciplinary setting including medication, etc)1,2 (Tables 3-10).

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