Article by Whitney Lowe
As a sizeable portion of the population in this country ages, it is important for health care practitioners to have a greater awareness of various diseases and conditions that are increasingly common in an older age group. One such condition is a connective tissue disorder that affects the palmar fascia of the hand, called Dupuytren’s contracture. This condition was originally named for Baron Guillaume Dupuytren in the 1830’s, although there is an indication that other physicians had actually described this clinical pathology a number of years earlier. 4 This disease is most common in Caucasians and especially those of Celtic descent. For that reason, it has sometimes been called the Viking disease.2, 3
Description of Pathology
The primary structure that is involved with Dupuytren’s contracture is the palmar fascia (see Figure 1). The fibers of the palmar fascia are arranged in different directions. However, it appears that the longitudinally-oriented fibers (ones parallel with the long tendons in the hand) are the ones most affected in this condition. The palmar fascia is strongly tethered to the skin and underlying bone, unlike most of the sub-cutaneous fascia in other regions of the body. This tethering is to increase the strength of the fascia against tensile stresses between the skin, fascia, and bones that would have a tendency to pull the fascia free from its attachments. The reason the skin and fascia in this region are so susceptible to this kind of problem is that significant tensile stresses occur on the soft tissues of the palm when grasping objects with strong force. These forces are significantly higher in the palm than in other areas of the body.5
Dupuytren’s contracture begins with a shortening and fibrosing of the fibers in the palmar fascia. Again, it is primarily the longitudinal palmar fascia fibers that will be affected. The pathological process that starts the contracture is still unclear. However, it appears that the process begins with a proliferation of fibroblasts in the palmar fascia, producing new collagen that forms into nodules and fibrous restrictions.
There are several different types of collagen in the body. Type 1 collagen is most prevalent in tendons, ligaments, and superficial fascia. Type 3 collagen is present in high concentrations in scar tissue. The fibrous nodules and collagen binding that occurs in Dupuytren’s contracture is predominantly Type 3 collagen, which may be one of the reasons it is so difficult to elongate.
As the collagen binding progresses, the fascia will further contract and draw the digits of the hand into a fixed flexion deformity (see Figure 2). The metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the 4th and 5th digits are the ones most commonly affected.
There appears to be a strong genetic predisposition to development of Dupuytren’s contracture. It is an autosomal dominant gene, and as mentioned earlier, it is most common in people who are of northern European descent. While the condition does not appear to be directly related to traumatic incidents in the hand or forearm, there is some indication that an inciting disease or event may cause the genetically-predisposed person to fully develop the condition.
There are several other common factors in the symptom picture of people with Dupuytren’s. It is about seven to 15 times more common in men than in women.4 It is also most common for people in their 40s or 50s. The incidence of this pathology increases with smoking, alcoholism, diabetes mellitus, epilepsy or other convulsive disorders. The reason that it is more prevalent in this group is not well understood.
Assessment
Information in the client history will be imperative in identifying any of the various risk factors mentioned above. If the condition is in the early stages, there may be some fibrous nodules that are palpable in the palm region, especially over the 4th and 5th digits. In many cases the skin will pucker a bit in the region over the fibrous nodules. The surface of the palm is also likely to be tender to palpation.
If the condition is in an early stage, there will probably be some limitation to active as well as passive extension in the digits; the full flexion deformity, however, will not be evident. In later stages, the flexion deformity will be much more pronounced and the hand will appear more like the image in Figure 2.
There are no specific diagnostic tests that validate Dupuytren’s contracture, and a physician will generally diagnose this condition based on clinical findings and relevant information from the medical history. However, it is also important to distinguish this condition from other hand and finger pathologies that may have similar symptoms. Trigger finger (stenosing tenosynovitis) is likely to have movement system restrictions and pain patterns that are similar to those in Dupuytren’s contracture. However, in this condition you can usually force the digit into full extension, even if the action is a bit painful. The palmar nodules are usually not prevalent in stenosing tenosynovitis.
Treatment
If a client has developed a more advanced stage of Dupuytren’s contracture, it may be difficult to achieve beneficial effects with massage treatment. However, in the early stages, massage and other forms of soft tissue manipulation are far more likely to be helpful.5 The greatest benefit will come from techniques that emphasize longitudinal tensile stress loads on the palmar fascia. Techniques such as deep longitudinal stripping, myofascial approaches, and very active regular stretching will be particularly helpful.
This condition involves the development of fibrous restrictions in the soft tissue. As a result, it is important to find a treatment strategy that will address these restrictions appropriately. The restricted connective tissue needs to be elongated, a process that will develop most effectively with frequent applications of tensile stress to the palmar fascia. The most effective means of accomplishing this is to teach the client an aggressive plan of self-stretching so the tissues can have the greatest opportunity to reduce the fibrous binding. Stretching the fingers and wrist in hyperextension (see Figure 3) is the motion that you want to emphasize most.
There is some indication that myofascial trigger points in the palmaris longus or other forearm muscles may contribute to either pain or movement restrictions that may exacerbate the fibrous restriction process.6 Therefore, when treating this problem, be sure not to ignore the forearm muscles and any other soft-tissues of the upper extremity that might also be contributing to further tension in the palmar fascia.
Other similar conservative treatment approaches may be used in physical or occupation therapy to address this condition. Yet, in many cases these conservative approaches will not be sufficient to halt or reduce the degree of fibrous restriction that has occurred in the soft-tissue. As a result, surgery is often performed to reduce the restrictions of the fascia and restore proper range of motion in the hand.
Surgical treatment will most often include procedures such as a fasciotomy, involving a longitudinal incision following the course of the hand and finger tendons in order to free up any restriction between the fascia and its adjacent tissues. In other cases, a fasciectomy may be performed. This is a procedure in which a portion of the palmar fascia may be resected or removed in order to enhance mobility. This mobility can be further enhanced by a surgical incision called a Z-plasty. In this procedure the incision looks like a zig-zag (see Figure 4). Due to the disruptive nature of this procedure, there can be a long period of post-surgical healing. However, mobility is restored for most people who have this surgical procedure performed.
There may be some alternatives to the surgical procedure in advanced cases of contracture. Initial trials indicate that injection of collagenase (an enzyme that can encourage the breakdown of collagen) can be beneficial in reducing the fibrosity of Dupuytren’s. However, further clinical trials are necessary to validate this theory.1
As a massage practitioner with significant palpation skills, you are in a position to identify this condition in its early stages. If the progressive connective tissue adhesion can be addressed early on, it is likely you can prevent it from becoming a much more serious problem. If the condition has progressed further and surgery has become necessary, you may still be able to make a significant contribution in the post-surgical phase. For example, the Z-plasty procedure runs the risk of scar tissue developing after the surgery. When sufficient time has passed, soft-tissue mobilization can be helpful to encourage free movement between the skin and adjacent fascia.
References
- Badalamente, M. A. and L. C. Hurst. Enzyme injection as nonsurgical treatment of Dupuytren’s disease. J Hand Surg [Am]. 25:629-636., 2000.
- Elliot, D. The early history of Dupuytren’s disease. Hand Clin. 15:1-19, v., 1999.
- Finsen, V., H. Dalen, and J. Nesheim. The prevalence of Dupuytren’s disease among 2 different ethnic groups in northern Norway. J Hand Surg [Am]. 27:115-117., 2002.
- Lee, S. Dupuytren Contracture. Available at: www.emedicine.com Accessed 6-14-2003, 2003.
- Rattray, F. and L. Ludwig. Clinical Massage Therapy: Understanding, Assessing and Treating over 70 Conditions. Toronto: Talus Incorporated, 2000
- Simons, D., J. Travell, and L. Simons. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Baltimore: Williams and Wilkins, 1999
