Orthopedic hand surgeons typically treat Dupuytren’s disease. Some doctors recommend cortisone injections to decrease nodules, and some try PRP injections with claims of success for Dupuytren’s patients. As far as I can tell, the jury is still out on stem cell injections for Dupuytren’s disease cases. Other doctors recommend patients start with a collagenase enzyme drug injection called Xiaflex that softens the fascia (the same drug used for Peyronie’s disease). Once the fingers are fixed in flexion at 20 to 40 degrees, hand surgery is recommended to release the tendons.
Dupuytren’s cords greater than 20 degrees can be treated by either:
Dupuytren’s hand contracture surgery is called fasciectomy or dermo fasciectomy. Usually, a hand surgeon makes an incision in the hand and removes all or part of the thin layer of fascia in the palm.
Besides surgery, doctors have a couple of less invasive ways to release the tight cord—needle aponeurotomy (using a sharpened needle to probe and cut the area) and injections with a collagenase enzyme (brand name Xiaflex) that softens the fascia. None of these treatments are curative, so symptoms will eventually recur, and the treatment itself has complications. I have only seen short- to medium-term results with this procedure. Most often, by the time I see Dupuytren’s patients, they have had repeated injections or surgeries. Repeated treatments are increasingly riskier and less effective. The chance of a permanent complication goes up with every invasive procedure (injections and operations that cut the skin).
I have seen a patient or two on Esbriet, also known as pirfenidone— an oral medicine approved for the treatment of adults with unclassifiable interstitial lung disease. This is a progressive fibrosing disease, so these doctors/patients are trying something off-label.
Dupuytren’s Disease Facts Overview
Nodules or lumps (an accumulation of cells) become cords (excess accumulation of tense and shortened collagen). Short cords become contractures.
Dupuytren nodules are located superficial to the flexor tendon.
Men usually are first diagnosed with Dupuytren’s disease 10 years before women.
Men are diagnosed around age 50.
At age 50, more men than women have Dupuytren’s by a 10 to 1 ratio.
By 80 years of age, the number of men and women with the disease is about the same (probably due to women living longer than men).
After age 80, women with the condition outnumber men.
Some people may have a lump or a slight finger bend as the only issue in their lifetime.
At any one time, only one in five people with Dupuytren’s are ready for a hand procedure.
Surgeons typically wait for a 20 to 40-degree bend of the fingers before doing surgery.
The more locations affected, the more likely Dupuytren’s disease will progress.
Approximately 300,000 to 500,000 Americans have treatment-resistant Dupuytren’s disease, which keeps coming back after treatment.
If the bent finger comes back soon after surgery, it is called a recontracture.
Biologically, Dupuytren’s disease is a failure of progression to normal tissue healing and resolution; the healing does not have a normal expiration date.
Radiation Therapy
Another non-invasive therapy that started outside the United States is radiation therapy, and it is gaining popularity. The objective of radiation therapy is to stop the disease from progressing further. Radiation therapy is intended for early-stage Dupuytren’s patients to prevent the disease from worsening and then requiring surgery.
This therapy will not make a bent finger straight. Once the disease has progressed beyond the early stage, it is less likely that radiation therapy will have any beneficial effect. Radiation therapy for Dupuytren’s is an early-stage treatment intended to prevent disease progression. When I asked Dr. Easton about his experience with radiation therapy, he said, “It killed cells and is about 50% long-term improvement.”
Several of my patients have had prior surgery and use my conservative approaches for managing and or improving self-reported function and symptom severity. I’m sure patients with Dupuytren’s will ask you about surgical versus nonsurgical (i.e., splint, steroid injection, or physical therapy) approaches and outcomes. I look at Dupuytren’s disease as a systemic problem that shows up most obviously in the hands but isn’t confined to them. This is true of many other diseases. Psoriasis, for example, is often seen as a local skin problem, but it’s not. Psoriasis is a systemic problem that shows up most obviously as a skin rash, but almost one-third of people with psoriasis will also develop psoriasis-related arthritis and other health issues. The traditional medical model is to look for a problem molecule in the blood; develop a blood test of the disease activity; and find medicines that affect these molecules. It’s a long process, and meanwhile, our Dupuytren’s patients can’t wait for “that” medication.
I have an in-office holistic treatment approach for Dupuytren’s disease. This includes any or all of the following modalities: focused and radial shockwave therapy, photobiomodulation (laser) therapies, cupping (LymphaTouch, D 6 Active) therapies, Dr. Fuji’s local vibration/ percussion therapy, pulsed electromagnetic frequencies (PEMF), and whole-body vibration, nutrition, and topicals. My rehabilitation and exercise therapy background gets intertwined with therapeutic approaches, including diet and home therapy.
It's a long process, and meanwhile, our Dupuytren's patients can't wait for "that" medication.
I examine the cervical spine for articular dysfunction and fascial restrictions; I do a detailed evaluation of the upper trapezius, levator scapulae, SCM, scalenes, pectoralis, pronator, and wrist flexor muscles for muscle length, hypertonicity, and fascial restrictions.
Home exercises usually include posture enhancement exercises, chin retractions, ELDOA fascial stretches, and median and ulnar nerve glides and floss. Joint mobilization and neurodynamic therapies should be performed and evaluated for possible therapeutic benefit. Other home instructions may include selective exercise to avoid repetitive wrist flexion or extension
Because most studies report a relationship between manual work stress and symptoms of Dupuytren’s, spend time questioning patients about their exercises and other activities. Some patients may be overdoing traditional push-ups and other recreational activities without even knowing they are contributing to increased fibrosis. The message usually is to avoid trauma, especially from sustained wrist and finger flexion. Splints that hold the fingers in a neutral or slightly extended position may reduce some worsening effects. However, I have not seen good patient compliance with these, and the use of a splint alone may not be sufficient treatment even for mild cases.
I do recommend a trial of conservative management before considering surgical alternatives. Hand surgeons do not think above the wrist as I do. People with Dupuytren’s don’t need a new operation. They need doctors who can help slow down the fibrosing process, and this includes a nutritional approach to turn off the process at the source in their bloodstream. Treatment strategies need to affect overall health.
Dr. Jeffrey Tucker is the current president of the ACA Rehab Council. Dr. Tucker practices in Los Angeles, CA. His website is www. DrJeffreyTucker.com
