By Makoto Tamai, MD, PhD

I’d like to thank ASSH for giving me this opportunity to share my experiences with the members. The topic I was asked to write on was “ethical dilemmas I have faced or mistakes I’ve made or almost made.” Since I cannot recall any particularly interesting mistakes I’ve made that are worth recounting here, I’d like to share my thoughts about the treatment challenges that I face in daily practice. I’ve been specializing for years in hand surgery at my private clinic in Hokkaido. After moving here from my previous job at a trauma hospital in Kyushu, I have been seeing an increasing number of patients suffering from chronic pain in the elbow, hands and fingers and with no signs of trauma or infection. The causes of such pain include osteoarthrosis, non-systemic arthritis, tenosynovitis, tendinosis and neuritis. Most of these patients have histories of being prescribed analgesics or receiving steroid injections at the site of their symptoms from previous doctors.

Now let’s consider the meaning of local pain in relation to specific activities. If there is no history of trauma and no evidence of infection or systemic disease, such pain is thought to be produced by the irritation of degenerated tissue or inflammation induced by physical stress on the injured tissue. The musculoskeletal tissues can suffer from damage by recurrent motion or stress from physical activities, and when such damage reaches its threshold, the nervous system sends pain messages and alerts the host to become aware of the site of damage. The pain effectively tells the host to allow the body part to rest in order to heal the injury and prevent further aggravation of the damage.

The fundamental anatomical structures of the extremities were established in an ancient amphibian over 200 million years ago, and four-legged animals inherited them. Having a modified form of primitive anatomy, humans came up with numerous new uses for limbs during work activities, hobbies and sports as civilization developed. Compared to other animals, humans use hands and fingers for a far greater proportion of each day and their lifetime. The mismatch of anatomy and function may be a major cause of the degeneration of musculoskeletal tissue, simply because the human anatomy was not especially created to fit the usages of the modern human being.

For the treatment of such tissue damage, prescribing analgesics or applying poultices may satisfy patients temporarily—that is, until they inevitably become aware that such treatments don’t actually work, since they do nothing to address the root cause of the pain. Of course, in severe cases surgery may be necessary. But my approach is to speak directly to my patients and to discuss with them the anatomical limits I have outlined above in order to seek ways of reducing the amount of movements and activities that may cause continuing pain. I believe that the solutions provided by modern medicine are rather limited. Such is the dilemma that I face in my daily practice, but I feel rewarded when patients respond positively to my treatment, take better care of their arms and hands in order to prevent severe damage, and maintain their functions as long as possible.