Dupuytren Contracture and Knuckle Pads
Knuckle pads are a variable finding of many conditions
Knuckle pads or Garrod pads are commonly associated with Dupuytren contracture. They are well-circumscribed, smooth, firm, and skin-colored slight elevations, papules, or nodules, approximately 0.5-3 cm in size. They are most commonly found on the back side of the hand at the main knuckles joints (metacarpophalangeal or MCP) and the first joints after them (the proximal interphalangeal or PIP), with the PIP being the most common site. They are not to be confused with a Dupuytren cord which is a structure associated with the lump on palm of the hand.
When associated with Dupuytren contracture, since they occur in 45-55% of cases, Garrod pads usually suggests a more aggressive representation of the disease (a Dupuytren diathesis).
When firm, the knuckle pads or nodules may be only tender to palpation, otherwise they do not cause pain or other symptoms. These nodules are closely adherent to the skin in Dupuytren contracture while movement of the nodule during finger flexion/extension suggests an association with the tendon sheath.
A history of repetitive injury to this part of the hand from work or sports activity is often present, as well as occurring without any physical explanation.
Garrod first described knuckle pads in the medical literature in 1893, but knuckle pads have been observed since the Renaissance era; Michelangelo’s statue of David has knuckle pads (Florence, Italy) as well as his statue of Moses (Rome, Italy).
In the U.S and the rest of the world knuckle pads are thought to be a common occurrence. The prevalence of knuckle pads is difficult to determine because this problem does not cause physical symptoms and so people do not often seek medical attention specifically for them. Knuckle pads can be present in any age group, with the most common in adults 40 years of age and older, especially males who engage in heavy manual labor. The condition also is seen in young children who suck their fingers.
Some cases of knuckle pads are clearly familial, having no other possible causation. Most often they are associated with other disease processes such as reported in Dupuytren disease, Peyronie disease, Ledderhose disease, pseudoxanthoma elasticum, esophageal cancer, hyperkeratosis, and oral leukoplakia.
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What is the difference between a Dupuytren’s nodule and Dupuytren’s cord?
Which is worse if you have Dupuytrens, cords or lumps?
Dupuytren’s contracture, sometimes called Morbus Dupuytren (MD), is a benign (non-lethal) process in which excessive collagen causes the connective tissue (fascia) to thicken in the palm of the hand; this is later followed by shortening of that same tissue. As Dupuytren contracture continues, the tissue alters appearance and normal hand function is reduced. The progression of the problem is fairly straightforward and clear, but the causes and reasons for the various cellular changes involved in the thickening and shortening remain unknown.
There are two well known physical elements of Dupuytren’s contracture. First, is the appearance of one or more nodules or lumps on the palm of the hand; the palm is sometimes dimpled or puckered over the nodule. The other is the development of a tight cord-like structure under the skin of the palm. It has been proposed in recent years that as Dupuytren contracture progresses the various cells and tissue elements of the early nodule convert into the later cords.
Natural treatment of Dupuytren’s contracture
Surgery is not always necessary to remove these palm lumps and cords. Since 2002 the Dupuytren Contracture Institute has worked with people from around the world to use natural Alternative Medicine methods instead of a hand operation. While surgery is always an option if a brief trial of natural methods is unsuccessful, most people prefer to first use non-surgical treatment to possibly avoid the inherent risks of surgery.
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Dupuytren nodule, lump or bump
One or more lumps or nodules are usually noticed when they are rather small and soft, and not firm and solid feeling as they will become later. Often the nodule is located in the flexible area of the skin in the vicinity of the diagonal crease at the base joints of the fingers. When a nodule appears in the lower palm, further down towards the wrist, involving a structure known as the palmar aponeurosis, it typically is less likely to become contracted and lead to reduced hand function and forced bending of the involved finger.
One or more lumps or nodules are usually noticed when they are rather small and soft, and not firm and solid feeling as they will become later. Often the nodule is located in the flexible area of the skin in the vicinity of the diagonal crease at the base joints of the fingers.
In most cases the nodule will appear at the base of the ring (4th) and/or little (5th) finger, although the middle (3rd) and index (2nd) finger are occasionally affected, while the thumb is rarely affected. A Dupuytren bump or nodule can also appear throughout the palm, sometimes in the digits, and in rare cases elsewhere. When a nodule appears in the lower palm, further down towards the wrist, involving a structure known as the palmar aponeurosis, it typically is less likely to become contracted, or lead to reduced hand function and forced bending of the involved finger.
Pitting and dimpling of the palm of the skin near or within the nodule can also develop during the early phase of disease progression when the lump changes the way underlying fascia connects to the skin.
These Dupuytren bumps or lumps are usually painless, especially during the later phases of the disease progression. When pain does occur later it is because a lump or nodule presses or rubs against a nearby tendon. As the disease progresses and finger contractures begin, the nodules tend to reduce or disappear.
Dupuytren nodules or lumps are frequently mistaken for calluses because of their location on the palm near other calluses, as well as appearance, general density and adherence to the skin like a callus.
Dupuytren cord
As Dupuytren’s contracture slowly progresses and nodule progression goes from small and soft to large and hard, the next stage is the development of long thin bands of collagen tissue located near and parallel to tendons. These tough rope-like structures, made of collagen connective tissue, are referred to as Dupuytren cords.
They start out from the pre-tendious bands that are extensions of the normal palmar fascia and eventually thicken over time as the disease progresses. For this reason the Dupuytren cord will develop parallel and near to the tendons of the hand and fingers.
Typically the tissue changes of Dupuytren’s disease tend to stabilize temporarily at some variable mid-point; for some people this can occur within a few months or even years after onset, and remain inactive for months or many years, typically 5-6 years.
Sooner or later at around this 5-6 year point additional nodule or cord growth development starts again at a variable speed and finger contracture worsens. This is about the time during Dupuytren’s disease that patients become serious about treatment. Eventually as the palmar tissues continue to thicken and shorten, the tendency increases for these structures to pull the involved fingers down or flex toward the palm. Over time, as the finger remains flex toward the palm, the muscles that straighten or extend the fingers become progressively weakened and eventually undergo atrophy. The overall effect is a hand that is progressively held in a flexed position.
Common daily tasks become increasingly more difficult to perform as the range of finger movement decreases and the degree of contracture increases. Dressing, bathing, toilet, operating an automobile, amongst other many other activities of daily living, are adversely impacted to a degree equal to the numbers of fingers affected by a Dupuytren nodule or cord, and the degree of fingers held in flexion.
What is the best therapy to treat Dupuytren contracture?
How should I treat my Dupuytrens disease?
“What is the most important product or vitamin I should use to treat the Dupuytren lump on my palm?” I am asked that question frequently.
The correct response is that there is not any single therapy that is more important than the others; they are ALL important, especially when used together. Each natural therapy product if taken by itself has limited ability to make a difference with the dense fibrous Dupuytren contracture tissue on the palm of the hand or fingers. However, when they are used together as we advocate at DCI, their combined effort we find is capable of generating a healing response. None when used separately will achieve the clinical results that compare to a broad-based synergistic approach to Dupuytren therapy using Alternative Medicine.
There is simply no way to predict which vitamin or mineral or enzyme therapy will do the most for you, if in fact any can make a difference to the contracted tissue when used alone. There is no one product that can cause the contracted palmar fascia tissue to be reabsorbed by the body.
Treatment of Dupuytrens like playing baseball – you need all players
It is similar to determining something similar about a baseball team. You cannot ask “What is the most important position on the team?” and expect a meaningful answer. Certainly some would answer, “Oh that is easy. The pitcher is the most important player.” If that were true, you only have to imagine how much trouble a team would have if there was no short stop or catcher or first baseman, or center fielder on a team, or if you tried to play a game with nine pitchers on the field. Each player is important in his own way and vital to the ultimate success of the team when they work together. The same is true with treatment of Dupuytren contracture.
Please read and re-read sections of the DCI website that describe the treatment philosophy and the principle of synergy, found at Dupuytren Contracture Treatment Philosophy. If you are having any concerns or indecisions about what you are doing while using Alternative Medicine to treat your hand lumps, you owe it to yourself to go over some of these points. Educate yourself well about this terrible problem and come to understand exactly why you are following this course of Alternative Medicine care.
There is a lot of good information for you on the DCI website. If you haven’t already spent considerable time reading the background and principles that explain why this therapy works for so many people, now is a good time to review what started you thinking in this direction in the first place. After you understand more about the philosophy that guides this process of eliminating the dense contracted hand tissue, it will be easier to successfully create and follow your own Dupuytren treatment program.
Is this lump in my palm anything to worry about?
Lump on palm of hand should be investigated
As a general rule, anytime you discover something new happening to your body you should be concerned enough to quickly determine if the new situation has important short- and long-term consequences. In the case of a bump, nodule or lump on the palm of the hand that appears without reason, it could be important and should not be dismissed.
Of course, the first explanation for a palm lump or nodule is that it could be a simple callus. If a callus makes sense based on new or greater manual work you have been doing recently, especially without the protection of gloves, then that is probably all the concern that is necessary.
However, if you have not been using your hands more than usual lately, then you should do a quick mental inventory of any other recent symptoms you have noted about your hand:
- Can’t extend or straighten one or more fingers
- Can’t open hand completely
- Can’t lay palm flat down on a table top
- Fingers won’t open up after being used
- Fingers won’t straighten
- Fingers are restricted in full movement
- Fingers curling in toward palm
- Pinky finger or ring finger won’t extend fully
- Lump, bump or nodule on the palm of the hand
- Can’t open hands without pain
- Stinging or burning pain in hand
- Feels like a swollen tendon in the palm of hand
- Feels like hand constricting and won’t open easily
If you note one or more symptoms that reduce your ability to use your hand and fingers, then you could have a fairly common condition known as Dupuytren contracture.
Lump in palm of hand common Dupuytren contracture finding
Dupuytren contracture is a problem of the soft tissue characterized by thickening and shortening of fibrous bands located in the deep tissue of the palm of the hand (palmar fascia), caused by an excess amount of a tissue protein called collagen. As this progresses a cord of tissue will develop below the surface or a lump in the palm on the surface, resulting in reduced mobility and contracture of the hand and finger. This involvement can affect one or both hands, and a variable number of fingers. Dupuytren contracture presents in a wide variation, from a mild and slowly progressing contracture of a single finger, to severe and rapidly progressive involvement of several fingers of both hands, or many variations in between.
Alternative medicine treatment when combined into an aggressive assembly of natural therapies (vitamin E, PABA, acetyl-L-carnitine, massage, stretching, copper peptides, systemic enzymes, etc.) are often effective in reducing or eliminating the excess collagen cord or nodule formation and the subsequent finger contracture that so often prevents the 4th and 5th finger from being able to extend or open fully and keeps the involved fingers curled in toward the palm. For information about using natural treatment methods to treat Dupuytren’s contracture, and to possibly avoid the need for Dupuytren release surgery, click natural Dupuytren Treatment Plan.
One or more dimpled and thickened bumps on the palm are most often caused by Dupuytren’s contracture. This is especially true for any unusual small nodule or lump on the hand that appears on the palm at the base of the 4th (ring) or 5th (pinky) fingers, especially if the involved finger or fingers won’t completely straighten out. Although it is always advisable to get a medical diagnosis of this kind of health problem, it is possible to develop a strong suspicion the problem is Dupuytren disease if several indicators and factors are present in your history:
- Ancestors who came from England, Ireland, Scotland, Wales, or a Scandinavian country
- One or more family members also have Dupuytren contracture
- Palm lump located immediately at the base of the ring and/or pinky finger
- Age 45 plus
- Male
- History of manual labor doing heavy or repetitive work, often with hands unprotected
- History of tobacco smoking
- Diabetes
- Alcohol abuse or liver disease
- Epilepsy
Dupuytren contracture will often return or recur within a few years after surgery that releases the finger contracture by removing the cords or lumps on the palm. In fact, some forms of Dupuytren surgery have am 80% recurrence rate 3-5 years after the first operation, and even faster recurrence for a 2nd or 3rd surgery. Hand surgery should not be seen as a solution or cure for Dupuytren’s contracture since recurrence is such a common problem not only for hand surgeons, but also the patients they serve.
Many surgeons voice the opinion that in many cases Dupuytren hand surgery seems to accelerate and worsen the development of cords and lumps on the palm. For this reason it is suggested that a person who has Dupuytren cords and lumps should first attempt a therapeutic trial of aggressive Alternative Medicine to determine if the body is capable of reversing or even eliminating the tissue changes that makes the fingers curl in toward the palm and prevents the hand from opening completely. If after two or three months of natural treatment no change is seen, Dupuytren surgery can always be done at a later time.
Natural alternative therapies such as suggested by the Dupuytren Contracture Institute do not receive evidence-based research because of their limited profit potential and easy access by laypeople, and so have little support from the medical profession. Even so, with a little independent research on this website it should be obvious that these natural healing ideas make sense and do not interfere with subsequent medical treatment.
Dupuytren hand surgery can be dangerous: Facts you should know
Risks of hand surgery as a limited Dupuytren treatment
Any type of surgery presents risks and can produce unintended side effects. Unanticipated complications following open hand surgery for Dupuytren contracture has been reported in 17% to 41% of cases. Further, these side effects are nearly twice as likely to occur for repeat surgery when Dupuytren’s contracture recurs after a first surgery.
This article will focus on the potential complications of Dupuytren’s contracture surgery, specifically a category called palmar fasciectomy.
Avoid Dupuytren hand surgery with Alternative Medicine
Anyone considering Dupuytren surgery should be encouraged to know that by natural Dupuytren treatment it might be possible to avoid a hand operation.
Medical research by Messina, Loos, and Bulstrod report successful outcomes for Dupuytren contracture after using the non-surgical methods of massage, exercise and traction, yet their work receives little attention. Research interest has always been primarily directed toward high profile profitable surgery and drug therapies. Alternative medicine is not a high profit way to treat hand contracture although the Dupuytren Contracture Institute has been helping people since 2002 deal with their hand problems.
Not all people respond to Alternative Medicine, just as not all people respond well to drugs and surgery. However, the advantage with using simple and low cost natural therapies and remedies is that when they do successfully assist the body to recover from a health problem, the need for drugs or surgery is lowered or eliminated. The idea of attempting a short therapeutic trial of natural remedies first, rather than last, takes advantage of conservative ideas at the beginning of care. Later, if Alternative Medicine fails to assist the healing response then more aggressive drugs or surgery can still be used.
The Dupuytren Contracture Institute is not against hand surgery for Dupuytrens contracture. Obviously there is a need for surgery when natural methods have been unsuccessful.
The risk and limitation of Dupuytren surgery should be considered not only because of the potential permanent consequences (permanent pain and numbness, reduced finger movement, reduced hand strength) that can occur, but also because surgery is not the only option to reduce palm lumps and finger cords.
Hand surgery is not final
Two primary cautions should be kept in mind before submitting to surgery for the hands: First, even when Dupuytren’s surgery is done well by a skilled surgeon, unintended consequences occur that no one can anticipate or explain. Second, Dupuytren surgery is well known to stimulate the recurrence of additional nodule and cord formation in the palm after removal – sometimes as soon as in a single year, often three or four years. Since Dupuytren contracture is famous for recurrence within a few years after surgery, anyone thinking about a surgical option should realize that once the first surgery is done it is just a matter of time before the next surgery will have to be done. The typical pattern is that with each Dupuytren surgery the next recurrence of hand nodules will be a little faster than the last.
The only way to know for sure if Alternative Medicine will stimulate the natural healing process is to use a solid round of natural remedies for a month or two to determine if positive changes occur. If successful, then the patient should consult with her physician to learn if surgery can be avoided. If it does not help, then surgery can proceed knowing any potential risk is justified by the lack of progress with conservative methods. .
To learn about Alternative Medicine self-management, please see Different Way of Looking at Dupuytren Contracture Treatment
