Transcript Flexion - VCOMcc

Upper Extremity Review
Stuart Williams D.O.
Chairman & Associate Professor
Osteopathic Manipulative Medicine
Objectives
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Recall the functional anatomy of shoulder, scapula, and clavicle
Define and discuss the relationship between glenohumeral and scapular motion
Describe the shoulder exam: Inspection, palpation, ROM, strength, instability, and sensory testing
Discuss physical exam findings including osteopathic diagnoses of the shoulder girdle
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Describe the anatomy and gross range of motion of the elbow, forearm, and wrist
Describe carrying angle
Describe “parallelogram” mechanics of the forearm
Describe somatic dysfunction of
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SC Joint
AC Joint
GH Joint
Scapulothoracic Joint
Ulna
Radius
Interosseus membrane
Carpals
List the components of the true wrist joint
Introduction
• Third most common musculoskeletal complaint in
primary care offices  shoulder pain
– Second only to knee pain for referrals to sports medicine
physicians
• Incidence 25/1000 patients
– Peak incidence in 50-70 year olds
• 8-13% of athletic injuries involve the shoulder
Stevenson, JH Evaluation of shoulder pain. JFP July 2002 51 (7)
• Shoulder pain:
Introduction
– Intrinsic disease
– Pathology of the peri-articular
structures
• Ex. Pancost tumor
– Referred pain
• Ex. MI
• History
• Thorough PE
• Role of structure and function
Shoulder Anatomy Review
• Relies on muscles for support
• Humerus is suspended from the scapula by soft tissue,
muscles, ligaments and a joint capsule
• Composed of joints and “articulations”:
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Acromioclavicular (AC) joint
Glenohumeral (GH) joint
Sternoclavicular (SC) joint
Scapulothoracic articulation
Subacromial articulation
JAMA. 2004;292:1989-1999
Sternoclavicular Joint (SC)
• Saddle shaped synovial joint
• Articular disc
– Separates the articular
surfaces
– Adds significant strength to
the joint
• Depends on capsular
ligament for strength
• Enables the humerus to
achieve 1800 of ABduction
Am Fam Physician 2000;61:3079-88
Acromioclavicular Joint (AC)
• Oval-shaped, synovial-lined
articulation
• Fibrous capsule
• Articular disc
• AC ligament stabilize
– Thick and strong superior
– Weaker inferior capsule
• Posterior-superior portions
of the capsule limit ant/post
translation of distal clavicle
Am Fam Physician 2000;61:3079-88
Acromioclavicular Joint (AC)
• Coracoclavicular ligaments
stabilize the clavicle to the
scapula
– Conoid ligament primarily
prevents anterior and superior
clavicular displacement
– Trapezoid ligament is the
primary constraint against
compression of the distal
clavicle into the acromion
Acromioclavicular
Joint Disruption
• Type I 17%
• Type II 43%
• Type III 40%
– 80% of RC tears
• 3% in Type I
Med Sci Sports Exerc. 30(4) Supplement 1 1998.12-17
Journal of Bone and Joint Surgery. 1997; 79: 1854-1868.
Subacromial Articulation
• Impingement
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Greater tubercle
Acromion
Coracoacromial ligaments
Supraspinatus tendon
• 48-72% of shoulder pain
in PCP office is
subacromial impingement
Stevenson, JH. Evaluation of shoulder pain. JFP July 2002 51 (7)
Glenohumeral Joint (GH)
• Multi-axial ball and socket
• Most support from
Rotator cuff
• Contraction of rotator cuff
pulls the humerus down
into lower/wider portion
of the glenoid cavity
– “dropping down”
• Full ABduction otherwise
impossible
• Hydrostatic component
Am Fam Physician 2000;61:3079-88
• Labrum
Glenohumeral Joint (GH)
– Ring of fibrocartilage
• Surrounds/deepens the glenoid
fossa
– Increases contact area ~70%
• Ligaments
– Superior Glenohumeral
– Middle Glenohumeral
– Inferior Glenohumeral
(important when shoulder is
abducted and externally
rotated)
Scapulothoracic Articulation
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Am Fam Physician 2000;61:3079-88
Body of the scapula and muscles covering the
posterior chest wall
Scapula is a mobile platform from which the
upper limb operates
Allows the scapula to glide and rotate over the
posterolateral chest cage
Scapula aligns itself to allow the glenoid to be in
the best position to receive the head of the
humerus
Neurologically complex
Dynamic
Scapulothoracic Articulation
• Necessary for
scapulohumeral
ABduction
• GH joint and scapula
move in a 2:1 ratio
• Pain/stiffness may disturb
motion
Muscle
Action
Innervation
Suprapinatus
ABduction
Suprascapular
C5-C6
Infraspinatus
External rotation (ER)
Suprascapular
C5-C6
Teres minor
External rotation
Axillary
C5-C6
Subscapularis
Internal rotation (IR)
Subscapular
C5-C6
Biceps brachii
Flexion
Musculocutaneous
C5-C7
Triceps brachii
Extension
Radial
C5-T1
Deltoid
Flexion/IR(a); ABd(m); Extension/ER(p)
Axillary
C5-C6
Pectoralis major
ADd/Flexion/ER
Lat/med pectoral
C5-T1
Latissimus dorsi
Extension/ADd/IR
Thoracodorsal
C6-C8
Teres major
ADduction/IR
Subscapular
C5-C6
Trapezius
Elev(s)/Retract(m)/Depress(i)
Accessory
CN XI
Levator scapulae
Elevate
Dorsal scapular
C3-C5
Pectoralis Minor
Depress
Med pectoral
C8-T1
Rhomboids
Retract
Dorsal scapular
C5
Serratus anterior
Protract
Long thoracis
C5-C7
Adapted from Table 11.1 Muscles of the Shoulder from Anderson et. al. Sports Injury Management 2nd ed. (2000).
Shoulder Exam
• Inspection
• Palpation**
– TART
• ROM (passive and
active)
• Muscle strength testing
• Neurovascular testing
• Special testing
Shoulder Examination—HISTORY
• OLDCARTS
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– Onset
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– Location
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– Duration
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– Character
– Alleviating/aggravating factors •
– Radiation
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– Timing/Treatment
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– Severity
• Hand dominance
• Specific mechanism of injury •
• Functional loss
Medical History
Family History
Surgical History
Medications
Allergies
Occupational history
Social (tobacco, alcohol)
History
Sexual history
Shoulder Examination—HISTORY
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Stiffness or loss of motion
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– Adhesive capsulitis
– Frozen shoulder
– Tears of the rotator cuff
• From not using
– Arthritis
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Pain with throwing
– Anterior glenohumeral instability
– Labral etiology
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Pain on rolling over in bed
– Bursitis
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Pain that wakes from sleep
– Rotator cuff tear
– 88% sensitive, 20% specific
Acute trauma with the arm abducted and
externally rotated
– Shoulder subluxation or dislocation
– Glenolabral injury
Chronic pain and loss of passive range of
motion
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Pain in shoulder coming from rotator cuff
or bursa radiates to lateral deltoid – NOT
past elbow!
Am Fam Physician 2000;61:3079-88
Jour Fam Pract July 2002 51 (7)
Differential
by Location
Differential Diagnosis based on History
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Neck pain and pain that radiates below the elbow are often subtle signs of a
cervical spine disorder
– Look for + suprlings test, Lhermitte’s Test, adsons test  think cerivical radiculopathy, MS, or
TOS
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Pneumonia, cardiac ischemia and peptic ulcer disease can present with shoulder
pain
A history of DM or thyroid disease consider adhesive capsulitis
A history of malignancy consider possibility of metastatic disease
Previous corticosteroid injections, particularly in the setting of osteopenia or
rotator cuff tendon atrophy, or weakness following injection
If <40, consider instability or tendonopathy
If >40, consider RC tears, adhesive capsulitis, or osteoarthritis
Shoulder Exam—Inspection
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Look for:
– Swelling, asymmetry, muscle atrophy,
scars, ecchymosis, venous distention
– Deformity
– Scapular "winging“
• Shoulder instability
• Serratus anterior or trapezius
dysfunction
• Long thoracic nerve dysfunction
– Atrophy of the supraspinatus or
infraspinatus
• Rotator cuff tear
• Suprascapular nerve entrapment
• Cervical neuropathy
Range of Motion
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Flexion 900
Extension 450
ABduction 1800
ADduction 450
Internal Rotation 550
External Rotation 40-450
Active ROM tests
• Apley “scratch” test:
– ER and aBduction (C7)
– IR and aDduction (T7)
• Asymmetry indicative of limited
GH adduction, internal/external
rotation, scapular movement
• Painful arc
– 33% sensitive
– 81% specific
Am Fam Physician 2000;61:3079-88
Jour Fam Pract July 2002 51 (7)
Strength Testing
Motor Strength Grading
C5
0/5
1/5
2/5
3/5
4/5
5/5
No contraction detected
Barely detectable flicker
Active movement w/o gravity
Active movement w/gravity
Active movement against
gravity with some resistance
Active movement against
gravity with full resistance
Strength testing
• Scapular elevation (shoulder shrug)
– Trapezius (CN XI)
– Levator scapula (C3, C4)
• Scapular retraction (shoulders back)
– Rhomboids (dorsal scapular nerve)
• Scapular protraction (reach forward)
– Serratus Anterior (long thoracic nerve, C5,6,7)
Rotator Cuff Testing
• True weakness should be distinguished
from weakness that is due to pain
• Supraspinatus (ABduction)
– Empty Can Test
– Full Can Test
• Subscapularis (Internal Rotation)
– Lift Off Test
• Infraspinatus (External Rotation)
• Teres Minor (External Rotation)
Supraspinatus Testing
• Abduction
• Scaption position
• 300 forward flexion
• Apply a downward force as the
patient resists
• The test is positive with weakness
or pain
– 89% sensitive; 68% specific
• “Empty Can Test”
AJSM 1999 27 (1), 65-68
AJSM 34 (4): 644-652: 2006
Am Fam Physician. 2008;77(4):453-460
– Impingement
– 86% sensitive; 74% specific
Subscapularis Testing
• Internal rotation
• 00 abduction and 450 IR of
humerus
• Patient IR against
resistance
• Ability to “lift off”
JFP July 2002 51 (7)
AJSM 1996; 24 (5): 581-588
Am Fam Physician. 2008;77(4):453-460
– 62% sensitive
– 100% specific
Infraspinatus/Teres Minor Testing
• External rotation
• Elbows at the side
• Patient ER against
resistance
• Difficult to differentiate
muscles
Am Fam Physician. 2008;77(4):453-460
Neurovascular Testing
• C5: lateral shoulder
• C6: lateral forearm
• C7: index & middle
fingers
• C8: medial forearm
• T1: medial arm
Neurovascular Testing
Deep Tendon Reflex (DTR)
Grading
0/4
1/4
2/4
3/4
4/4
Absent
Decreased but present
Normal
Brisk, unsustained clonus
Brisk, sustained clonus
Special tests
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Cervical nerve root irritation
Shoulder joint instability
Shoulder Impingement testing
AC joint pathology
Bicipital tendon pathology
SLAP lesions
Shoulder Exam
• Remember referred pain (C-spine)
– Spurling’s Test
– Lhermitte’s Test
GH Instability—Apprehension Test
• The patients shoulder is
abducted to 900 and ER
• The test is positive when the
patient feels the shoulder is
going to “pop out” or has
pain
• “Apprehension” look on face
JAMA. 2004;292:1989-1999
GH Instability
• Apprehension Test
– Sens 54-88%
– Spec 44-100%
• Jobe Relocation Test
– Sens 30-85%
– Spec 58-100%
• Anterior Release Test
– Sens 85-92%
– Spec 87-89%
JAMA. 2004;292:1989-1999
Impingement Testing—Neer’s Test
• Patient seated, passively IR arm so that
thumb is downward
• Flex the arm while stabilizing scapula
• The test is positive if discomfort or
pain is elicited
• Impingement of the humerus against
the coracoacromial arch
• 75% sens; 50% spec
• 85% sensitive for rotator cuff tears
JSES 2000; 9(4): 299-301
Am Fam Physician 2000;61:3079-88
Impingement Testing—Hawkins Test
JFP July 2002 51 (7)
JSES 2000; 9(4): 299-301
Am Fam Physician 2000;61:3079-88
• Tests supraspinatus impingement
against the coracoacromial ligament
• The test is positive when there is pain
or discomfort
• False ‘+’ with AC pathology and labral
tears
• 90-92% sens, 60% spec
• 88% sensitive for Rotator Cuff Tears
AC Joint Pathology—Cross Arm Test
Am Fam Physician. 2008;77(4):453-460
• With the patient seated, bring
the arm across the chest as far as
possible
• The test is positive if there is pain
elicited at the AC joint
• By comparison with the opposite
side one can ascertain the
tightness or laxity of the
posterior capsule
Superior Labral Anterior Posterior
Lesions (SLAP)
• Pain posterior-superior
• Posterior tightness
• Eccentric loading of biceps
during throwing
• Fall with compressive loading
• Excessive traction from
weight lifting
SLAP Testing—O’Brien’s Test
• Shoulder 900 flexion, 100 adduction,
thumb pointed down
• Patient resists downward pressure
– Pain
• Rotate to supination and resist
flexion
– Gets better
• Test is positive if pain alleviated in
palm-up position
• Sensitivity 54-67%
• Specificity 31-49%
AJSM 2002; 30(6): 806-809
SLAP Testing—Biceps Load Test
• Loads the superior labrum
• Positive test is pain or
apprehension
• Test I is 900/900 Sens
91%, Spec 97%
• Test II is 1200/900 Sens
90%, Spec 97%
JAMA. 2004;292:1989-1999
AJSM 1999, 27 (3): 300-303
Arthroscopy 2001, 17 (2):160- 164
EFCTAIP
Elephant flatulating
constantly
Annoyed, “intelligent”
person
Spencer Technique
The seven stages of motions are:
4. Traction with circumduction on
1. Engage GH extension barrier with elbow straight arm
flexed
 Start small circles, then gradually
2. Engage GH flexion barrier with the elbow
increase size
flexed
 Clockwise and counterclockwise
3. Circumduction with compression
5. Engage abduction barrier
• Start small circles, then
6. Internal rotation with elbow
gradually increase size
flexed
• Clockwise and
7. GH pump with distraction and
counterclockwise
compression along straight arm
• May also do ME of IR/ER
barriers
Seven Stages of Spencer
Extension
Traction
Flexion
Abduction
Compression
Internal Rotation
Pump
Foundations 2nd Edition, pp. 848-851
7 Stages of Spencer
Stage 1 – Extension
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Cephalad hand cups pt’s shoulder to
stabilize clavicle and scapula
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Flex elbow & carry humerus into
extension with caudal hand to restrictive
barrier
Apply isometric muscle energy
1° muscle(s) activated (by pt)  biceps,
anterior deltoids
7 Stages of Spencer
Stage 2 – Flexion
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Caudal hand cups pt’s shoulder to
stabilize clavicle and scapula
With cephalad hand flex pt’s arm
through approx. 180 degree arch to
restrictive barrier
Apply isometric muscle energy
1° muscle(s) activated (by pt) 
latissimus dorsi
7 Stages of Spencer
Stage 3 – Circumduction with Compression
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Cephalad hand cups pt’s shoulder to
stabilize clavicle & scapula
Caudal hand flexes pt’s elbow & aBducts
humerus to 90 degrees
Circumduct elbow clockwise & counterclockwise directions
Start with small diameter circle &
gradually increase to full ROM
Modify elbow pressure and direction for
areas of resistance
7 Stages of Spencer
Stage 4 – Circumduction with Traction
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Cephalad hand cups pt’s shoulder to stabilize
clavicle & scapula
Grasp forearm, extend elbow, aBduct humerus to 90
degrees & apply traction toward ceiling
Circumduct arm clockwise & counter-clockwise
directions
Start with small diameter circle and gradually
increase to full ROM
Modify arm traction and/or change circumference
of cone for areas of resistance
7 Stages of Spencer
Stage 5 – ABduction
• Cephalad hand cups pt’s shoulder
to stabilize clavicle & scapula
• Caudal hand grasps elbow and
aBducts humerus to restrictive
barrier
• Apply isometric muscle energy
• 1° muscles activated (by pt) 
pectoralis major, latissimus dorsi
7 Stages of Spencer
Stage 6 – Internal Rotation
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Cephalad hand cups pt’s shoulder to stabilize
clavicle & scapula
Move pt’s hand to lumbosacral area/hip
Pull elbow anteriorly to internally rotate the
humerus into restrictive barrier
Apply isometric muscle energy
Caution: internal rotation is very sensitive &
should be applied very slowly
1° muscles activated (by pt)  teres minor,
infraspinatus
7 Stages of Spencer
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Stage 7 – Pump
Extend elbow, abduct humerus & place pt’s
forearm or hand on physician’s shoulder
Place both hands on humerus with fingers
spread over humeral head
Intermittently apply caudal force to scoop
humeral head from glenoid fossa & create
general pumping motion of joint
Aim pumping motion in any direction & repeat
until better motion is achieved
Elbow & Radial Head
Inspection
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Carrying Angle
– Normally 10-15º
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Female > male
Cubitus valgus
– Cubitus angle >15º
– Resulting the forearm deviating outwards
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Cubitus varus
– Cubitus angle <100
– Resulting the forearm deviating towards the
midline
Palpation-Elbow
Radial – Lateral epicondyle, capitulum, radial
head, wrist extensor/supinator group and insertion
Ulnar – Medial epicondyle, ulnar groove and
nerve, sublime tubercle, wrist flexor/pronator
group and insertion
Anterior – Cubital fossa (biceps tendon,
brachial a. and median n. and musculocutaneous n.,
bicipital aponeurosis)
Posterior – Olecranon process, fossa and
bursa, triceps tendon and aponeurosis
ROM-Elbow and Forearm
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Flexion (1500)
– Coracobrachialis, Biceps, Brachialis, Brachioradialis
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Extension (00 in ♂; up to 50 in ♀)
– Triceps, Anconeus
• 150 of hyperextension in females/children
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Pronation (00 to 80-900)
– Pronator teres & quadratus
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Supination (00 to 80-900)
– Supinator, Biceps, Brachioradialis
Anterior Pain
Biceps Tendonitis
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Overuse syndrome caused by repetitive
overloading
– Excessive elbow flexion and supination activities
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Symptoms
– Anterior elbow pain with flexion and supination
– Weakness secondary to pain
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Increased pain on resisted shoulder flexion and
forearm supination
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Biceps tender to palpation
Anterior Pain
Biceps Tendon Rupture
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Traumatic event
Pre-existing degenerative changes make it
vulnerable
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97% ruptures are proximal
Weakness of supination and flexion
– Brachioradialis
– Supinator
– Decreased by about 40%
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Tenderness, swelling, and ecchymosis
Deformity as muscle belly retracts
Risk factors
– Male
– >30 years of age
– Recent steroids
Anterior Pain
Biceps Tendon Rupture
• X-ray (you may see)
– Avulsion fragment from the
radial tuberosity
– Degenerative changes on the
volar aspect radial tuberosity
• Treatment
– Surgery?
– Immobilize for 8 weeks
– Then proceed with
strengthening and ROM
Posterior Pain
Olecranon Bursitis
• Minor’s elbow or student’s elbow
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Repetitive compression trauma
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Relatively painless posterior swelling
Fluctuant mass
No erythema or increased temperature
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Irritation to the bursa
• X-ray is negative unless traumatic
• Differential diagnosis
– Septic bursitis (infection)
• Treatment
– Protection
– Aspirate/culture if suspect septic
Lateral Pain
Nursemaid’s Elbow
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Young children
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Typically 6mos to 6 years
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Peak in 2-3 year olds
Girls > boys
Mechanism
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Axial traction on extended and pronated arm
Pulls the radius distally
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Slips through the annular ligament
• Right arm is flexed at the elbow and
forearm pronated, held close to the
body
Lateral Pain
Nursemaid’s Elbow
• Easily reduced in exam room
– Supination +/- flexion
• Success 80-92%
• May be more painful for patient
– Hyperpronation
• Success rate 91- 97%
• Parents perceived as less painful
• X-rays often negative
• +/- sling for a few days
• Recurrence 26-39%
Lateral Pain
Epicondylitis
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AKA Tennis elbow
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Overuse of the wrist extensors
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Causes micro tears of the tendon at the lateral epicondyle
10x more common than medial
• Predisposing factors
– Age 30-50 years of age
– Faulty backswing
• 18-31% of tennis players
– Poorly fitted equipment
– Repetitive job at work
• 15% industrial workers
• Aching over the lateral epicondyle
• Difficulty with wrist extension
– Such as picking up a coffee cup
Lateral Pain
Epicondylitis
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X-ray
– May see small calcium deposits in the extensors due to the micro tears bleeding and
the chronicity of the condition
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Treatment
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Rest and ice
Forearm splint
OMM
Rehab exercises
Steroid injection
– Prolotherapy/PRP
– Surgery last resort
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Medial Pain
Epicondylitis
AKA Golfer’s Elbow
Overuse of the wrist flexors
Causes micro tears of the tendon at the medial
epicondyle
• Predisposing factors
– Age 30-50 years of age
– Faulty mechanics
– Poorly fitted equipment
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Tenderness at flexor origin medial epicondyle
Increased pain with resisted wrist flexion and forearm
pronation
Negative Tinel’s test at cubital tunnel
Medial Pain
Epicondylitis
• X-ray
– Usually negative but can see small calcific
deposits
• Treatment
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Rest and ice
Forearm splint
OMM
Rehab exercises
Steroid injection
Prolotherapy/PRP
Surgery last resort
Medial Pain
Cubital Tunnel Syndrome
• 2nd most common compression
neuropathy behind Carpal tunnel
syndrome
– >40% athletes with valgus instability
– 60% athletes with medial
epicondylitis
• Mechanical compromise of ulnar
nerve
– Direct insult
– Excessive traction, compression, or
friction
Medial Pain
Cubital Tunnel Syndrome
• Medial elbow pain
– +/- radiation
– Paresthesis (4-5th digits)
–“Clumsiness” of hand
• Positive Tinel’s test
• Weakness late finding
– Intrinsic hand muscles
• Conservative
– Night splint 200 flexion
• Surgical decompression of
and/or transposition
Flexor-Pronator Mass Syndrome
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Purely sensory syndrome
Median n. becomes trapped between heads of
pronator teres muscle
Symptoms
– Pain
– Paresthesia
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Mechanism
– Repetitive pronation
– Anomalous anatomy
Flexor-Pronator Mass Syndrome
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Resisted flexion of FDS tendon of index/middle
finger
– Papal sign
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Resisted pronation of forearm reproduce symptoms
Negative Tinel’s/Phalen’s test at wrist
Conservative
– Splinting
• Surgery, if fail conservative
treatment
Quick Review of Anatomy
Quick Review of Anatomy - Extension
•Extension is limited by:
1. Impact of the olecranon process within the fossa.
2. Tension of the anterior ligament
3. Resistance of the flexor mm.
•In extension, the posterior aspect of the trochlear grove makes contact with the
trochlear notch. The oblique nature of the trochlea causes a deviation of the ulna in
extension that we call the carrying angle.
Quick Review of Anatomy - Flexion
•Active Flexion - is limited by the anterior mm of the arm and forearm. Flexion is limited to 145o
•Passive Flexion is limited by the head of the radius against the radial fossa and of the coronoid
process against the coronoid fossa, tension of the posterior capsular ligament, and tension
developed passively in the triceps. Flexion up to 160o.
Important Definitions
• ADDUCTION:
• ABDUCTION:
• IS A MOVEMENT WHICH
BRINGS A PART OF THE
ANATOMY CLOSER TO THE
MIDDLE SAGITTAL PLANE
OF THE BODY
• IS A MOVEMENT WHICH
BRINGS A PART OF THE
ANATOMY AWAY FROM
THE MIDDLE SAGITTAL
PLANE OF THE BODY
Carrying Angle
 The Trochlear Notch of the Ulna has a slight
spiral allowing for slight ABduction of
forearm and slight ADduction of wrist in
anatomical position.
 Carrying Angle is the angle between the Blue
and Red Line.
 It can be measured grossly by visual
inspection.
Carrying Angle
Using the recalled pieces of data, we can explain
what an increased Carrying Angle might cause.
C.
B.
•(A.) Normal Carrying Angle.
•(B.) As the Forearm ABducts, the Radial head (RH) will
be pushed into the Capitulum of the Humerus pinning the
RH to the Humerus.
•(C.)With increased Forearm ABduction, pinned Radius
forces the hand/wrist to ADduct.
Thus creating inflammation at the lateral aspect
of the elbow and wrist, and creating a strain in
the IO membrane .
____________
A.
Carrying Angle
•Left: Adduction of the ulna
(#1), will cause the radius
to be pulled proximal (#2).
This will result in abduction
of the wrist (#3).
•Right: Abduction of the
ulna (#1) will cause the
radius to be pushed distal
(#2). This will result in
Adduction of the wrist (#3)
Quick Review of Anatomy - Supination and Pronation
In Supination, the radius and ulna have parallel
axes and lie side by side with the ulna on the medial
side. The radial head moves anterior during
supination.
In Pronation, the radius “crosses” over the ulna
and the reciprocal motion of the radius causes the
radial head to move posteriorly.
Remember this for dx and tx of somatic
dysfxn of the radial head.
Radius in
supination
Radius in
Pronation
Posterior Radial Head
Anterior Radial Head
Dx of Radial Head SD
• With thumb and index finger
grasp radial head- monitor for
reciprocal motion at end of
pronation & supination
– (pronation = radial head
posterior)
– supination = radial head
anterior)
• Name SD for direction Radial
Head will move
(monitor)
Tx: Radial Head Posterior- Direct Muscle
Energy
•
•
•
•
•
Correct Abduction or Adduction first
Contact the posterior aspect of radial head
with thumb of lateral hand
Grasp distal radius and ulna and engage
barrier with forearm supination & wrist
extension
Patient attempts to pronate (Dr. resists)
Relax, engage new barrier
– Dr.’s thumb and supination force will
move radial head anterior
Thumb on anterior distal
radius
supinate
*
Tx: Radial Head AnteriorDirect Muscle Energy
• Grasp the hand on
the side of the
dysfunction
contacting the dorsal
aspect of the distal
radius with the
thumb
Quick Review of Anatomy - Interosseous
membrane
The interosseous membrane has anterior (1) and posterior fibers
(2)
The anterior fibers run obliquely distally and medially
The posterior fibers run proximally and laterally
This is the only anatomic structure that prevents descent of the
radius relative to the ulna
This membrane with the different directions of the fibers
transmits forces from wrist to elbow, elbow to wrist, ulna to radius,
and radius to ulna.
It intimately connects the elbow and wrist - (elbow dysfxn is
often perceived as wrist pain).
Wrist and Hand
Wrist and Hand Examination
 Wrist joints: radiocarpal(rc),
radioulnar, intercarpal; rc
provides most flex/ext
 Hand joints:
metacarpophalangeal(MCP),
proximal interphalangeal(PIP),
and distal interphalangeal(DIP)
joints
Palpation
• Palpate PIP (RA or
Bouchard’s nodes in
DJD)
• DIP(Heberden’s
nodes)
Motion Testing and Maneuvers
 Wrist
 Flexion – flexor carpi
radials and ulnaris
 Extension- ext carpi
radialis longus and brevis,
ext carpi ulnaris
 Adduction (ulnar
deviation 30 deg) – flex
carpi ulnaris
 Abduction (radial
deviation 20 deg) flex carpi
radialis
Palms down
http://media3.washingtonpost.com/wpdyn/content/photo/2007/02/02/PH2007020200815.jpg
Wrist and Hand Examination Maneuvers
 Sensation
 Grip strength – tests function of
wrist joints, finger flexors, and
intrinsic muscles and joints of
hand ( wrist pain and grip
weakness : de Quervain’s, CTS,
DJD, cervical radiculopathy,
epicondylitis)
Wrist and Hand Examination Maneuvers
• Thumb movement
•
Finkelstein’s - ask pt to grasp
thumb against the palm and then
move wrist in ulnar deviation (
de Quervain’s tenosynovitis –
inflammation of abductor
pollicus longus and ext pollicus
brevis tendons and sheaths)
Wrist and Hand Examination
 Carpal Tunnel
 Thumb abduction – ask pt to raise
thumb as you apply downward
resistence (weakness of abductor
pollicus longus – median n.)
 Tinel’s sign - tapping over coarse
of median n. pos. if numbness in
distribution of median n.
 Phalen’s sign – hold wrist in
flexion for 60 sec, median n
compression, numbness in
distribution of median n.
Tinel’s
Phalen’s
Thumb
abduction
Fingers ROM and Maneuvers
•
•
•
•
•
Flexion - have pt make fist with
thumb across the knuckles
Extension – have pt extend and
spread the fingers
Test flex/ext at : MCP, PIP, and DIP
Abduction – spread fingers
apart(dorsal interossei)
Adduction – bring fingers back
together (palmar interossei)
Thumb ROM and Maneuvers
 Flexion – move thumb across palm
and touch base of 5th finger
 Extension – move thumb back
across and away from fingers
 Abduction – palm up, thumb
neutral, move thumb away from
palm
 Adduction - palm up, thumb
neutral, move thumb back
 Opposition (movements of thumb
across the palm) - have pt touch
thumb to each fingertip
Hand and Wrist Anatomy
http://www.handuniversity.com/images/illustrations/wrist_arthroplasty_anat01.jpg
http://www.eorthopod.com/images/ContentImages/wrist/wrist_fusion/wrist_fusion_anat02.jpg
Innervation
 Median Nerve
 Crosses the elbow medially and
passes through the two heads of the
pronator teres, a potential site of
entrapment
 Ulnar Nerve
 Passes along the medial arm and
posterior to the medial epicondyle
through the cubital tunnel, a likely
source of entrapment
 Radial Nerve
 Descends the arm laterally, dividing
into the superficial (sensory) branch
and the deep (motor or posterior
interosseous) branch
 The deep branch passes through the
Arcade of Frohse, where it is most
susceptible to injury
Arthritis; hand, thumb, and wrist
 Rheumatoid Arthritis –chronic
inflammatory polyarthritis
 Women > men
 Commonly begins age 25-50
 Immune stimulation changes synovial
cells so they invade articular cartilage
and adjacent tissues .
RA
Arthritis
• Osteoarthritis (OA) is not a
single disease but rather the
end result of a variety of
disorders leading to the
structural or functional failure
of one or more of your joints.
Osteoarthritis is the most
common cause of chronic
joint pain, affecting over 25
million Americans.
Arthritis
• Osteoarthritis involves the
entire joint, including the
nearby muscles, underlying
bone, ligaments, joint lining
(synovium), and the joint cover
(capsule).
• Osteoarthritis also involves
progressive loss of cartilage
Osteoarthritis
Patients may have
bony nodule at the
DIP (Heberden’s) and
PIP (Bouchard’s)
Ganglion Cyst
•
Soft tissue mass of the hand/wrist
– Usually attached to a tendon sheath or joint
•
Commonly from tear in ligaments overlying
the lining of tendons or joints
– Most commonly the scapholunate joint
•
•
•
The lining herniates out of the ligamentous
defect causing the “cyst”
Inflammatory processes produce jelly-like
fluid
Mechanism unknown
–
–
–
–
no specific injury
?degenerative
More common in sports
Repetitive loading
Ganglion cyst
 Symptoms
 As mentioned above
 Signs
 Typically find a fusiform mass freely mobile, sometimes tender
 Positive transillumination
 May be mistaken for bony prominence
 More common in sports or work with repetitive wrist loading
 X-rays are negative
 Treatment




Alleviate symptoms/observation
If remains symptomatic consider aspiration (seldom curative)
May inject with steroids
Surgery
DeQuervain’s Tenosynovitis
 Inflammation of the tendons
and synovial sheaths
 In particular the first dorsal
compartment of the wrist
 Abductor pollicis longus
 Ext pollicis brevis
 Common in repetitive motion
activities
DeQuervain’s Tenosynovitis
• S/Sx:
– Pain in first dorsal compartment
– Pain with gripping and rotational motions
(removing lid from jar)
– Positive Finkelstein test
• Treatment
–
–
–
–
–
–
–
X-rays negative
Splinting in thumb spica
Avoid the repetitive activity
OMT
NSAIDs
Steroid injection
Surgery
Dupuytren’s Disease
• First described in 1834
• Not a consequence of activity
• Insidious onset of thickening and
contracture of the palmar fascia
• The skin on the distal side of the
primary nodule is drawn up into a fold
• Eventually the fingers become
progressively flexed at the MCP and
PIP joints
Dupuytren’s Disease
• Isolated nodular thickening
– Usually seen in flexor tendons
– Common with the 4th and/or 5th
digit
– 2nd and 3rd digits are usually
spared
Nerve Entrapment Injuries
• Carpal tunnel is a fibro-osseous canal
containing 9 finger flexion tendons and
the median nerve
• Compression of the median nerve occurs
with decrease in the space of the tunnel
• Carpal Tunnel Syndrome
– Tingling in the finger tips
– Numbness/pain at night waking the patient
– Compensatory or referred pain into the
elbow, shoulder, neck
Carpal Tunnel Syndrome
 Hallmark findings
 Positive Tinel’s test
 Positive Phalen’s test
 Late findings include:
 Weakness of abductor pollicus brevis
muscle
 Atrophy of thenar eminence
 Sensory loss of median nerve
distribution
 Electromyography (EMG) and
Nerve Conduction Velocity
(NCV) are positive
Ulnar Nerve Entrapment
Guyon’s Canal
 Lies medial to the carpal tunnel
 Ulnar nerve passes between the
pisiform and hook of the hamate
and overlying ligament
 Often from repetitive trauma
 Mass lesion (ganglion cyst)
 Direct trauma (fracture in hook of
hamate)
 Mechanical factor’s related to
wrist position (cyclists’ palsy or
jackhammer use)
Felon and Paronychia
 Infections occur at distal
pulp (felon) and soft tissue
fold around the finger nail.
 Felon; usually puncture
wound, tender, red, swollen;
tx surgical drainage
 Paronychia; swelling,
abscess around nail fold; tx
is incision and drainage
Range of Motion
• Flexion- 80 to 90 degrees
• Extension- 70 degrees
• Ulnar deviation- 30 degrees
• Radial deviation- 20
degrees
How to Diagnose Flexion or Extension
Somatic Dysfunction of the Wrist
• Have patient flex and extend the wrist-look for freedom
of motion and restriction of motion.
• Passively move the patient’s wrist in Flexion and
Extension-see how far it can move in either direction
and how it feels.
• Where it moves more easily is the diagnosis (the
motion it is “stuck in”).
• Where it is restricted represents the restrictive barrier.
• Dx: Flexion SD or Extension SD
Treatment of Flexion Somatic Dysfunction
 Patient seated, doctor standing or sitting facing patient.
 Doctor grasps the patient's wrist with the doctor’s thumbs on
the dorsal aspect of the wrist, pressing on the dysfunctional
bone.
 The doctor may reinforce the pressure of the treating thumb
by adding pressure with the other thumb.
 The doctor’s hands wrap around the wrist to contact the
palmar aspect of the patient’s hand.
 The patient’s wrist is initially held in flexion
 A simple repeated motion is carried out, moving the wrist
from flexion to extension, while maintaining pressure
over the displaced carpal bone.
Treatment of Extension Somatic Dysfunction
Patient seated, doctor standing or sitting facing
patient.
Doctor grasps the patient's wrist with the doctor’s
thumbs on the dorsal aspect of the wrist, resting on
the dysfunctional bone.
The doctor’s hands wrap around the wrist so that the
index fingers can press on the dysfunctional bone.
The patient’s wrist is initially held in extension.
A simple repeated motion is carried out, moving the
wrist from extension to flexion, while maintaining
pressure over the displaced carpal bone.
How to Diagnose
• Have the patient adduct and abduct the wrist – look for
differences from side to side
• You move the patient’s wrist in abduction and
adduction – check for how far it can move in either
direct AND how it feels
• Where it moves more easily is the diagnosis.
• Where it is restricted represents the restrictive barrier.
• DX: Abduction SD vs Adduction SD
Treatment for Abduction Somatic Dysfunction of the
Wrist
 Doctor and patient facing each other,
seated or standing
 Doctor grasps patient’s wrist and places
it into pronation and abduction
 Doctor moves patient’s wrist from the
original position in abduction to and
just past the adduction barrier in a
smooth gentle motion.
Treatment for Adduction Somatic Dysfunction of Wrist
 Doctor and patient facing each other,
seated or standing
 Doctor grasps patient’s wrist and
places it into pronation and
adduction
 Doctor moves patient’s wrist from
the original position in adduction to
and just past the abduction barrier in
a smooth, gentle motion
How to Diagnose
Patient with signs of paresthesia in left hand or
right hand.
Assess for possible carpal tunnel syndrome by
performing Tinel’s sign or Phalen’s sign.
The Opponens Roll
• Grasp first digit and fifth digits with
each hand
• Thumbs contact pisiform and navicular
(scaphoid) bones with thumbs
• Extend wrist, abduct and laterally
rotate first digit with counterforce over
hypothenar area