Presentation on theme: "EAST CUMBRIA VOCATIONAL TRAINING SCHEME"— Presentation transcript:
1 EAST CUMBRIA VOCATIONAL TRAINING SCHEME MusculoskeletalUpper Limb
2 Differential Diagnosis Local ProblemReferred painWith paraesthesia/anaesthesia always check spineLocal and referred can exist togetherWith UL problems need to check the cervical spine
3 Assessment Cyriax Orthopaedic Medicine Subjective Objective: Range of movement – how far and qualitySoft tissue structuresNervePalpationCyriax Orthopaedic Medicine
4 Soft Tissue Healing Bleeding (injury to max 24 hours) Inflammation (essential for tissue repair starts within 2 hours and can last up to 2 weeks)Proliferation (starts hours, reaches a peak at 2-3 weeks when the bulk of the scar tissue is formed, and lasts several months)Remodelling (results in an organised and functional scar starts about 2 weeks and goes on for months)
5 Soft Tissue Injury AND R I C E M It is important to reassure patients that it is important to move when it is appropriate to do so.
6 Physiotherapy Treatment FrictionsSoft tissue mobilisationExercisesAcupunctureTrigger point releaseElectrotherapyRe-education of movement
8 Shoulder Joint Complex Scapulothoracic JointAC and SC JointsGlenohumeral joint – ball and socket, head of humerus articulates in the glenoid cavity of the scapula deepened by the glenoid labrumLarge ROMUnstableSupported by ligaments and rotator cuff muscles
10 Fracture Clavicle Fall onto an outstretched arm or shoulder. Collision with opponent in a contact sportUsually fractured in middle third and is very painful.Treatment: immobilise for pain relief, analgesia,mobilise and strengthen shoulderIncreased likelihood if surface is hard
11 Acromioclavicular Joint Fall onto tip of shoulder, elbow or outstretched handPain felt over the tip of the shoulder-epauletteTender over the AC JointDepending on the severity of the injury a step may be visible if ligament rupturePositive Scarf testDegenerative osteoarthritis especially active sporty peopleOveruse can provoke traumatic arthritisTreatment: rest, ice use of sling, strapping, analgesia, exercises, surgery if chronic ?steroid injectionTreatment would include ice, US, IFTH, exercises to mobilise and strengthenSurgery for Grade 3 with large step deformity.
13 Shoulder Dislocation Common traumatic injury – usually anterior. Arm usually in abduction and lateral rotationPosterior 3%(fall onto outstretched hand, epileptic seizures)Causes damage to joint capsule, tendon, ligament and glenoid labrum. Also nerve, vascular damage.Can be recurrent problemTreatment: reduction, immobilise, rehabilitationSurgery may be necessaryPopping sensation, Loss of shoulder contour, arm by side
15 Rotator Cuff InjurySupraspinatus and infraspinatus most commonly affected.Sports involving shoulder rotation/over arm mvt.Acute Tear:– sudden powerful action or fall onto outstretched hand at speed– sharp pain.- limited mobility- inability to abduct shoulder
16 Rotator Cuff InjuryChronic: develops over period of time overuse & usually associated with impingement syndromeUsually found on the dominant sideMore often an affliction of the 40+ age groupPain is worse at night, and can affect sleepingGradual worsening of pain, eventually some weaknessEventually unable to abduct arm (lift out to the side) without assistance or do any activities with the arm above the headSome limitations of other movements depending on the tendon affected
17 Impingement Syndrome generic term rotator cuff lesions caused by the rotator cuff and long head of biceps tendons becoming irritated and inflamed as they pass under the acromion - Subacromial Space. Tendons become thickened and are impinged further. Eventually partial or complete tears can occurCan be due to: - bony changes of the acromion- poor scapular control, athletes swimming/throwing- overuse , cumulative microtrauma- muscle imbalanceTreatment: rest, ice, frictions, nsaids, correct posture, correct movement pattern in sport, sub acromial steroid injection, surgery last resortExplain poor scapular control
18 Adhesive Capsulitis (Frozen Shoulder) 40-70 age range. 3% of the population affectedslightly higher incidence in womenfive times higher prevalence in diabetics.Often no significant reason for problem although it can follow trauma, illness or surgery
19 Adhesive Capsulitis (Frozen Shoulder) Painful Stage: short duration suggests shorter recovery refered pain distally more severeache, pain at night unable to lie on affected side. 2-9 monthsFreezing Stage: Increasing symptomsache, restriction of mobility, problems with daily activities monthsThawing Stage:Decrease pain and stiffness months.Treatment: analgesia, Steroid injections, mobilising and strengthening exercises, MUA.
20 Elbow JointArthritis , older patient history of recurrent joint pain over months or yearsLoose body , typically ‘twinges’ of pain and locking although tennis elbow can cause twinge on grippingTreatment:refer young person for loose body surgical removal/manipulate older analgesia, ?steroid injection,rehabilitationElbow joint stiffen v easily so early rehab necessary
21 Tennis ElbowTennis Elbow: overuse or repetitive strain caused by repeated extension of the wrist against resistance.Symptoms:Pain and weakness on gripping and lifting activities.Pain on extending the wrist and or fingers against resistance.Tenderness on palpation around the lateral epicondyle at common extensor originTreatment: frictions, ultrasound, exercisesacupuncture, injection, support, surgery.Using screwdriver, painting, keyboards, racket grip/set up.
22 Golfers ElbowGolfers elbow: overuse injury affecting common flexor origin. Common in throwers and golfers.Symptoms:pain and weakness on resisted wrist and finger flexion, forearm pronation.tenderness on palpation over the common flexor originTreatment: as for tennis elbow
23 Wrist Fracture Colles fracture: 25% of all fractures fall onto outstretched hand,dinner fork deformitySmiths fracture:fall onto flexed wrist or backward fall onto outstretched hand.Rehabilitation: reassurance, mobilisation and strengthening programmeComplex Regional Pain SyndromeMany not given good accurate advice and reassurance at fracture clinic and do not move
24 WristRepetitive Strain injuries: occupational – typing, using computer mouse, manual/production line workers, cleaners, musicians or sport related - racket sports.exacerbated by poor posture, inadequate wrist support or desk set-up, poor sporting technique or inadequate equipment.Symptoms: Pain, dull ache, throbbing, tingling, numbness, tightness.Treatment: ice, rest, work place assessment, regular breaks, local treatment of symptoms, steroid inj
26 Carpal Tunnel Syndrome Compression of the median nerve as it passes through the carpal tunnel. Three times more common in women and affects dominant hand more commonlyCauses: pregnancy, hypothyroid, traumatic injury, overuse, arthritis, use of vibrating equipment.Symptoms: ache/pain in wrist, forearm and radiation into thumb and 2-4 fingers, worse at night, burning and tingling into same area, weakness of fingers.
27 Carpal Tunnel Syndrome Tests:Tinels sign - Tap with two fingers over the palm side of the wrist - positive if any symptoms are reproduced.- Phalens test - Place hands in front at chest height with the fingers of the two hands touching. Flex the wrists and put the backs hands together. Hold for a minute. Symptom reproduction is a positive.Treatment: Conservative initially, rest, splint, ice, medication, stretching and strengthening, injection and surgery if conservative measures fail .
28 De Quervian’s Tenosynovitis inflammation of the abductor pollicis longus and extensor pollicis longus tendon sheathsCauses: repetitive wrist and hand movements – production line work, tennis, squash or badminton canoeing.Symptoms: crepitus, local tenderness and swelling over radial wrist , positive Finkelstein’s test (thumb flexion, wrist adduction)Treatment: rest, splint, physio, injection.
29 Scaphoid Fracture Most frequently injured carpal bone Fall onto outstretched hand (younger age group)10-15% not identified on initial XrayComplications of non union, avascular necrosisSymptoms: local pain and tenderness in the anatomical snuff boxTreatment: as a fracture with immobilisation and then rehab.Skateboarding. Often left and non union
30 Thumb and Finger Hyperextension Hyperextension injury strain of ligaments of the metacarpo-phalangeal joint or phalangeal joints.common in skiing (thumb), contact sports and ball sports e.g. rugby, goal keeper, basketball and netballSymptoms: Pain with thumb extension, in the web of the thumb when it is moved, swelling over the MCP joint, laxity and instability in the joint.Treatment: RICE, exercises to regain mobility and strength, may need strapping to return to sport initially
31 Hand Trigger finger/Thumb Dupuytrons contracture Arthritis in small joints 1st MCP most commonlyTreatment : analgesia, steroid injection if appropriate to trigger finger/joints if meets criteria refer for surgery
32 Neck Pain-upper limb symptoms could be refered Red flags :Under 20 or 1st episode over 55Vertebrobasilar /carotid artery symptomsTraumaMalignancy /Osteoporosis historyConstant/unremitting pain /rest painSystemically unwell, fever weight lossDrug use/immunosuppressionNerve signs in more than one root
33 History Occupation, hobbies,sports Age, onset duration, Refered arm pain from a disc lesion usually >35yrsSite and spread of painExacerbating/relieving factorsDizziness/drop attacksPHx medications
34 ManagementIf no trauma/instability gentle mobilisation, physio, analgesia , if worsening neurological symptoms or nerve root pain unresolving after 6 weeks refer neurosurgeon.Cervical traction/manipulation should not be done unless properly trained and contraindications excludedYellow flags-social problems , mental illness, gain from medical problems benefits etc passivity and inactivity, symptoms and signs don’t fit .
35 BibliographyTurner, Howard., Diagnosis of the Sporting Shoulder; Sportex Medicine 9, Jan 2001.Henry, Gray., Anatomy of The Human Body.Cyriax, J., Textbook of Orthopaedic Medicine,