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Presentation on theme: "EAST CUMBRIA VOCATIONAL TRAINING SCHEME"— Presentation transcript:

Musculoskeletal Upper Limb

2 Differential Diagnosis
Local Problem Referred pain With paraesthesia/anaesthesia always check spine Local and referred can exist together With UL problems need to check the cervical spine

3 Assessment Cyriax Orthopaedic Medicine Subjective Objective:
Range of movement – how far and quality Soft tissue structures Nerve Palpation Cyriax 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
Frictions Soft tissue mobilisation Exercises Acupuncture Trigger point release Electrotherapy Re-education of movement

7 Shoulder Joint Complex

8 Shoulder Joint Complex
Scapulothoracic Joint AC and SC Joints Glenohumeral joint – ball and socket, head of humerus articulates in the glenoid cavity of the scapula deepened by the glenoid labrum Large ROM Unstable Supported by ligaments and rotator cuff muscles

9 Posterior Shoulder

10 Fracture Clavicle Fall onto an outstretched arm or shoulder.
Collision with opponent in a contact sport Usually fractured in middle third and is very painful. Treatment: immobilise for pain relief, analgesia, mobilise and strengthen shoulder Increased likelihood if surface is hard

11 Acromioclavicular Joint
Fall onto tip of shoulder, elbow or outstretched hand Pain felt over the tip of the shoulder-epaulette Tender over the AC Joint Depending on the severity of the injury a step may be visible if ligament rupture Positive Scarf test Degenerative osteoarthritis especially active sporty people Overuse can provoke traumatic arthritis Treatment: rest, ice use of sling, strapping, analgesia, exercises, surgery if chronic ?steroid injection Treatment would include ice, US, IFTH, exercises to mobilise and strengthen Surgery for Grade 3 with large step deformity.

12 Glenohumeral Joint

13 Shoulder Dislocation Common traumatic injury – usually anterior.
Arm usually in abduction and lateral rotation Posterior 3%(fall onto outstretched hand, epileptic seizures) Causes damage to joint capsule, tendon, ligament and glenoid labrum. Also nerve, vascular damage. Can be recurrent problem Treatment: reduction, immobilise, rehabilitation Surgery may be necessary Popping sensation, Loss of shoulder contour, arm by side

14 Posterior Shoulder

15 Rotator Cuff Injury Supraspinatus 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 Injury Chronic: develops over period of time overuse & usually associated with impingement syndrome Usually found on the dominant side More often an affliction of the 40+ age group Pain is worse at night, and can affect sleeping Gradual worsening of pain, eventually some weakness Eventually unable to abduct arm (lift out to the side) without assistance or do any activities with the arm above the head Some 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 occur Can be due to: - bony changes of the acromion - poor scapular control, athletes swimming/throwing - overuse , cumulative microtrauma - muscle imbalance Treatment: rest, ice, frictions, nsaids, correct posture, correct movement pattern in sport, sub acromial steroid injection, surgery last resort Explain poor scapular control

18 Adhesive Capsulitis (Frozen Shoulder)
40-70 age range.  3% of the population affected slightly higher incidence in women five 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 severe ache, pain at night unable to lie on affected side. 2-9 months Freezing Stage: Increasing symptoms ache, restriction of mobility, problems with daily activities months Thawing Stage: Decrease pain and stiffness months. Treatment: analgesia, Steroid injections, mobilising and strengthening exercises, MUA.

20 Elbow Joint Arthritis , older patient history of recurrent joint pain over months or years Loose body , typically ‘twinges’ of pain and locking although tennis elbow can cause twinge on gripping Treatment:refer young person for loose body surgical removal/manipulate older analgesia, ?steroid injection,rehabilitation Elbow joint stiffen v easily so early rehab necessary

21 Tennis Elbow Tennis 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 origin Treatment: frictions, ultrasound, exercises acupuncture, injection, support, surgery. Using screwdriver, painting, keyboards, racket grip/set up.

22 Golfers Elbow Golfers 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 origin Treatment: as for tennis elbow

23 Wrist Fracture Colles fracture: 25% of all fractures
fall onto outstretched hand, dinner fork deformity Smiths fracture: fall onto flexed wrist or backward fall onto outstretched hand. Rehabilitation: reassurance, mobilisation and strengthening programme Complex Regional Pain Syndrome Many not given good accurate advice and reassurance at fracture clinic and do not move

24 Wrist Repetitive 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 commonly Causes: 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 sheaths Causes: 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 Xray Complications of non union, avascular necrosis Symptoms: local pain and tenderness in the anatomical snuff box Treatment: 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 netball Symptoms: 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 commonly Treatment : 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 55 Vertebrobasilar /carotid artery symptoms Trauma Malignancy /Osteoporosis history Constant/unremitting pain /rest pain Systemically unwell, fever weight loss Drug use/immunosuppression Nerve signs in more than one root

33 History Occupation, hobbies,sports Age, onset duration,
Refered arm pain from a disc lesion usually >35yrs Site and spread of pain Exacerbating/relieving factors Dizziness/drop attacks PHx medications

34 Management If 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 excluded Yellow flags-social problems , mental illness, gain from medical problems benefits etc passivity and inactivity, symptoms and signs don’t fit .

35 Bibliography Turner, Howard., Diagnosis of the Sporting Shoulder; Sportex Medicine 9, Jan 2001. Henry, Gray., Anatomy of The Human Body. Cyriax, J., Textbook of Orthopaedic Medicine,


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