Upper Extremity Review

Upper Extremity Review
Stuart Williams D.O. Chairman & Associate Professor Osteopathic Manipulative Medicine

Objectives 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 SC Joint AC Joint GH Joint Scapulothoracic Joint 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 Ulna Radius Interosseus membrane Carpals List the components of the true wrist joint Define and discuss the relationship between glenohumeral and scapular motion - Every 3 deg you move your arm, 2 deg is due to gnelohumeral motion and 1 deg is due to scapular motion  KNOW THIS

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 year olds 8-13% of athletic injuries involve the shoulder Low back is the most common musculoskeletal complaint that a person will come into a doc to see URI in general is the most common complaint in general Stevenson, JH Evaluation of shoulder pain. JFP July (7)

Introduction Shoulder pain: History Thorough PE
Intrinsic disease Pathology of the peri-articular structures Ex. Pancost tumor Referred pain Ex. MI History Thorough PE Role of structure and function Know viscerosomatic and somatovisceral reflexes here

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”: Acromioclavicular (AC) joint Glenohumeral (GH) joint Sternoclavicular (SC) joint Scapulothoracic articulation Subacromial articulation Tampa Skyway Bridge

JAMA. 2004;292:

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 Clavicle is first to ossify (7 weeks), last to fuse (SC at 25yrs; AC at 20 yrs) Know that the most important thing this joint does is connect the upper extremity to the thoracic cage Am Fam Physician 2000;61:

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:

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 Grade 1 tear  stretch ligament of AC ligament Grade 2 tear  complete tear of AC ligament Grade 3 tear  tear of both AC and coracoclavicular ligaments

Acromioclavicular Joint Disruption
Type I 17% Type II 43% Type III 40% 80% of RC tears 3% in Type I Bigliani, L. Subacromial impingement syndrome. Journal of Bone and Joint Surgery ; 79: He said to know this for sure (grade 1 – 3, see last slide) Med Sci Sports Exerc. 30(4) Supplement Journal of Bone and Joint Surgery ; 79:

Subacromial Articulation
Impingement 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 (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 Extremely mobile joint Rotator cuff holds it in place For every 3 deg of movement, the GH provides 2 deg of it (the scapulothroacic provides the other 1 deg) Am Fam Physician 2000;61:

Glenohumeral Joint (GH)
Labrum 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
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 For every 3 deg of motion, this provides 1 deg (the other two are by GH) Am Fam Physician 2000;61:

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) Teres minor External rotation Axillary Subscapularis Internal rotation (IR) Subscapular Biceps brachii Flexion Musculocutaneous C5-C7 Triceps brachii Extension Radial C5-T1 Deltoid Flexion/IR(a); ABd(m); Extension/ER(p) Pectoralis major ADd/Flexion/ER Lat/med pectoral Latissimus dorsi Extension/ADd/IR Thoracodorsal C6-C8 Teres major ADduction/IR 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 C5 Serratus anterior Protract Long thoracis Muscles of shoulder include rotator cuff, extrinsic shoulder muscles, scapular muscles, and muscles that act to move upper arm Review charts Foundations p.643 He said know the ones in red If you lesion the long thoracic nerve  winged scapula Adapted from Table 11.1 Muscles of the Shoulder from Anderson et. al. Sports Injury Management 2nd ed. (2000).

Shoulder Exam Inspection Palpation** ROM (passive and active)
TART ROM (passive and active) Muscle strength testing Neurovascular testing Special testing “Functional Exam” Inspection; AROM (painless); Functional testing; A(P)ROM; Special testing with Palpation last

Shoulder Examination—HISTORY
OLDCARTS Medical History Onset Family History Location Surgical History Duration Medications Character Alleviating/aggravating factors Allergies Radiation Occupational history Timing/Treatment Social (tobacco, alcohol) History Severity Hand dominance Sexual history Specific mechanism of injury Functional loss <1% shoulder in <30yrs ar RC tearsmore likely biomechanical, instability, tendonosis 35% shoulder in >45 are RC tears (Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7) Medical History Birth history, developmental milestones, other injuries, Family History Genetic disorders: osteogenesis imperfecta, skeletal dysplasia, rickets, hypophosphatemia, hypercalciuria, arthritis

Shoulder Examination—HISTORY
Stiffness or loss of motion Chronic pain and loss of passive range of motion Adhesive capsulitis From not using Frozen shoulder Arthritis Tears of the rotator cuff Pain with throwing Pain on rolling over in bed Anterior glenohumeral instability Bursitis Labral etiology Pain that wakes from sleep Acute trauma with the arm abducted and externally rotated Rotator cuff tear 88% sensitive, 20% specific Shoulder subluxation or dislocation Pain in shoulder coming from rotator cuff or bursa radiates to lateral deltoid – NOT past elbow! Glenolabral injury Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7) Am Fam Physician 2000;61: Jour Fam Pract July (7)

Differential by Location
Essentials of Musculoskeletal Care. Ed. Snider, RK. American Academy of Orthopaedic Sugeons: Rosemont, IL p. 70

Differential Diagnosis based on History
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 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
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 Flexion 900 Extension 450 ABduction 1800 ADduction 450
Internal Rotation 550 External Rotation Know a ball park range of these

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 Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7) Am Fam Physician 2000;61: Jour Fam Pract July (7)

Strength Testing Motor Strength Grading C5 0/5 No contraction detected
1/5 Barely detectable flicker 2/5 Active movement w/o gravity 3/5 Active movement w/gravity 4/5 Active movement against gravity with some resistance 5/5 Active movement against gravity with full resistance C5 C5: Deltoid/ Biceps C6: Biceps/Wrist extensors C7: Triceps/Wrist flexors/Finger Extensors C8: Hand intrinsics/Finger Flexors T1: Hand intrinsics

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) Serratus anterior  also called boxers muscle

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” Impingement 86% sensitive; 74% specific Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7) Itoi, E, et al. Which is more useful, the “full can test” or the “empty can test” in detecting the torn supraspinatus tendon? AJSM (1), Thigpen, CA, et al. Scapular kinematics during supraspinatus rehabilitation exercise: a comparison of full can versus empty can techniques. AJSM 34 (4): : 2006. AJSM (1), 65-68 AJSM 34 (4): : 2006 Am Fam Physician. 2008;77(4):

Subscapularis Testing
Internal rotation 00 abduction and 450 IR of humerus Patient IR against resistance Ability to “lift off” 62% sensitive 100% specific Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7) Kelly, BT. The manual muscle examination for rotator cuff strength: an electromyographic investigation. AJSM 24 (5): : 1996. JFP July (7) AJSM 1996; 24 (5): Am Fam Physician. 2008;77(4):

Infraspinatus/Teres Minor Testing
External rotation Elbows at the side Patient ER against resistance Difficult to differentiate muscles Am Fam Physician. 2008;77(4):

Neurovascular Testing
C5: lateral shoulder C6: lateral forearm C7: index & middle fingers C8: medial forearm T1: medial arm Know sympathetics as well upper extremities – T2 – T8 No parasympathetics Lower extremities – T 11 – L 1

Neurovascular Testing
Deep Tendon Reflex (DTR) Grading 0/4 Absent 1/4 Decreased but present 2/4 Normal 3/4 Brisk, unsustained clonus 4/4 Brisk, sustained clonus C5 reflex: biceps C6 reflex: brachioradialis C7 reflex: triceps

Special tests Cervical nerve root irritation
Shoulder joint instability Shoulder Impingement testing AC joint pathology Bicipital tendon pathology SLAP lesions Know all the special tests he is about to go over…..

Shoulder Exam Remember referred pain (C-spine) Spurling’s Test
Lhermitte’s Test Spurlings - The examiner passively hyperextends and laterally flexes the patient's neck toward the involved side. The test is positive if axial loading by the examiner's hands reproduces symptoms Lhermittes – flexion of the head forward causes shooting, tingling pain down the neck (can be indicative of Multiple sclerosis, osteoarthritis, B12 deficiency, transverse myelitis)

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 Hoppenfeld JAMA. 2004;292:

GH Instability Apprehension Test Jobe Relocation Test
Sens 54-88% Spec % Jobe Relocation Test Sens 30-85% Spec % Anterior Release Test Sens 85-92% Spec 87-89% JAMA. 2004;292:

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 ***False + = arthrosis, Calcific tendonitis, bony lesion JSES 2000; 9(4): Am Fam Physician 2000;61:

Impingement Testing—Hawkins Test
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 ***False + = AC pathology, labral tears Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7) JFP July (7) JSES 2000; 9(4): Am Fam Physician 2000;61:

AC Joint Pathology—Cross Arm Test
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 Am Fam Physician. 2008;77(4):

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% Compared to MRI 92% sensitive and 42% specific AJSM 2002; 30(6):

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% Kim SH, Ha KI, Han KY: Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations. Am J Sports Med 1999, 27 (3): Kim SH, Ha KI, Ahn JH, et al: Biceps load test II: a clinical test for SLAP lesions of the shoulder. Arthroscopy 2001, 17 (2): JAMA. 2004;292: AJSM 1999, 27 (3): Arthroscopy 2001, 17 (2):

EFCTAIP Elephant flatulating constantly Annoyed, “intelligent” person
Adhesive Capsulitis: “7 Stages of Spencer” Elephants flatulate constantly to annoy intelligent people

Spencer Technique Start small circles, then gradually increase size
The seven stages of motions are: 1. Engage GH extension barrier with elbow flexed 2. Engage GH flexion barrier with the elbow flexed 3. Circumduction with compression Start small circles, then gradually increase size Clockwise and counterclockwise May also do ME of IR/ER barriers 4. Traction with circumduction on straight arm Start small circles, then gradually increase size Clockwise and counterclockwise 5. Engage abduction barrier 6. Internal rotation with elbow flexed 7. GH pump with distraction and compression along straight arm Kimberly Manual, p Direct articulatory/ME Elephants flatulate constantly to annoy intelligent people

Seven Stages of Spencer
Review of Muscle Energy -- Definition: “An activating force where the physician instructs the patient to contract muscle fibers in a specific direction against the physician’s counter force.” (Kimberly) A system of diagnosis & treatment in which the patient voluntarily moves the body as specifically directed by the practitioner. This directed patient action is from a precisely controlled position against a defined resistance by the practitioner. The technique can be used to restore normal muscle tone or improve joint mechanics. Mechanism: This basic principle is applied to joint restriction by functionally reversing the origin & insertion of the related muscle with the goal of restoring normal mechanics. To treat dysfunctional muscles, the physician uses reciprocal inhibition and post contraction relaxation principles. Application ISOMETRIC The physician’s resistance equally matches the patient’s force and no motion is allowed to shorten during contraction. To treat hypertonic muscles physicians use isometric contractions to employ afferent reciprocal inhibition of antagonists and cross pattern inhibition of muscle homologues of the affected muscles. Review of Articulatory Technique -- Direct technique – a low velocity/moderate to high amplitude technique where a joint is carried through its full range of motion with the therapeutic goal of increased range of movement. By moving a displaced joint through its range of motion you are able to rearticulate it back into its proper position within its own joint space. Application: The activating force is either a repetitive springing motion or a repetitive concentric movement of the joint through the restrictive barrier. Extension Flexion Compression Traction Abduction Internal Rotation Pump Foundations 2nd Edition, pp

7 Stages of Spencer Stage 1 – Extension
Cephalad hand cups pt’s shoulder to stabilize clavicle and scapula 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 “The fixed shoulder girdle provided a resistant structure against which to stretch the soft tissues bridging the glenohumeral articulation as the arm was used as a long lever.” Patriquin DA, “The evolution of osteopathic manipulative technique: the Spencer technique” JAOA, Sept; 92(9):1136.

7 Stages of Spencer Stage 2 – Flexion
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
Cephalad hand cups pt’s shoulder to stabilize clavicle & scapula Caudal hand flexes pt’s elbow & aBducts humerus to 90 degrees Circumduct elbow clockwise & counter-clockwise 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
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 You can take them into a combination of abduction and flexion to get the arm up to ~180 degrees.

7 Stages of Spencer Stage 6 – Internal Rotation
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 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 Helps get lymphatics going and get rid of build up of lactic acid

Elbow & Radial Head

Inspection Carrying Angle Female > male Cubitus valgus
Normally 10-15º Female > male Cubitus valgus Cubitus angle >15º Resulting the forearm deviating outwards Cubitus varus Cubitus angle <100 Resulting the forearm deviating towards the midline Female normal is about 10 – 12 deg Male is about 5 deg normally Know this slide

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 Flexion (1500)
Coracobrachialis, Biceps, Brachialis, Brachioradialis Extension (00 in ♂; up to 50 in ♀) Triceps, Anconeus 150 of hyperextension in females/children Pronation (00 to ) Pronator teres & quadratus Supination (00 to ) Supinator, Biceps, Brachioradialis

Anterior Pain Biceps Tendonitis
Overuse syndrome caused by repetitive overloading Excessive elbow flexion and supination activities Symptoms Anterior elbow pain with flexion and supination Weakness secondary to pain Increased pain on resisted shoulder flexion and forearm supination Biceps tender to palpation

Anterior Pain Biceps Tendon Rupture
Traumatic event Pre-existing degenerative changes make it vulnerable 97% ruptures are proximal Weakness of supination and flexion Brachioradialis Supinator Decreased by about 40% 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 Repetitive compression trauma Irritation to the bursa Relatively painless posterior swelling Fluctuant mass No erythema or increased temperature X-ray is negative unless traumatic Differential diagnosis Septic bursitis (infection) Treatment Protection Aspirate/culture if suspect septic

Lateral Pain Nursemaid’s Elbow
Young children Typically 6mos to 6 years Peak in 2-3 year olds Girls > boys Mechanism Axial traction on extended and pronated arm Pulls the radius distally 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 % May be more painful for patient Hyperpronation Success rate % Parents perceived as less painful X-rays often negative +/- sling for a few days Recurrence 26-39%

Lateral Pain Epicondylitis
AKA Tennis elbow Overuse of the wrist extensors Causes micro tears of the tendon at the lateral epicondyle 10x more common than medial Predisposing factors Age 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 Know this affects extensors *

Lateral Pain Epicondylitis
X-ray May see small calcium deposits in the extensors due to the micro tears bleeding and the chronicity of the condition Treatment Rest and ice Forearm splint OMM Rehab exercises Steroid injection Prolotherapy/PRP Surgery last resort

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 years of age Faulty mechanics Poorly fitted equipment Tenderness at flexor origin medial epicondyle Increased pain with resisted wrist flexion and forearm pronation Negative Tinel’s test at cubital tunnel Drew Weaver at Masters Know this affects wrist flexors*

Medial Pain Epicondylitis
X-ray Usually negative but can see small calcific deposits Treatment 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
Purely sensory syndrome Median n. becomes trapped between heads of pronator teres muscle Symptoms Pain Paresthesia Mechanism Repetitive pronation Anomalous anatomy Feels similar to carpal tunnel syndrome

Flexor-Pronator Mass Syndrome
Resisted flexion of FDS tendon of index/middle finger Papal sign 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: Impact of the olecranon process within the fossa Tension of the anterior ligament 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: IS A MOVEMENT WHICH BRINGS A PART OF THE ANATOMY CLOSER TO THE MIDDLE SAGITTAL PLANE OF THE BODY ABDUCTION: 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. (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 . C. B. A. Know B  when increased carrying angle (>15deg) the forearm abducts, the wrist will adduct Opposite of this  when decreased carrying angle (< 10deg) the forearm adducts the wrist will abduct This is the parallelogram affect….KNOW THIS ____________

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

Anterior Radial Head Posterior 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 Anterior- Direct 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). Always check one joint above and below the SD area

Wrist and Hand Dr. Williams’s lecture stopped here…..he ran out of time.

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

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
Thumb abduction 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

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

Innervation Median Nerve Ulnar Nerve Radial 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 .

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 Signs
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 Oxygen free radicals stimulate myofibroblast proliferation and increases in type III collagen and platelet derived growth factor B. Intrinsic/extrinsic theories

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 Paronychia : Drainage is sufficient for many cases of paronychia with abscess formation. For more severe cases, oral antibiotic therapy can be used after 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. Flexion Somatic Dysfunction = Dorsal Carpal Dysfunction The Nicholas text says that traction is not needed for this technique. However, if you want to use traction, you can try it and see how it works for you. If you choose to use traction, realize that it will only be a small amount

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. There is no Nicholas reference for this technique, but it is basically the reverse of the previous one. It is in kimberly Sitting Direct HVLA

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 Have the students walk through these motions with me

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. the picture shows the final position of the wrist and hand no nicholas reference

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 the picture shows the final hand position. Note that these 2 treatments are HVLA treatments, but they don’t follow the usual rules for HVLA. usually with HVLA we place the patient right up against the barrier and make a very small, quick thrust. In these 2 cases, we start away from the barrier and make larger, but still quick, thrusts toward the barrier. no nicholas reference

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

Upper Extremity Review

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