AD I Elbow Study Guide.docx

Elbow 9/17/2023 Elbow/Wrist Evaluation Subjective history Observation/posture Valgus (carrying angle) Allows forearms to clear hips when you swing your arms Valgus increased angle Varus decreased angle Clear C-spine, shoulder, wrist Sensation Look at specific myotomes/dermatomes Palpation Joint play...

Elbow 9/17/2023 Elbow/Wrist Evaluation Subjective history Observation/posture Valgus (carrying angle) Allows forearms to clear hips when you swing your arms Valgus increased angle Varus decreased angle Clear C-spine, shoulder, wrist Sensation Look at specific myotomes/dermatomes Palpation Joint play R/U deviation (ulna on humerus); A/P of radius; distraction (olecranon from humerus) Examination ROM AROM, PROM, joint play (GH, humeroulnar, humeroradial, proximal/distal radioulnar) Flexibility MMT/strength Shoulder Elbow flexion/extension Wrist flexion/extension, pronation/supination (differentiate between ulnaris/radialis) Core/hip strength Ex: IF they are a throwing athlete, you might want to look at these areas Motor control/ergonomics/functional mobility Special tests Examination/Diagnosis Duration and Timing Chronic Typically overuse injuries Occupation, sports, hand dominance Overuse can lead to loose bodies arthritic Acute Pain/swelling fracture, dislocation, tendon/ligament rupture Mechanism of injury Flexion biceps, brachialis, brachioradialis, MCL, LCL, joint capsule, ulnar nerve, etc. Extension Triceps, LCL, joint capsule, median nerve, bursa, etc. Pronation Lateral structures Supination Medial structures Pain (location, severity) Medial/lateral/anterior/posterior Severity after activity (chronic), during (subacute), or at rest (acute) Differential Diagnosis Based upon symptom location Anterior Anterior capsular strain Distal biceps tendon rupture/tendinitis Dislocation of the elbow Pronator syndrome Lateral Lateral epicondylitis Radial head fracture Radial tunnel syndrome Posterior interosseous nerve syndrome LCL injury Medial Medial epicondylitis UCL injury Ulnar nerve involvement Flexor pronator muscle strain Little league elbow Posterior Olecranon bursitis Triceps tendonitis Post operative Examination Surgical details should guide the exam and treatment determined by Type of motion allowed Safe arc of motion Splint positioning May limit ROM Limitations for functional use of the UE Pathomechanics Acute injuries Dislocations (high energy mechanism) Described by direction and degree Fractures Combination of both Overuse injuries Activities that place high load forces on the joint and surrounding structures Ligament, tendon, capsule, muscle Inflammation, instability Tensile Forces lead to acute and chronic injuries to the UCL Compressive forces degeneration at the radio-capitular joint, which will lead to loose body and arthritis Posterior shearing stress fractures of the olecranon Medial Ligaments UCL Anterior oblique ligament primary restraint against valgus stress at the elbow at 30, 60, and 90 degrees of elbow flexion Esp. in OH sports Taught in 0-60 degrees elbow flexion Posterior oblique forms the floor of the cubital tunnel Plays a role in restraint of valgus force in higher degrees of flexion Transverse oblique Ulnar nerve sits on top of this Inserts onto the olecranon Lateral Ligaments LCL Originates on the lateral epicondyle and is made up of radial collateral and lateral ulnar collateral ligaments LUCL Blends with the annular ligament distally (the ligament that wraps around the head of the radius) and supported by the LCL Prevents posterolateral instability Secondary stabilizers Common extensor tendon, posterior capsule, insertion of the capsule on the annular ligament Bony Articulation Coronoid, radial head, and humeral-ulnar junction are primary restraints to instability at the elbow At least 50% of the coronoid is required to maintain stability during elbow extension Varus and valgus stability is affected by removal of a small section of the olecranon In situations where the UCL is insufficient, the radial head is going to play a strong role as a secondary stabilizer to valgus stress Elbow Instability Timing acute, chronic, recurrent Articulations involved Ulnohumeral joint Radioulnar joint Both? Direction of displacement Valgus (post traumatic or repetitive overload) , varus (typically combined), anterior (rare, but usually from a blow to a flexed elbow, driving olecranon anterior), posterior (ulna is displaced posterior in relation to the distal humerus; broken into 3 ctategories), PLRI (posterior lateral rotary instability) Degree of displacement Associated fractures Elbow Instability Subluxation or dislocation Varies from simple to complex Most common in pediatrics Mechanism of injury Patient presentation Physical examination Interventions Mechanism of Injury Most common is FOOSH Results in posterolateral rotary instability (PLRI) Most common mechanism of acute elbow instability Stage 1 subluxation into PLR direction Stage 2 incomplete dislocation with the coronoid perched under the trochlea Stage 3 complete dislocation – coronoid sits behind the humerus Subsequent positive lateral pivot shift test Dislocation- Patient Presentation History of traumatic event Deformity- asymmetry dorsal view of the humeral condyles with the olecranon tip Assess for symptoms of vascular or neural injury Must assess for any associated injuries to the UE Subjective Vague elbow discomfort May report clicking or snapping that is worse with supination Feeling of “giving away” during loaded elbow flexion w/ supination Examination Assess severity of the injury within that area (applied between 5-30 degrees of elbow flexion allows olecranon to move out of the fossa) Lateral pivot shift test- assess injury stage 1 and 2 (this test causes the elbow to sublux at approximately 40-70 of elbow flexion Observable clunk with continued flexion as the elbow reduced Becomes more congruent Treatment for dislocation Timing- acute, chronic, recurrent Articulations involved Direction of displacement Degree of displacement Presence of absence of fracture Interventions- Simple Dislocation Non-operative Reduction and placement of arm in padded splint Determined by assessing the position of greatest stability Once reduced and elbow stable, rehab w/o restrictions Once reduced elbow is stable but beyond 60 of extension, rehab with hinged extension brace blocked beyond 60 degrees Assess arc of stability (between elbow flexion/extension) Once reduced and elbow is not stable t/o arc of motion-surgical repair is necessary PROM of flexion and extension (in full pronation) is important to prevent stiffness Operative Elbow is typically immobilized in full pronation and 90 degrees of flexion x 3 weeks f/b hinged brace allowing 30 of extension and 90 of flexion for three weeks Complex Dislocation Extensive soft tissue injury in addition to fractures Most common radial head and coronoid process Treatment reduction of the dislocation; fixation of the fracture, establish a stable arc of motion May require fixation, reconstruction of ligament Often use palmaris longus or hs tendon Loss of 5-15 degrees of terminal extension is not uncommon with reconstructive surgeries IR of the shoulder can cause a varus force at the elbow ER of the shoulder can cause subluxation of the radial head in the posterolateral direction Terrible Triad Elbow dislocation Fracture radial head Fracture coronoid process Typical protocol Avoid any varus or valgus forces, shoulder IR or ER Initially exercises will be performed with a hinge brace on to protect the repair Terminal extension is limited to 30 degrees for at least 4 weeks PROM applied very carefully Strengthening at 8-12 weeks depending on healing and surgeons’ preference Valgus Stress Dislocation uncommon in the medial direction Most common in throwing athletes Anterior oblique ligament is most commonly injured Medial Collateral Ligament Insufficiency Patient presentation Athletes commonly have chronic and acute injuries to the UCL with or without medial epicondylitis and possible ulnar nerve symptoms Laterally, they start to get compression, leading to radial-capitular degeneration, loose bodies, shearing forces, olecranon stress fractures, etc. Chronic results in micro tears, which results in decreased force Physical examination Interventions Valgus- Patient Presentation Report episode of sudden onset of pain and giving way during throwing Pain usually at anterior-medial aspect of the elbow May hear a “pop” If it’s a throwing athlete, they may report decreased throwing velocity Acute exacerbation of chronic injury Associated ulnar neuropathy (pain and numbness ulnar nerve distribution) Point tenderness at insertion of UCL May present with an epicondylitis Examination Valgus stress test Stress radiographs Posteromedial Impingement Development of extensor valgus overload Compression of the olecranon against the humerus with valgus stress Patient presentation Flexion contracture Valgus stress at 20 degrees of elbow flexion Painful active extension Pain at mid flexion (between 70 and 100 degrees) Pain with releasing the ball if it’s a throwing athlete Pain with passive pronation, valgus, and ext Tenderness posteromedial near olecranon There would be anterior subluxation of the ulnar nerve when you have them flex at 90 degrees Examination Differential Diagnosis Medial epicondylitis/algia Flexor/pronator rupture Posteromedial impingement via ulnohumeral compression Radiocapitellar overload Because of the incompetence of the MCL Stability rely on secondary stabilizers putting the radial head at risk for compression by the capitulum Chondromalacia and bony/cartilaginous degeneration can occur in older adults Ulnar neuritis Olecranon Bursa Valgus Stress Intervention Non-operative Rest from overhead sport (bracing) Pain medication and anti-inflammatory Rehab Operative Surgical repair with immobilization (dislocations/ruptures) Early protected movement Fractures Coronoid most commonly occur in conjunction with a posterior dislocation Classified Type I to III Olecranon Usually due to a direct blow and is repaired with an ORIF If stability is good, ROM is initiated in a few days to a week No pushing or pulling for a few weeks Radial Head Simple or complex, common with elbow trauma Operative typically repaired with ORIF May require replacement of radial head Distal Humerus about 2% of elbow fractures in young men due to high force trauma and older individuals due to moderate force trauma Mobilization in less than 3 weeks to avoid contractures has best outcomes Muscle and Tendon Pathology 9/18/2023 Epicondylar Tendinopathy Occurrence Medial Less common Lateral ECRB and ED Tendons Higher ratio incidence More of a degenerative condition Etiology Theory Repetitive overuse Combination of inflammation and degeneration Common Terms Lateral epicondylitis/epicondylalgia Tennis elbow Medial epicondylitis/epicondylalgia Golfers elbow Lateral Epicondylitis History Repetitive movement: wrist and finger extension S/S Point tenderness at the distal lateral humerus distal to the epicondyle Pain wrist extension and pronation (MMT), lifting and may radiate down arm. Can be described as dull ache Normal elbow ROM Cozen test Mill test Resisted finger extension Grip strength testing creates pain and/or grip strength is decreased Differentiate Radial tunnel syndrome/cervical nerve root, LCL sprain, radial head fracture Diagnosis EMG (r/o nerve) Differential diagnosis lateral elbow pain Cervical nerve root (typically C6-C7) Radial Tunnel PLRI Inter-articular disease Medial Epicondylitis History Repetitive movements forceful work or overuse, active wrist flexion and pronation, gradual onset 3 Common causes Flexor pronator tissue fatigue (overuse/stress) A sudden change in level of stress (predisposed) UCL failure to stabilize valgus forces S/S Pain with gripping/lifting, upon palpation, with MMT Wrist flexion and pronation Decreased grip strength ROM is typically not affected Could develop flexion contracture in chronic cases Physical Examination Provocative testing of particular muscles/muscle groups Passive positioning (supination with wrist and finger ext) Isometric contraction (wrist flexion w/ pronation) Differential diagnosis Cervical spine nerve root compression C7, C8, or T1 Usually motor weakness would also be present Ulnar nerve injury Thoracic outlet syndrome Medial joint instability Epicondylar Tendonopathy Intervention Pain Relief promotion of healing Protection, modalities General conditioning Cortisone injections for short-term relief Control of force load Stretching, strengthening (address disuse atrophy) Bracing, taping Ergonomics Improved fitting of equipment Controlled intensity/duration of activity Mobilization/ movement with mobilization TFM (transverse friction massage) Intervention: Epicondylalgia Acute Cold ROM – wrist, elbow, and forearm Avoid painful activities Subacute Initiate strengthening Continue ROM Friction massage Use brace with activity and ice afterward Chronic Emphasize eccentric/ concentric Continue flexibility Ice as needed Discontinue brace Equipment modification Equipment Modification Frequency (vibration) Decrease String tension Graphite Tennis racquet head size (larger sweet spot) Size and Weight of equipment Too heavy increases torque Tennis racquet head size- too large – increases torque (mid-size is best) Grip size Evidence does not clearly define as a risk factor Environment changes Tennis Change surface hard courts- increase ball velocity- higher force transmission) Games singles vs. doubles (vary swings) Forehand strike the ball in front of you, if behind, less bodu involvement, all arm Knee bend reduces shoulder and elbow torque Serves greater than ½ force should be generated from hip/pelvis vs. UE Shoulder (21%), elbow (15%), wrist (10%) Tendon Injuries Brachialis strain- Climber’s elbow Associated with repetitive pull ups, hyperextension, repeated forceful supination Pain with extension, resisted flexion. Supination Triceps tendonitis/strain/rupture Triceps tendon rupture is rare Weightlifters and football players (Common at distal site) Steroid abuse can be a cause Patient unable to extend against gravity if there is a tear Palpable defect in the tendon at the olecranon Distal Biceps Tendon Rupture Mechanism of Injury Rapid load of eccentric force to the elbow at 90 degrees of flexion Failure occurs at the insertion site (not the musculotendinous insertion) Patient presentation Tenderness of the tendon Patient may report hearing a “pop” Proximal migration of the muscle Pain and weakness with supination and flexion Interventions for Biceps Tendon Rupture Operative management more favorable outcomes Minimally invasive OP procedure Best when occurs 2 weeks or less post injury Reattachment to the radial tuberosity Best return of strength into flexion, supination Rehabilitation Immobilization ranges from 1-6 weeks 70-90 degrees flexion and supination or neutral f/b ROM brace Gentle ROM following d/c from splint Full ROM expected at week 4 Strengthening begins week 6 to 3 months Return to sports 3-6 months (hinged brace) Bursitis Olecranon spend a lot of time on their elbows Fall onto the elbow History prolonged pressure/trauma Intervention Rest, anti-inflammatory Compression dressing Bursa may be aspirated Gentle active ROM after aspiration (no excessive motion or activity) General Principles post-op rehab of the elbow Balance the benefits of early motion with protecting the repaired tissue PT and OP setting typically initiated 203 weeks post-op Primary focus post-surgery Edema Pain control Initiation of early motion (self ROM by the patient every 2-3 hours) Safe and effective position for elbow flexion/extension is supine with shoulder in 90 flexion and wrist neutral (no varus or valgus stress) Elbow flexion and extension will be gravity assisted Complications following Elbow Trauma and surgery Elbow stiffness/contractures most common Primary complaint is loss of extension; may get popping, clicking, locking which is indicative of loose bodies NSAIDs, pain relief, and gentle mobilization is recommended Heterotopic Ossificans Bony formation in the soft tissue Wound Infection Nerve injury Forced flexion can cause ulnar nerve traction Common Elbow Interventions Core and endurance Deep Friction Massage ROM into Elbow flex/ext Wrist flex/ext Forearm supination/pronation Grip Strength Putty, small ball, isotonics, digiflex, dynamometer Progressive strengthening Wrist and reverse curls Neutral wrist curls Pronation/supination Hammer/dumbbell Broomstick curl roll up string attached to dowel (can add weight to the end of the string) Elbow curls different pronation/supination positions PNF/ plyometrics Complex Regional Pain Syndrome Common terms Reflex sympathetic dystrophy Sudeks atrophy Minor causalgia Shoulder hand syndrome Causes/ pathophysiology unknown Associated with SCI and trauma Stages Acute/traumatic (early signs) Soft, puffy edema, acute pain, hyperesthesia, spams, limited ROM, hyperthermia Not a normal, tolerable pain Dystrophic (2-6 months) Decreased pain, taut, shiny cyanotic skin, hyperesthesia, hypothermia, progressive loss of ROM, hair and nail growth, diffuse osteoporosis Atrophic Muscular/bony atrophy, thickening fascia, soft tissue atrophy, joint ankylosis, cool, glossy taut skin Intervention Modalities heat, NO ICE, hot pack, US, Fluidotherapy Desensitization (cornmeal-Fluidotherapy) Weight bearing both UE and LE (BAPS) May not tolerate it Trigger point treatment, massage Elevation edema control Biofeedback CPM for pain-free movement Pool especially LE- gets weight bearing TENS effective if started within 3 months of onset of pain – do not put electrodes on the affected area Splinting controversial NO assistive devices, ice, amputation Team approach MD- anti inflammatory agents, corticosteroids, anti-depressants, nerve blocks Upper Extremity Nerve Entrapment/Injury 9/18/2023 Introduction Endoneurium connective tissue sheath around each nerve fiber Epineurium Outermost connective tissue sheath surrounding multiple fascicles Perineurium connective tissue sheath surrounding a bundle of nerve fibers (fascicle) Nerve Injury Types Stretching Compression can cause numbness, paresthesia, pain, and sometimes muscle weakness if going on for a long time Longer than 2 hours can cause lasting damage Tearing/cutting can happen in sites of vulnerability where the nerve is proximal to the surface or where the nerve is close to a hard interface (bony prominence) Vibration Construction machinery for example is damped to decrease vibration that travels into the UE Prolonged periods of vibration can shut off the electrical impulse of the nerve Sites of Vulnerability Tunnels Branches Hard interfaces near bony prominences Proximity to surface Areas where it is fixed Stretching Injury Stage 1 Normal coiling to allow for movement Stage 2 stretch causes blood vessels to become compressed Stage 3 Cessation of blood flow occurs at 15% elongation, cross-section of nerve is reduced Can get ischemia to that part of the nerve and can lead to Wallerian degeneration of the axon Levels of Nerve Injury Grade I Neuropraxia First degree segmental demyelination Grade II Axonotmesis Loss of axon continuity with preservation of endoneurium and fascicular structure. Wallerian degeneration Grade III Mixed axonotmesis/neurotmesis Characterized by loss of axons and endoneurium with retained fascicles and perineurium Grade IV Loss of fascicles, continuity maintained only by epineurium Grade V Neurotmesis Severance Peripheral Nerve Injury Patient History Posture work, sleep, habits etc. Diagnosing Provocation Tests trying to reproduce symptoms Sensory/manual muscle testing Dermatome/myotome vs. peripheral nerve distribution Nerve conduction velocity EMG Thoracic Outlet Syndrome Anatomy Brachial Plexus Upper Trunk C5,C6 Middle Trunk C7 Lower Trunk C8, T1 Trunks pass the anterior and middle scalene and go above the first rib. The trunks further divide and travel behind the clavicle, branching into lateral, posterior, and medial cords Scalenes Can be tight, hypertrophied, enlarged, etc. Certain cervical motions such as extension and lateral flexion puts tension on the scalenes and therefore the brachial plexus. Plexus also travels under the clavicle and pec minor. If the pec minor is tight, this pulls on the coracoid process, anteriorly tilting the scapula, and decreasing the costoclavicular space. Any pathology that closes this space can cause impingement of the cords (elevated first rib, depressed clavicle, etc.) First rib, cervical rib Border of the thoracic outlet Anterior scalene, middle scalene, and first rib Causes Osseous Some individuals have an “extra first rib” off of the C7 transverse process there is a mini rib that does not attach to everything. It interferes with the triangular space the brachial plexus is coming out of. (Sometimes there is no joint, so an individual just has an extra long C7 transverse process). Some individuals have a first rib with an upward curvature to it, decreasing the costoclavicular space Muscular Scalenes hypertrophied or tight Some people have a scalene minimus too, decreasing the space Pectoralis minor Positioning/compression Upper Cross Syndrome tight UT and LS and tight pecs Inhibited neck flexors, rhomboids, and SA Forward head, rounded shoulders Clinical Findings Pain Neurological Paresthesia/numbness Weakness Loss of manual dexterity (hand) inability to handle really small objects Vascular Arterial cool/pale extremity Often has diffuse pain Venous swelling/edema, feeling “heavy” Arm fatigue decreased endurance Evaluation Elevated stress test (Roo’s test) Have patient raise arm above 90 degrees of abduction with elbow flexed and they will start to open and close their hand. If TOS has a vascular component, they may complain of fatigue and heaviness If TOS has a nerve compression component, they may have pain and tingling True test is 3 min long Hyperabduction/ER maneuver Wright’s test Feel patient’s pulse, then have them raise arm to 80 degrees abduction with palm facing forward (ER), feel if there is a decrease in the pulse (vascular) or if you are reproducing their symptoms Adson’s maneuver Keep arm down, elbow extended, and extend the shoulder. Have patient look down towards their hand, look for radial pulse and see if there is a decrease or if you reproduce the symptoms they are complaining of. Looks more at scalenes Costoclavicular Maneuver Depress the patient’s clavicle while you extend the arm with the elbow extended. Feel for a decrease in pulse or reproduction of their symptoms. Looks more between first rib and clavicle Treatment Conservative Patient education Manual Therapy joint mob first rib and scapula Soft tissue work scalene and pec minor Strengthening scapular stabilizers Neuromobilization Surgical First rib resection May lose accessory breathing patterns Scalenotomy Suprascapular Nerve Anatomy Comes off the upper branch of the plexus, goes underneath the trapezius, into the suprascapular fossa, through the suprascapular foramen and innervates the supraspinatus. Then, goes around the spine of the scapula to innervate the infraspinatus Superior transverse scapular ligament forms the roof of the suprascapular foramen Causes Compression usually in the foramen area due to heavy backpacks, heavy squatting from the bar, etc. Can build up scar tissue over the years as a protective mechanism Repetitive stretch Where the nerve traverses around the spine of the scap. Any OH athlete who does repetitive protraction and retraction Trauma scapular fracture or forceful protraction can cause nerve tearing because of the closeness in proximity to the suprascapular nerve Clinical Findings Pain deep GH joint/posterolateral shoulder Will not be able to reproduce with normally impingement or UE tests Weakness infraspinatus/supraspinatus if trapped in the foramen area If it’s trapped or because of a stretching injury of the protraction, the infraspinatus will be weak (ER) Imbalance scapula/GH rhythm If you have damage to the nerve, there will be a muscle imbalance, so there will be decreased scapular humeral rhythm Treatment Conservative rest and anti-inflammatories; medial and inferior scapular glides Surgical If there is a space occupying lesion, it should be decreased May cut the transverse scapular ligament to create more space in the foramen May do osseous transformation of the spine of the scapula to create a groove for the suprascapular nerve to go, decreasing the tension before it goes to the infraspinatus Upper Extremity Nerve Entrapment/Injury Part 2 9/19/2023 Radial Nerve Anatomy Comes off the posterior cord Innervates the triceps, comes through the intermuscular septum, and then supplies the brachioradialis, brachialis, and ECRL. It then travels anterior to the LE within the radial tunnel and divides into a superficial and deep branch (posterior interosseous nerve) Deep branch enters into the supinator muscle through the arcade of frohse Areas of injury Sleep palsy (Saturday night/Honeymoon) Cause pressure near intermuscular septum Can cause clinical signs if held long enough Clinical Signs Motor Decrease wrist extension Normal triceps because they are innervated before this area of the nerve is compressed Finger and thumb drop Sensation Paresthesia Forearm and into the hand Mid-arm Cause Fracture of humerus Compression in spiral groove Clinical signs Similar to sleep palsy Decreased wrist and finger extension Radial Tunnel Syndrome Proximal to arcade of frohse Causes Entrapment in the tunnel Lateral epicondylitis inflammation can cause scarring or swelling which can entrap the radial nerve Clinical Findings Pain along the extensor wad Pain reproduced with resisted forearm supination or finger extension Posterior Interosseous Syndrome Causes compression of the deep branch, direct trauma, repetitive motion (supination) Clinical findings Motor Loss Finger extension at MCP No real sensory change Pain posterior forearm Differential Diagnosis Radial Nerve Injury at the Elbow Cause Damaged or entrapped down at the elbow or midarm Symptoms reported Radial nerve also traverses C6 and C7, so brachioradialis, loss of finger extension, etc. could be reported Tests/Measures C5 radiculopathy Cause Symptoms reported symptoms stay within the dermatome/myotome Tests/Measures Median Nerve Anatomy Median Nerve at the Elbow Comes off the medial and lateral cord of the brachial plexus Medial to brachial artery and anterior to the brachialis muscle. It passes between the two heads of the pronator teres and at the wrist it goes through the carpal tunnel underneath the flexor retinaculum Carpal Tunnel Formed by the concavity of the carpal bones (floor) and the ceiling being the flexor retinaculum Pronator Syndrome Cause compression of median nerve by pronator teres or flexor superficialis arch, ligament of Struthers, or retinaculum coming off of the biceps Clinical Findings Forearm pain anteriorly Paresthesia into the thumb, index, and middle finger No weakness Evaluation Provocative tests Resisted forearm pronation with elbow going from flexion to extension Resisted elbow flexion in full arm supination Resisted middle finger PIP flexion Anterior Interosseous Syndrome (branch of median nerve) Cause trapped between pronator teres Clinical signs Pain at anterior forearm Weakness Flexor pollicis longus Flexor digitorum profundus particularly index and middle finger Pronator quadratus Functional unable to flex index finger and thumb Carpal Tunnel Most frequent peripheral nerve entrapment in UE Most prevalent Females Middle age Individuals with diabetes as well as high BMI Pregnant females Cause Repetitive motion pronation/supination or Flexion/extension of wrist Prolonged pressure Prolonged vibration Etc. Ulnar Nerve Anatomy Comes off the medial cord of the brachial plexus Follows along the medial head of the triceps and into the groove between the olecranon and medial epicondyle Distally, it travels through the forearm next to the ulnar artery and enters the hand through the canal of Guyon Areas of entrapment At the elbow close to medial epicondyle Guyon canal (at the wrist) formed by the pisiform, pisa-hamate ligament, and hook of the hamate. The roof of the canal is the volar carpal ligament Areas of Injury Elbow Tardy Ulnar Palsy Causes valgus deformity-prolonged stretch; s/p fracture The carrying angle is 8-15 degrees. More than 15 degrees puts a constant stretch on the nerve, possibly causing nerve damage Medial epicondyle avulsion fracture or fracture in the area can damage the nerve Clinical findings Numbness/tingling 5th digit Weakness- clawing of ring of 5th finger Atrophy of hypothenar eminence Cubital Tunnel Causes entrapment in weaknesel Clinical findings same as Tardy Ulnar Palsy No deformity, but entrapment can be due to direct pressure, such as resting on the elbow, direct trauma Treatment protective/surgical (transpose ulnar nerve) Guyon Canal (ulnar tunnel syndrome) Causes direct pressure on the tunnel Typing in slight wrist extension with ulnar deviation and rest on that area can create pressure Increased edema Wrist fracture Hook of hamate fracture Clinical findings Proximal or within Proximally you get sensory and motor Within the canal, muscle weakness and sensory deformity Distal When it exits, you typically only get motor Superficial branch On top of the canal, so you would only get sensory changes Hypothenar eminence is affected, which would mostly impact 5th finger and ring finger Peripheral Nerve Injury Treatment Conservative Desensitization hypersensitive when nerve starts to repair ROM/protective splinting protect nerve as it heals itself Strengthening especially if there was weakening Edema/inflammation control decrease compression on nerve Neuromobilization Decrease muscles spasms Soft tissue work Decrease tightness Patient education stop repetitive motion that may have caused the compression Joint mobilization of the carpal bones to alleviate carpal tunnel syndrome (esp, lunate) Corticosteroid injection decrease inflammation Surgical Release Repair Removal of cause of compression cyst or bony growth Lab 9/23/2023 Neural tension tests Passive neck flexion Could be indicative of cervical radiculopathy and not an elbow pathology Stabilize the sternum (so T/S does not flex); ask them to chin tuck (places tension on the dura), and passively flex the patient’s C/S Positive sign is a reproduction of symptoms Negative sign is pulling in the spine (normal stretch) UE Peripheral Nerve Impingement ULTT Median 1 and 2 Depress the scapula and Abduct to 110 degrees. Externally rotate the shoulder, extend the wrist and fingers, elbow in flexion and supination. Slowly take the patient into extension. (You can also tell the patient to laterally flex to the contralateral side to increase tension) Positive test is a reproduction of symptoms Depress the scapula, abduct to 10 degrees, externally rotate the shoulder, extend the wrist and fingers. Elbow in flexion and supination. Slowly extend the patient into elbow extension. This puts pressure on the median, axillary, and musculocutaneous nerves. (you can also tell the patient to laterally flex to the contralateral side to increase tension). Positive test is a reproduction of symptoms Radial Depress the shoulder and scapula, 10 degrees shoulder abduction, elbow flexion, shoulder IR and pronation. Wrist flexion and have the patient make a fist and tuck the thumb. Take the patient into elbow extension and ulnar deviation. (You can also tell the patient to laterally flex to the contralateral side to increase tension). Positive test is a reproduction of symptoms Ulnar Depress shoulder and scapula. 90 degrees abduction, slight elbow flexion, pronation and external rotation. Have patient make an “ok” sign and bring them into **Cervical Radiculopthaty CPR Passive neck flexion, ULTT1&2, distraction, and spurling’s test** Thoracic Outlet Roos Patient in 90 degrees abduction and elbow flexion. Have them open and close their hands for 3 minutes. A positive test is reproduction of symptoms, or a difference between sides (ex: extreme fatigue on one vs the other) Adsons Patient in 10 degrees abduction and external rotation. Feel their pulse and bring them into extension. A positive test is reproduction or worsening of symptoms or diminished pulse. Wright’s (elevated abduction) Patient in abduction and external rotation. Feel their radial pulse and bring them into full abduction. Ask the patient to turn their head to the contralateral side and look up to the ceiling. A positive test is reproduction or worsening of symptoms or a diminished pulse. Costoclavicular Find T1 and palpate the first rib. Perform joint mobilization. If depression makes symptoms better, positive test. Elbow Special Tests Provocative test – Median nerve – pronator syndrome (MMT - pronation) Start in supination. Tell the patient to move into elbow flexion and pronation while the therapist resists. A positive test is symptom provocation. Tinel tests: Ulnar (cubital tunnel) Moderate tap where the patient is describing pain in order to elicit a neural response Varus/Valgus stress tests Elbow in 20-30 degrees flexion. Apply varus and valgus force to test for ligament stability. Lateral epicondylitis Mill’s test Provocative test for stretching the extensor wad. Bring arm into 90 degrees flexion, pronation, wrist flexion, finger flexion, and radial deviation. A positive sign would be provocation of symptoms. Cozen’s Resisted wrist extension Resisted wrist flexion for medial epicondylitis Palpation Most important thing you could do. Maudely’s sign Separating extensor carpi radialis brevis (middle finger) from the longus (index finger). Perform MMTs. Joint Play – Elbow Humeroulnar joint Distraction Medial / Lateral Glide Medial / Lateral Gap Humeroradial joint Distraction Dorsal/Ventral Glides Proximal/ Distal Radioulnar joints Dorsal/ Ventral Glides Interventions Mobilization with movement Neural Glides Soft tissue mobilization (non and instrument assisted) Taping and splinting