Elbow and Forearm Anterior Structures PDF

ELBOW AND FOREARM: ANTERIOR STRUCTURES Biceps Aponeurosis At the cubital fossa of the elbow, the distal tendons of the biceps brachii conjoin to form the biceps aponeurosis, also known as the lacertus fibrosus. The aponeurosis assists in the movement of the elbow along with distal biceps tendon ins...

ELBOW AND FOREARM: ANTERIOR STRUCTURES Biceps Aponeurosis At the cubital fossa of the elbow, the distal tendons of the biceps brachii conjoin to form the biceps aponeurosis, also known as the lacertus fibrosus. The aponeurosis assists in the movement of the elbow along with distal biceps tendon insertion at the radial tuberosity, but it also provides additional stability to the cubital fossa. Because the fibers of the aponeurosis blend into the deep fascia of the medial flexor tendons, lesions at the aponeurosis are often present in patients with medial elbow tendinitis, also known as golfer’s elbow. Biceps brachii Biceps tendon Biceps aponeurosis Palpation Procedure • Place the patient supine with the elbow in a relaxed flexed position. • Ask the patient to perform resistive supination, which will reveal the margins of the biceps aponeurosis. • Once the aponeurosis is located, strum across E6296/Speicher/Fig. 10.01/532303/JG/R1 its fibers with your forefinger and middle finger. • In a well-defined patient, the aponeurosis can be traced as far as the medial epicondyle. • Note the location of any tender points or fasciculatory response along the tissue. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient in a supine position with the elbow in a flexed and relaxed position. • With your far hand, grasp the patient’s hand with your palm over its dorsal aspect. • Using the far hand, flex and extend the elbow to determine the maximal position of comfort or the fasciculatory response, or both. • Apply supination and pronation with your far hand. • Apply compression and distraction with your far hand. • Apply finger flexion with your far hand for fine-tuning. 240 Biceps aponeurosis palpation procedure. Biceps aponeurosis PRT clinician procedure. • Corollary tissues treated: Pronator teres, medial flexors, medial epicondyle, brachioradialis, biceps brachii T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. ELBOW AND FOREARM: ANTERIOR STRUCTURES Brachioradialis Biceps brachii (long head) Biceps brachii (short head) Brachioradialis Brachialis Pronator teres The brachioradialis is the most superficial muscle on the radial aspect of the forearm, and its muscle belly is readily visible with resistive hammerlike elbow movements. Proximally, the brachioradialis is often fused with the brachialis; distally, its tendon inserts just proximal to the styloid process of the radius. Even though innervation is derived from an extensor nerve, the muscle produces elbow flexion. Origin: Proximal two thirds of the humerus Insertion: Radius (proximal to the styloid process) Action: Elbow flexion; assists forearm supination and pronation Innervation: C5-C6 (radial nerve) Anterior Palpation Procedure • Place the patient supine or in a seated position with the forearm in a neutral position, or the 09.05/532252/JG/R1 thumbE6296/Speicher/Fig. pointing upward. • To visualize the brachioradialis, ask the patient to perform resistive elbow flexion with the thumb pointed upward. • Strum across the muscle belly of the brachioradialis just below the joint line of the elbow. The belly can also be pinced. • Trace the brachioradialis to its tendinous attachments inferior and posterior as far as possible. • Note the location of any tender points or fasciculatory response along the muscle and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient supine with the elbow at 90°. • Place your far hand through the patient’s. • With your far hand, flex and extend the patient’s elbow. • Apply marked radial deviation of the wrist with your far hand; then apply internal and external forearm rotation. • Apply marked compression toward the elbow at the wrist with your far hand. • Corollary tissues treated: Extensor carpi radialis, brachialis Brachioradialis palpation procedure. Brachioradialis PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 241 ELBOW AND FOREARM: ANTERIOR STRUCTURES Flexors of the Wrist and Fingers The five muscles that comprise the flexors of the wrist and fingers originate from the medial elbow. The superficial layer contains the flexor carpi radialis, ulnaris, and palmaris longus. The middle and deep layers contain the flexor digitorum superficialis and flexor digitorum profundus, respectively. The digitorum muscles are not directly accessible for palpation, but their contractions can be felt. Nevertheless, treatment of the other flexors should produce a release of these deeper tissues as well. Triceps brachii Triceps brachii Pronator teres Flexor carpi radialis Flexor digitorum profundus Flexor carpi ulnaris Flexor digitorum superficialis Palmaris longus Flexor carpi ulnaris Superficial Common flexor tendon Common flexor tendon Intermediate Deep Flexor Carpi Radialis Origin: Humerus (medial epicondyle by the common flexor tendon) E6296/Speicher/Fig. 10.05b/497354/JG/R1 Insertion: Second and third metacarpals (base and palmar surfaces) E6296/Speicher/Fig. 10.05c/497359/JG/R1 E6296/Speicher/Fig. 10.05a/532316/JG/R1 Action: Wrist flexion, radial deviation, elbow flexion (weak) Innervation: C6-C7 (median nerve) Flexor Carpi Ulnaris Origin: Humerus (medial epicondyle via the common flexor tendon), ulna (posterior upper two thirds) Insertion: Fifth metacarpal, pisiform Action: Wrist extension, ulnar deviation, elbow flexion (weak) Innervation: C7-C8 (ulnar nerve) Palmaris Longus Origin: Humerus (medial epicondyle via the common flexor tendon) Insertion: Flexor retinaculum, palmar aponeurosis, intermuscular septa Action: Thumb abduction, tense palmar fascia and wrist flexion (weak), elbow flexion (weak) Innervation: C7-C8 (median nerve) Flexor Digitorum Superficialis Origin: Humerus (medial epicondyle via the common flexor tendon), ulnar collateral ligament of the elbow, coronoid process, intramuscular septa Insertion: Second through fifth digits (sides of the middle phalanges) Action: Second through fifth Proximal interphalangeal (PIP) and Metacarpal phalangeal (MP) flexion; assists wrist flexion Innervation: C8-T1 (median nerve) 242 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. ELBOW AND FOREARM: ANTERIOR STRUCTURES Flexor Digitorum Profundus Origin: Ulna (upper three quarters of the anterior and medial surface and coronoid process), interosseous membrane Insertion: Second through fifth distal phalanges, palmar surface and base Action: Second through fifth distal interphalangeal (DIP) flexion, MP and PIP flexion; assists wrist flexion Innervation: Second and third digits: C8-T1 (median nerve) Fourth and fifth digits: C8-T1 (ulnar nerve) Palpation Procedure The superficial muscle bellies of the flexors that act on the wrist and fingers and possibly the elbow are often difficult to discern under palpation when starting at the elbow. However, working distally from the tendons at the wrist, you can trace muscle bellies proximally to the common flexor tendon at the medial elbow. • To visually locate the wrist flexor tendons, ask the patient to flex the wrist with ulnar (wrist adduction) and radial (wrist abduction) deviation. • Place the wrist in a neutral position and the elbow in a relaxed flexed position. • Strum the tendon of the flexor carpi radialis (FCR) upward (most lateral tendon at the wrist) to its muscle belly and onward to the common flexor tendon. • To determine whether the patient possesses a palmaris longus (it is absent in some people), ask the patient to move the thumb and ring finger toward one another while flexing the wrist. Its tendon will be just medial to the FCR. Repeat the palpation procedure for the FCR. • The flexor carpi ulnaris (FCU) tendon at the wrist can be visually located by having the patient flex the wrist while performing ulnar deviation. The tendon can also be strummed upward to its muscle belly, which is located just a finger width anterolateral to the ulnar shaft as it courses toward the common flexor tendon. • The insertion sites of the wrist flexor tendons should also be palpated. • The density of the flexor digitorum muscles can be felt under contraction at the medial side of Flexor group palpation procedure. the ulnar shaft. Place the elbow and wrist in 90° of flexion, and ask the patient to squeeze the pinky and thumb together while flexing the wrist to feel the contraction of these deep flexors. • Note the location of any tender points or fasciculatory response at these muscles or their tendons and attachment sites. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. > continued T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 243 ELBOW AND FOREARM: ANTERIOR STRUCTURES Flexors of the Wrist and Fingers > continued PRT Clinician Procedure • Place the patient supine with the elbow in slight flexion (approximately 20°). • Rest the dorsum of the wrist against your torso. • With your far hand, apply marked wrist and finger flexion. • Apply deviation (ulnar or radial) with your far hand to target specific musculature (e.g., radial = FCR). • Individual finger flexion can be accentuated to target specific muscles (e.g., the fifth digit for the flexor carpi ulnaris). • Using the far hand, apply rotation coupled with wrist compression or distraction. • Corollary tissues treated: Medial epicondyle, pronator teres, flexor group tendons at the wrist Flexor group PRT clinician procedure. 244 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. ELBOW AND FOREARM: ANTERIOR STRUCTURES Supinator Flexor carpi ulnaris (anterior muscle) Supinator Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensor indicis The supinator is a broad muscle located deep on the lateral side of the elbow. As the name dictates, it supinates the forearm. Its fibers originate from the lateral epicondyle and traverse to wrap around the head of the radius. Because of its deep location, indirect palpation of this muscle is used. Origin: Lateral epicondyle of the humerus, radial collateral ligament, annular ligament, dorsal surface of the ulna Insertion: Radius (proximal third) Action: Forearm supination Innervation: C6-C7 (radial nerve) Deep Palpation Procedure • Place the patient supine with the elbow at 90°. E6296/Speicher/Fig. 10.03/532309/JG/R1 • Place your hand in the patient’s as if shaking hands. Locate the humeral lateral epicondyle and the proximal anterior shaft of the radius. The supinator lies between these two landmarks underneath the extensor fibers. • Apply firm pressure through the extensor fibers while asking the patient to supinate against your resistance while the elbow is at 90°. The deep contraction medial to the brachioradialis will be felt with this maneuver. • Note the location of any tender points or fasciculatory response at this muscle during treatment. Rule out any tender points that may exist at the extensors prior to assessment and treatment because of the supinator’s deep location. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • Place the patient supine with the arm off the treatment table. • Place the patient’s proximal arm on your thigh with the elbow extending beyond your thigh. • Using your far hand, apply mild extension to the elbow at the distal wrist. • Apply marked supination with your far hand. Supinator palpation procedure. Supinator PRT clinician procedure. • Apply a valgus force to the elbow with your far hand, using your near hand’s thenar mass for stabilization. • With your far hand, apply axial compression and distraction at the wrist to fine-tune. • Corollary tissues treated: Forearm extensors, lateral epicondyle T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 245 ELBOW AND FOREARM: ANTERIOR STRUCTURES Pronator Teres Biceps brachii Brachialis Triceps brachii Pronator teres Brachioradialis Flexor carpi radialis Flexor pollicis longus Palmaris longus Flexor carpi ulnaris The pronator teres is located on the anterior aspect of the forearm, coursing medially from the medial epicondyle across the cubital fossa to the middle of the radial shaft. The primary function of the muscle is to produce forearm pronation. Lesions of the pronator teres may produce nerve compression at the proximal portion of the median nerve and the anterior interosseous nerve, producing pronator teres syndrome. Origin: Humeral (shaft proximal to the medial epicondyle), common flexor tendon, coronoid process Insertion: Radius (middle of the lateral surface of the radial shaft) Action: Elbow pronation; assists elbow flexion Superficial Palpation Procedure • Place the patient supine with the elbow in a E6296/Speicher/Fig. flexed and relaxed10.04/532312/JG/R1 position. • Locate the medial epicondyle and the biceps aponeurosis. The pronator teres courses between these two landmarks. • Slide medially off the bicep aponeurosis onto the proximal fibers of the pronator teres. • Orient your forefinger and middle finger across the oblique fibers of the pronator teres and strum them until they blend into the medial flexor fibers and disappear under the brachioradialis. • Note the location of any tender points or fasciculatory response at this muscle. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Innervation: C6-C7 (median nerve) Pronator teres palpation procedure. PRT Clinician Procedure • Place the patient supine with the involved arm at the side. • With your far hand, grasp through the patient’s hand with the palmar aspect of your hand over the dorsal aspect of the patient’s. • Using your far hand, apply marked wrist flexion and pronation while moving the dorsal aspect of the wrist toward the torso and maintaining wrist flexion. 246 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. ELBOW AND FOREARM: ANTERIOR STRUCTURES • Using your far hand, apply light axial compression toward the elbow. • Fine-tune the position by applying radial and ulnar deviation with the far hand. • Corollary tissues treated: Elbow flexors, pronator quadratus, biceps brachii, brachioradialis See video 10.1 for the pronator teres PRT procedure. Patient Self-Treatment Procedure • Lie supine with your involved arm at your side. • Attempt to palpate the pronator teres with your other hand to determine the position of comfort or a fasciculatory response, or both, while moving into position. • Move your arm upward in a maximally pronated position with the dorsal aspect of your wrist along your torso producing marked wrist flexion. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Pronator teres PRT clinician procedure. Pronator teres patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 247 ELBOW AND FOREARM: MEDIAL STRUCTURES Medial Epicondyle and Common Flexor Tendon Common flexor tendon Ulnar nerve Medial epicondyle The medial epicondyle is a common site of irritation because it is a universal site of origin for all of the finger flexors and forearm pronators. Additionally, the common flexor tendon stabilizes the medial elbow against valgus and rotational forces. Therefore, the medial epicondyle and its common flexor tendon can become stressed when the joint opens during overhead throwing or a golf swing. Irritation at this site is also common among rock climbers who train primarily on indoor climbing walls. Medial collateral ligament Palpation Procedure • PlaceE6296/Speicher/Fig. the patient in a10.06/532319/JG/R1 supine position with the elbow flexed and relaxed. • Gently grasp the elbow across its anterior cubital fossa with your thumb and fingers over the humeral condyles. • Gently roll over the medial condyle with either your fingers or thumb to feel its borders and its most prominent point, the medial epicondyle. • Slide your finger or thumb distally off the medial epicondyle and strum across the common flexor tendon, moving distally. Note the distinct, but small depressions in the tendon as palpation progresses toward the flexor muscle bellies, which are the individual flexor tendons arising to fuse into the common flexor tendon. • Note the location of any tender points or fasciculatory response at the bone and its common tendon. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Medial epicondyle and common flexor tendon palpation procedure. PRT Clinician Procedure • Place the patient supine with the elbow flexed to approximately 90°. • With your far hand, grasp the patient’s hand with your thumb in the palmar aspect and your fingers over the dorsum of the patient’s hand. • Apply wrist and finger flexion with your far hand while applying compression toward the elbow. (Note: Apply compression over the distal radioulnar joint to avoid wrist discomfort.) 248 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. ELBOW AND FOREARM: MEDIAL STRUCTURES • Apply ulnar deviation and forearm rotation with your far hand. • Apply individual finger flexion with the fingers of your far hand for fine-tuning. • Corollary tissues treated: Flexor group, pronator teres, supinator, biceps aponeurosis Patient Self-Treatment Procedure • Adopt a comfortable and relaxed position with the elbow on a firm surface in a 90° flexed position. • Use your noninvolved hand to explore the tissues for tenderness or a fasciculatory response, or both. • Position the elbow at approximately 90° while palpating the most tender or dominant point at the medial elbow. Apply wrist flexion and ulnar deviation while simultaneously applying forearm rotation. • Once you have found the position of comfort or fasciculatory response (or both), apply downward compression with the noninvolved hand to the top of the involved hand toward the elbow. If tenderness or a fasciculatory response is still present upon reassessment, repeat the procedure. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Medial epicondyle and common flexor tendon PRT clinician procedure. Medial epicondyle and common flexor tendon patient selftreatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 249 ELBOW AND FOREARM: POSTERIOR STRUCTURES Triceps Brachii Triceps brachii (lateral head) Triceps brachii (long head) The triceps is the only muscle on the posterior arm in the extensor compartment. The triceps is composed of three heads (long, lateral, and medial) that share a common tendon insertion on the olecranon. The triceps brachii produces elbow extension and shoulder extension and adduction. The origin of the long head at the infraglenoid tubercle of the scapula enables the triceps to produce shoulder extension and adduction. The lateral and long heads are the most accessible and visible on the dorsal arm, but the inferior fibers of the medial head can also be accessed at the medial and lateral borders of the common triceps tendon just above the olecranon. Origin: Long head: Scapula (infraglenoid tuberosity) Lateral head: Humerus (proximal posterior surface) Triceps brachii (medial head) Medial head: Humerus (distal posterior surface) Insertion: All heads: Ulna (olecranon process) Anconeus Action: All heads: Elbow extension Posterior Long head: Assists shoulder extension and adduction Innervation: C6-C8 (radial nerve) Palpation Procedure E6296/Speicher/Fig. 10.08/532330/JG/R2-alw • Place the patient prone with the arm at approximately 90°. • Locate the olecranon process. • Strum across the triceps tendon working upward to the muscular fibers of the long and lateral heads. • Strum across the fibers of the long and lateral heads using the humerus below as a base against which to apply palpation pressure. As the proximal aspect of the long head is gained, it will dip under the posterior deltoid as its tendon slips between the teres minor and teres major on its way to its origin at the infraglenoid tuberosity. To palpate the tendon, press firmly through the posterior deltoid and strum across its fibers. • The fibers of the medial head can be palpated by strumming up and down medial and lateral to the distal tendon with the thumb and forefinger. • Note the location of any tender points or fasciculatory response at the muscle, its tendon, and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. 250 Triceps brachii palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. ELBOW AND FOREARM: POSTERIOR STRUCTURES PRT Clinician Procedure • Place the patient supine with the upper arm supported by your thigh and the elbow off your thigh. • Place the arm into approximately 30 to 50° of abduction and extension. • With your far hand at or above the wrist, apply elbow hyperextension. • Apply humeral rotation with your far hand according to the area being treated (internal for the medial and long heads of the triceps and external for the lateral and medial heads). • Apply humeral compression or distraction with your far hand. • Corollary tissues treated: Posterior deltoid, anconeus, olecranon Triceps brachii PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 251 ELBOW AND FOREARM: POSTERIOR STRUCTURES Olecranon The olecranon is found at the proximal end of the ulna. The hooklike shape of the olecranon is simply the pointy part of the posterior elbow, its anterior or internal surface articulating with the trochlea of the humerus and its posterior or external surface serving as a major attachment site for the triceps brachii muscle. Lesions at the olecranon often result from either forceful hyperextension of the elbow or excessive and repetitive pulling on the bone from the triceps. Olecranon process Radius Ulna Radial styloid process Ulnar styloid process Palpation Procedure E6296/Speicher/Fig. • With the patient supine10.07/532327/JG/R1 or seated, support the patient’s forearm and elbow in a relaxed position. • Palpate over the posterior aspect of the elbow while moving the elbow through flexion and extension to discern the border of the olecranon. • Just above the olecranon, the triceps tendon can be found. Strum across the tendon, moving distally to its insertion site on the olecranon. • Note the location of any tender points or fasciculatory response at the bone and the tendon attachment of the triceps. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient supine with the upper arm on your thigh and the elbow joint off your thigh. • Place the involved upper extremity into approximately 30° of extension and abduction. • Apply hyperextension of the elbow at or above the patient’s wrist with your far hand. • Rotate the wrist or forearm with your far hand. • With your far hand, apply compression or distraction at the wrist for fine-tuning. • Corollary tissue treated: Triceps brachii 252 Olecranon palpation procedure. Olecranon PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. ELBOW AND FOREARM: POSTERIOR STRUCTURES Anconeus An often-forgotten elbow extensor, the triangular anconeus lies on the posterior surface of the elbow just lateral to the olecranon. The anconeus assists the triceps in extending the elbow. Lesions at the anconeus are often present with lateral and medial elbow tendinopathy. Anconeus Origin: Humerus (lateral epicondyle) Extensor carpi ulnaris Insertion: Ulna (olecranon and posterior quarter of the upper ulnar shaft) Extensor digiti minimi Action: Elbow extension Innervation: C6-C8 (radial nerve) Extensor retinaculum Superficial 10.09/532333/JG/R1 PalpationE6296/Speicher/Fig. Procedure • Place the patient either prone or supine with the elbow extended. • Locate the lateral epicondyle of the humerus and olecranon. • Orient the palpation fingers or thumb obliquely across the fibers of the anconeus between these two landmarks. Strum across the fibers working distally toward the shaft of the ulna. • Note the location of any tender points or fasciculatory response at the muscle, its tendon, and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure. • Place the patient supine with the elbow off the edge of the treatment table. • Take the patient’s hand with your far hand as if shaking hands, and wrap your thumb around the hypothenar aspect of the patient’s hand. • With your far hand, apply hyperextension of the elbow with marked wrist extension. • Using your far hand, apply rotation to the forearm. • Apply compression or distraction to the joint of the elbow with your far hand. • Corollary tissues treated: Triceps, posterior deltoid Anconeus palpation procedure. Anconeus PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 253 ELBOW AND FOREARM: POSTERIOR STRUCTURES Extensors of the Wrist and Fingers Four primary muscles produce wrist and finger extension. The extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ulnaris, and extensor digitorum are bracketed by the brachioradialis and ulnar shaft at the posterolateral forearm. Although the extensor digiti minimi is often indicated as an extensor of the wrist and fingers as well, the minimi is typically viewed as an extension of the extensor digitorum. Like the muscles of the medial flexor group, which form a common tendon attachment at the medial epicondyle, the muscles of the extensor group also converge into a common tendon attachment at the lateral epicondyle. Triceps brachii Brachioradialis Extensor carpi radialis longus Anconeus Extensor carpi radialis brevis Extensor carpi ulnaris Extensor digitorum communis Abductor pollicis longus Extensor digiti minimi Extensor pollicis brevis Extensor retinaculum Extensor pollicis brevis (tendon) Extensor indicis (tendon) Superficial Extensor Carpi Radialis Longus Origin: Humerus (distal third of the lateral supracondylar ridge), common extensor tendon E6296/Speicher/Fig. 10.10/532336/JG/R1 Insertion: Second metacarpal (dorsal base on the radial side) Action: Wrist extension and radial deviation; assists elbow flexion Innervation: C6-C7 (radial nerve) Extensor Carpi Radialis Brevis Origin: Humerus (lateral epicondyle via the common extensor tendon), radial collateral ligament Insertion: Third metacarpal (dorsal base on the radial side) Action: Wrist extension and radial deviation (weak) Innervation: C7-C8 (radial nerve) Extensor Carpi Ulnaris Origin: Humerus (lateral epicondyle via the common extensor tendon), ulna (posterior aponeurosis) Insertion: Fifth metacarpal (based on the ulnar side) Action: Wrist extension, ulnar deviation Innervation: C7-C8 (radial nerve) Extensor Digitorum Origin: Humerus (lateral epicondyle via the common extensor tendon) Insertion: Second through fifth digits (digital expansion over the proximal and middle phalanges with lateral slips to the distal phalanges) Action: Second through fifth MP, PIP, and DIP extension; assists with wrist extension Innervation: C7-C8 (radial nerve) 254 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. ELBOW AND FOREARM: POSTERIOR STRUCTURES Palpation Procedure • Place the patient in either a seated or supine position with the elbow flexed at 90° and the forearm in a neutral position, thumb pointing up. • Grasp the brachioradialis like a hamburger and pull it up away from the radius. Directly inferior to the brachioradialis lie the extensor carpi radialis longus and brevis. • Keeping your fingers perpendicular to the fibers of the extensor carpi radialis longus and brevis, move onto their muscle fibers (not distinguishable from one another) and continue strumming distally to their tendinous aspects. (Note: To determine whether you are on the brachioradialis or the extensor carpi radialis brevis and longus, instruct the patient to extend the wrist under palpation. The brachioradialis does not contract with wrist extension, but the others do. • Drop down or move medially onto the fibers of the extensor digitorum. A distinct valley or demarcation exists between the extensor digitorum and extensor carpi radialis longus and brevis. To differentiate between them, instruct the patient to tap the fingers as though playing a piano. The digitorum fibers will produce a robust contraction. • Move onto the ridge of the ulna. The extensor carpi ulnaris lies against the shaft of the ulna. Capture the medial border of the extensor carpi ulnaris by moving off its fibers onto the ulna and then strum over the fibers by pulling up or away from the ulnar ridge with firm pressure. • Also explore the extensor group’s distal insertion sites. • Note the location of any tender points or fasciculatory response at the muscles, their tendons, and their attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is supine with the forearm resting on your thigh. • Place your far palm on the patient’s palm and apply marked wrist and finger extension. • Apply wrist deviation using your far hand and either radial or ulnar deviation depending on the targeted muscle (radial deviation for the Extensor group palpation procedure. Extensor group PRT clinician procedure. • • • • extensor carpi radialis and ulnar deviation for the extensor carpi ulnaris). Finger extension is accentuated according to the targeted muscles (e.g., second through fifth fingers for the extensor digitorum, second and third fingers for the extensor carpi radialis, and fifth finger digit extension for the extensor carpi ulnaris). Apply rotation with your far hand. Apply compression with your far hand for fine-tuning. Corollary tissues treated: Common extensor tendon, extensor group tendons at the wrist, supinator T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 255 ELBOW AND FOREARM: LATERAL STRUCTURES Lateral Epicondyle and Common Extensor Tendon Humerus Lateral epicondyle Common extensor tendon Although complaints of elbow pain on the lateral side are typically more common than those on the medial side, lateral and medial elbow pain often present together because of the synergist and antagonist relationships they perform. Much like the common flexor tendon at the medial elbow, the extensors of the fingers and supinators of the wrist also attach to the lateral epicondyle via a common extensor tendon. The extensors at the lateral elbow cocontract with the flexors, and their common tendon and its site of origin can also become stressed during overhead throwing, racket sports, climbing, or any activity that calls unduly on the extensors, such as excessive use of a screwdriver. Ulna Palpation E6296/Speicher/Fig. Procedure 10.11/532323/JG/R1 • Place the patient in a supine or seated position with the elbow flexed and relaxed. • Gently grasp the elbow across its anterior cubital fossa with your thumb and fingers over the humeral condyles. • Gently roll over the lateral condyle with either your fingers or thumb to feel its borders and its most prominent point, the lateral epicondyle. • Slide your finger or thumb distally off the lateral epicondyle and strum across the common extensor tendon, moving distally. Note the distinct, but small depressions in the tendon as palpation progresses toward the extensor muscle bellies, which are the individual extensor tendons arising to fuse into the common extensor tendon. • Note the location of any tender points or fasciculatory response at the bone and its common tendon. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Lateral epicondyle and common extensor tendon palpation procedure. PRT Clinician Procedure • Place the patient supine with the elbow flexed to approximately 90°. • With your far hand, grasp the patient’s hand with your fingers in the palmar aspect and your thumb over the dorsum of the patient’s hand. 256 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. ELBOW AND FOREARM: LATERAL STRUCTURES • Apply wrist and finger extension with your far hand while applying compression toward the elbow. (Note: Apply compression over the distal radioulnar joint to avoid wrist discomfort.) • Apply radial deviation and forearm rotation with your far hand. • Apply individual finger extension with the fingers of your far hand for fine-tuning. • Corollary tissues treated: Extensor group, pronator teres, supinator, distal biceps tendon See video 10.2 for the lateral epicondyle and common extensor tendon PRT procedure. Patient Self-Treatment Procedure • Adopt a comfortable and relaxed position with the elbow on a firm surface in a 90° flexed position. • Use your noninvolved hand to explore the tissues for tenderness or a fasciculatory response, or both. • While palpating the most tender point at the lateral elbow, actively position the elbow in approximately 90° of flexion, while moving the wrist through extension, radial deviation, and forearm rotation. • Once the position of comfort or fasciculatory response (or both) is found, apply downward compression with the noninvolved hand. If tenderness or a fasciculatory response is still present upon reassessment, repeat the procedure. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Lateral epicondyle and common extensor tendon PRT clinician procedure. Lateral epicondyle and common extensor tendon patient selftreatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 257