Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand.pdf

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WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice  EHR520 – Week 12 Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand Tim Miller (ESSAM AES AEP) E: [email protected] Ph: (02) 6338 4442 Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand FUNCTIONAL ANATOMY OF THE ELBOW, WRIST AND HAND Elbow Anatomy Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 4 Elbow Anatomy Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 5 Forearm Anatomy - Anterior Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 6 Forearm Anatomy - Posterior Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 7 Wrist Ligaments Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 8 Wrist Ligaments Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 9 Functional Movements Elbow: Flexion and extension PRUJ / DRUJ: Pronation and supination Wrist: Flexion and extension; radial deviation (abduction) and ulnar deviation (adduction) Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 10 Unique Elbow Characteristics Most muscles cross more than one joint Open chain: Large velocities impart high forces on joint Deceleration: Forces applied to biceps, brachioradialis, & brachialis Closed chain: Compression and torsional stresses on distal arm Lateral elbow receives compression stresses Medial elbow receives distraction stresses Greater stress if lacking lateral rotation during cocking phase One capsule for three joints Weak anterior capsule Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 11 Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand EXERCISE FOR THE ELBOW, WRIST AND HAND Flexibility Exercises Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 13 Exercise Equipment Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 14 Strength Exercises Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 15 Strength Exercises Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 16 Gripping Strategies Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 17 Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand PATHOPHYSIOLOGY OF THE ELBOW, WRIST AND HAND Epicondylopathy Also called epicondylalgia Must discover and correct the cause of the problem or risk of recurrence is very high Lateral epicondylopathy = tennis elbow Medial epicondylopathy = golfer’s elbow Causes Unaccustomed use Cumulative microtrauma Improper technique Unsuitable equipment (e.g. racquet grip too large, strings too tight) Lack of strength in forearm muscles Lack of flexibility in wrist & elbow Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 19 Medial Epicondylopathy (Golfer’s Elbow) Mechanism Results from overload causing excessive stress on medial side Caused by strain of origin of medial wrist flexor muscle group Signs & symptoms Tenderness over medial epicondyle Gradual onset of pain Pain grasping objects & shaking hands Pain flexing wrist against resistance Weakened grip strength & wrist flex/ext – Due to pain Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 20 Medial Epicondylopathy (Golfer’s Elbow) Treatment Nonsurgical epicondylopathy progression: Figure 20.24 p.758 Relieve pain, swelling, spasm AROM & PROM of elbow, forearm, wrist, hand Shoulder/scapula strength UL WB exercises for stabilisation/proprioception Isometric progressing to isotonic exercises Plyometric, functional & performance-specific Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 21 Lateral Epicondylopathy (Tennis Elbow) Small site of origin for extensor muscle group Large load per unit area Mechanism Poor technique especially backhand in tennis Off-centre ball contact Signs & symptoms Tenderness over lateral epicondyle Gradual onset of pain Pain extending wrist against resistance Weakened grip strength & wrist flex/ext – Due to pain Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 22 Lateral Epicondylopathy (Tennis Elbow) Treatment Nonsurgical epicondylopathy progression: Figure 20.24 p.758 Relieve pain, swelling, spasm Forearm brace – dissipates forces before they reach the epicondyle AROM & PROM of elbow, forearm, wrist, hand Shoulder/scapula strength UL WB exercises for stabilisation/proprioception Isometric progressing to isotonic exercises Plyometric, functional & performance-specific Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 23 Epicondylopathy Management Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 24 Epicondylopathy Management Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 25 Epicondylopathy Management Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 26 Epicondylopathy Management Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 27 Tendinopathy – Theories of Aetiology Mechanical stresses Repeated stresses applied to tendon cause fatigue, resulting in tendon failure Vascular supply Tendons lack good blood supply, making them more susceptible to compromised perfusion, which results in tendon failure Neural basis Chronic tendon overuse leads to disproportionate substance P neurotransmitter facilitation, promoting mast cell production Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 28 Factors Contributing to Tendinopathy Intrinsic Age Pathomechanics Structural abnormalities/muscle imbalances Genetic or acquired systemic disease (eg. Psoriasis, T2DM, RA and SLE) Extrinsic Overtraining Poor equipment or training surface Excessive durations or distances Excessive increases in speed Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 29 Tendinopathy Management Framework Identify the cause Correct the cause Identify the level of tendinopathy Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 30 Tendinopathy Management Framework Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 31 Elbow Dislocation Common in sport, but most are simple Mainly in contact sports (e.g. AFL, rugby, skiing, cycling, wrestling, weight- lifting) Mechanism: Tend to occur posteriorly and follow sudden hyperextension and abduction force applications Falling on outstretched hand with elbow bent Radius & ulna forced posteriorly Signs & symptoms Intense pain Swelling Limited mobility Deformity – Olecranon prominent posteriorly Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 32 Elbow Dislocation Treatment Ice, splint Check blood & nerve supply Reduced – braced for 2-5 weeks Immobilised in sling – collar & cuff Complications Lengthy ligament healing time Damage to blood vessels & nerves May become recurrent if treatment is inadequate Accompanying fracture (possible ORIF) – Intra-articular fracture (#) can lead to OA Myositis ossificans – Calcification of soft tissue around elbow Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 33 Elbow Dislocation Exercise Rehabilitation Progression for simple elbow dislocations: Figure 20.29 (p.770) Relieve pain, swelling, spasm Maintain UL ROM Maintain strength of shoulder & scapula muscles AROM of elbow, forearm, wrist & hand Hand exercises (e.g. ball squeeze, putty exercises) Wrist & shoulder exercises w/out elbow stress/pain Begin isometrics Straight plane/multi-plane WB exercises Dynamic, plyometric, functional exercises Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 34 Elbow Dislocation Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 35 Elbow Dislocation Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 36 Elbow Dislocation Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 37 Wrist Sprains Most common wrist injury Most poorly managed Mechanism Falling onto hyperextended wrist (palmar radiocarpal ligament) Repeated flexion, extension, lateral or rotary movements Any abnormal, violent torsion of the wrist Signs & Symptoms Difficult to distinguish clinically between tendon injury & carpal fracture (scaphoid/navicular) Generalised swelling, tenderness, inability to flex wrist Treatment Ice – cold therapy Supportive taping/bracing Graduated exercise rehabilitation Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 38 De Quervain’s Tenosynovitis Inflammation of the synovium of the abductor pollicis longus & extensor pollicus brevis tendons as they pass through their synovial sheath in the fibro-osseous tunnel at the level of the radial styloid Common in racquet sports, golf, tenpin bowling, rowers & kayakers Signs & Symptoms Local tenderness & swelling along course of the tendons Crepitus may be felt Positive Finkelstein’s test Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 39 De Quervain’s Tenosynovitis Treatment Splinting – Wrist in 15° extension & thumb in abduction Stretches & graduated strengthening Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 40 Carpal Tunnel Syndrome Median nerve may become compressed as it passes through the carpal tunnel along with the flexor digitorum profundus & flexor digitorum superficialis & flexor pollicus longus tendons Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 41 Carpal Tunnel Syndrome Signs & Symptoms Anterior wrist pain & numbness Paraesthesia in the distribution of the median nerve (thumb, index finger, middle finger & radial side of ring finger) Tinel’s sign elicited by tapping on anterior surface of wrist Treatment Mild cases treated conservatively (NSAID’s & splinting) Persistent cases may require surgery Exercise rehabilitation: Figure 21.69 p.835 Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 42 Carpal Tunnel Syndrome Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 43 Carpal Tunnel Syndrome Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 44 Rheumatoid Arthritis Inflammatory disease caused by immune pathology – abnormal tissue called pannus erodes articular cartilage & bone The synovial membrane is affected first, then articular cartilage, fibrous joint capsule & surrounding ligaments & tendons Common in fingers, feet, wrists, elbows, ankles & knees but other joints can be affected Tissues of the lungs, heart, kidneys & skin can also be affected Signs & symptoms RA can cause fever, rash, poor circulation & generalised aching/stiffness Swollen joints – ‘boggy’ on palpation, red/shiny skin that is tight due to swelling Complications Excessive exudate in synovial cavity can form cysts in articular cartilage or sub- chondral bone which can rupture with strenuous physical activity Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 45 Effects of Rheumatoid Arthritis on Exercise Response Vigorous exercise is contraindicated in presence of acute joint inflammation or uncontrolled systemic disease People with arthritis – less active and deconditioned, resting energy expenditure may be elevated in RA leading to fatigue and reduced exercise capacity Pain, stiffness, biomechanical inefficiency & gait abnormalities can increase metabolic cost of PA by up to 50% Joint ROM – restricted by stiffness, swelling, pain, bony changes, fibrosis and ankyloses May be unable to perform rapid, repetitive movements & therefore restrict exercise performance (e.g. walking, cycling, agility exercises) Joint site & severity determines exercise mode Deconditioned & poorly supported joints are at higher risk of injury from intense exercise or poorly controlled movements Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 46 Effects of Rheumatoid Arthritis on Exercise Training People with inflammatory or degenerative joint diseases are able to participate in regular conditioning exercise to: Improve cardiorespiratory fitness, muscular strength & endurance, flexibility & general health This in turn: Improves function Decreases joint swelling & pain Increases social & PA in daily life Reduces depression & anxiety Most immediate benefit = diminished effects of physical inactivity Low to moderate, gradually progressed exercise programs produce most favourable outcomes Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 47 Recommendations for Exercise Programming in RA Need to protect joints, recommendations include: Low impact activities Avoid contact sports, prolonged SLS, rapid stop & go actions Condition muscles (i.e. strength, power, endurance) prior to increasing exercise intensity Flexibility & ROM included as key components of program Avoid overstretching & hypermobility If pain or swelling appears/persists, reduce load on joint(s) Footwear for shock absorption during FWB activities Consider PWB/NWB activities (e.g. aquatic rehabilitation) Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 48 Recommendations for Exercise Programming in RA Individualised programming in regard to progression of intensity & duration: Use low intensity & duration during initial phase of programming Accumulate exercise dose if necessary Consider alternate exercise modes & interval or cross‐training methods Time vs. distance goals to encourage pacing Choose appropriate exercise/fitness goals Include functional exercises Stretching & warmup should be used daily even on days when disease flares Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 49 Osteoarthritis and Rheumatoid Arthritis OA & RA commonly affect the wrist & hand – significant impact on ADLs & QOL Predictors of OA: Older age, genetics, being female, menopausal, use of vibratory tools/equipment, high-impact PA, repetitive use of the hands to perform work MCP, IP & DIP joints most commonly affected Associated with pain, loss of function Loss of pinch & grip strength Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 50 Osteoarthritis and Rheumatoid Arthritis RA: Chronic, systemic inflammatory disease Wrists & hands involved – reduced grip strength Wrist deformity in flexion & radial deviation Ulnar deviation of MCP joints Exercise Rehabilitation Maintain wrist & hand mobility & strength Strength exercise more important than flexibility exercise Dose of exercise is individually-based on function & stage/severity of disease Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 51 Elbow, Wrist and Hand – Special Tests Mill’s Test – Lateral epicondylalgia https://www.youtube.com/watch?v=r_A84ox9JRM Cozen’s Test – Lateral epicondylalgia https://www.youtube.com/watch?v=8K7jzDIUpLI Medial epicondylalgia Test https://www.youtube.com/watch?v=u5H9iG8QhYA Valgus Stress Test – Ulnar collateral ligament https://www.youtube.com/watch?v=3xF9_5fbJ8A Varus Stress Test – Radial collateral ligament https://www.youtube.com/watch?v=5zl8GsG3hR4 Tinel’s Sign: Wrist – Carpal tunnel syndrome https://www.youtube.com/watch?v=U8cPjPeZgFw Finkelstein Test – De Quervain’s Tenosynovitis https://www.youtube.com/watch?v=8WBVXBx34W0 Week 12 - Functional Anatomy and Rehabilitation of the Elbow, Wrist and Hand 52