COMMON MSK PBS OF ELBOW, WRIST & HAND Flashcards
ASSESSMENT: steps & characteristics of each
Subjective assessment + objective assessment = PT diagnosis
Subjective assessment
- History of presenting condition
- Severity irritability nature
- 24h pattern
- Special questions / red & yellow flags - Social / Past medical history
Objective assessment
- Observation
- Functional task
- Active & Passive ROM
- Muscle strength / length test - Special tests
COMMON ELBOW PBS
- Lateral epicondyle tendinopathy
- Medial epicondyle tendinopathy
- Nerve entrapment neuropathies
- Elbow instability
ELBOW INSTABILITY: etiology, 2 ≠ types of instability
E: Post-traumatic origins (falls, sports injuries):
- Dislocation - dislocation with fracture
- Estimated incidence of 7/100,000 persons
- 1/4 associated with fractures (CED – Complex Elbow Dislocation) -♂>♀
- Average age 30 y
Acute & chronic forms caused by factors congenital, rheumatic, post- infectious or neurological (very rare)
Posterolateral rotatory instability & varus posteromedial rotatory instability
POSTEROLATERAL ROTATORY INSTABILITY: def, mechanism of injury, signs & symptoms, special tests
Most common pattern of elbow instability
Primary cause: disruption of lateral
Collateral Ligament => Posterolateral rotatory sublaxation of ulna & radial head
MECHANISM OF INJURY: Fall on outstretched arm with shoulder in Abduction, axial compression, forearm supination & forced flexion of elbow => Radial head + proximal ulna subluxate posterolaterally, away from humerus in rotatory fashion detaching or tearing lateral collateral ligament (LCL) complex
SIGNS & SYMPTOMS: Recurrent painful clicking, snapping, clunking or locking of elbow occurring in extension of arm with supinated forearm
- Noted at 40° of flexion as arm goes into extension
SPECIAL TESTS: chair push up test
VARUS POSTEROMEDIAL ROTATORY INSTABILITY: def, mechanism of injury & special test
Result of traumatic injury to major elbow stabilizers, anteromedial facet of coronoid & lateral collateral ligament (LCL)
MECHANISM OF INJURY: Fall on outstretched hand with shoulder flexed & abducted resulting in axial loading & varus force at elbow with pronation of forearm
SPECIAL TEST: In subacute stage : mechanical-type symptoms (clicking, popping, and slipping) during elbow flexion & extension
LATERAL EPICONDYLE TENDINOPATHY: ≠ terminology, description, mecha of injury, risk factors, signs & symptoms, special tests
T: Tennis Elbow, Lateral Elbow Pain, Lateral Epicondylalgia (LE), Lateral Epicondylitis, Lateral Elbow Tendinopathy (LET)
D:
- Most frequent
- 40% of people
- Peakage: 40-60 y
- Very frequent in racquet sports, mainly tennis (50% prevalence > 30 y backhand stroke)
Lateral elbow pain involving:
- Extensor carpi radialis brevis tendon - Extensor Digitorum Communis
- Overuse injury and/or microtrauma to tendon with manual tasks requiring wrist stabilization or wrist extension mvts
- Excessive repetitive use or eccentric strain of wrist / forearm muscles
MoI: schema
RF: Dominant side
- Workers in manual occupations involving repetitive arm & wrist mvts at increased risk & more resistant to treatment, with poorer prognosis
- Office work
- Older age
- Tobacco user
- Concurrent rotator cuff pathology
S&S: Pain on elbow around lateral epicondyle & proximal forearm
- Gradual onset, following repetitive activity (within 24-72 hours)
OR
- Sudden onset, following single instance of exertion
- Pain reproduced with resisted wrist extension/ middle finger extension/ forced grip
-↓ Grip strength
- +/- Pins and needles
- Tenderness on palpation along tendon & associated muscles
ST: Cozen test, Maudsley test & Mill’s test
MEDIAL EPICONDYLE TENDINOPATHY: ≠ terminology, description, mechanism of injury, etiology, risk factors, signs & symptoms, special tests
T: Golfer’s Elbow, Pitcher’s Elbow, Medial Epicondylalgia, Medial Epicondylitis, Medial Elbow Tendinopathy (MET)
D = overuse syndrome of common flexor tendon (CFT)
MoI: Chronic repetitive concentric or eccentric loading of wrist flexors & pronator teres, combined with valgus overload
- Age: 45–64 y
- ♀>♂
- Accounts for 10 – 20% of all elbow epicondylitis - 0.4% of general population
- 3.8% to 8.2% in certain occupations
- 3 cases out of 4 are in dominant arm
E: Common flexor tendon (CFT): 1. Pronator teres (PT)
2. Flexor carpi radialis (FCR) 3. Palmaris longus (PL)
4. Flexor digitorum superficialis (FDS) 5. Flexor carpi ulnaris (FCU)
RF: - Athlete: Golf, American football, Archery, Weightlifting, Javelin throwing, Baseball
- Training errors
- Improper technique
- Wrong equipment
- Functional risk factors: Lack of strength, endurance & flexibility
=> More than 90% of cases are not sport related
- Occupational: Heavy physical work (>20 kg), Excessive repetition, High psychosocial work demands, Exposure to constant vibratory forces
- General: High BMI, Presence of comorbidities, Tobacco use, Type 2 diabetes mellitus
S&S: - Tenderness below or just at medial epicondyle
- Pain with resisted flexion/ pronation of forearm - Persisted, medial sided elbow pain with ADLS
- Usually, pain does not improve with rest
- Most of times normal Passive & Active ROM
ST: reverse cozen test & medial epicondylitis stress test
NERVE ENTRAPMENT NEUROPATHIES: description, mechanism of injury, ulnar neuropathy, special tests, ≠ syndromes
D: - Caused by mechanical dynamic compression of short segment of single nerve at specific site, frequently as it passes through fibro- osseous tunnel or opening in fibrous or muscular tissue
MoI: - Represent subset of compressive neuropathies groups as they characterize by chronic compression
Acute compression: often abrupt onset, usually severe weakness & less pain and sensory
Entrapment neuropathy: slowly progressive, late features of weakness & prominent pain and sensory
ULNAR NEUROPATHY
- 2nd most common entrapment neuropathy after carpal tunnel syndrome - Common site of compression: cubital tunnel (cubital tunnel syndrome)
ST: Tinel’s tear for ulnar nerve, Elbow flexion test for ulnar nerve, neurodynamic tests
S: cubital tunnel syndrome & carpal tunnel syndrome
CUBITAL TUNNEL SYNDROME: causes & physical examination
C: - Direct pressure on nerve
- Prolonged stretching on nerve
- Trauma
- Rheumatic & degenerative joint disease
- Immobilization during surgery
- Repetitive elbow flexion & extension
- Valgus deformities at elbow increase its vulnerability to injury
PE:- Insidious onset
- Numbness & paresthesia over small finger, ulnar half of ring finger & hypothenar eminence
- Muscle atrophy & weakness of intrinsic muscles innervated by UN resulting in decreased pinch strength & difficulty in fine motor activities
CARPAL TUNNEL SYNDROME: def, etiology, risk factors, signs & symptoms, special tests
D: - Most common presentation of medial nerve entrapment
- Compression & traction of median nerve as it travels through carpal tunnel - Presents in 3.8% of general population
- Affects people between age of 45- 60 y
- More common in females, ♀ > ♂
E: - Majority of cases: idiopathic
- Females > Males
- Correlated with hypertrophy of synovial membrane of flexor tendons - Sex, age, genetic & anthropometric factors
Secondary CTS:
- Abnormalities of carpal bones abnormalities of shape of distal extremity of radius - Joint abnormalities
- Tenosynovial hypertrophy
- Inflammtory tenosynovitis
- Abnormalities of fluids
RF: ENVIRONMENTAL / OCCUPATIONAL: repetitive tasks, force, posture, vibration EXTRINSIC FACTORS: pregnancy, menopause, obesity & hypothyroidism INTRINSIC FACTORS: trauma & osteoarthritis
NEUROPATHIC FACTORS: diabetes mellitus, alcoholism
S&S: - Pain in hand
- Numbness & tingling in distribution of median nerve
- Proximal radiation of pain or paresthesia to elbow or even shoulder - Clumsiness & weakness in affected hand, worse with activity
- Night pain & paresthesia
- Thenar atrophy: sign of advanced CTS
ST: - Phalen’s test - Tinel’s sign
COMMON WRIST & HAND PBS
- Carpal tunnel syndrome
- Carpal instability
- TFCC injury
- De Quervain Tenosynovitis
- OA of 1st CMC
DE QUERVAIN TENOSYNOVITIS: def, mechanism of injury, signs & symptoms, special tests
D = Tenosynovitis of abductor pollicis longus (APL) & extensor pollicis brevis tendons (EPB)
- Inflammation & thickening of extensor retinaculum
- More common in Women (especially ante/postpartum)
MECHANISM OF INJURY: Associated with repetitive wrist motion, specifically motion requiring thumb radial abduction & simultaneous extension & radial wrist deviation
SIGNS & SYMPTOMS:
- Feeling of sharp or dull pain & swelling
- Radial-sided wrist pain worsened by grasping & lifting objects - Tenderness overlying radial styloid
SPECIAL TESTS: Finkelstein test
CARPAL INSTABILITY: 2≠ types + description, mechanism of injury, signs & symptoms, and special tests of each
DORSAL FLEXED INTERCALATED SEGMENT INSTABILITY (DISI)
D: - Lunate extending dorsally on scaphoid
- Related with disruption of scapholunate (SL) ligament
- Scaphoid bone destabilized
MoI: Usually occurs in case of fall with wrist positioned in extension, ulnar deviation & carpal supination
S&S: Dorsal pain over SL joint, audible clunk
ST: Watson’s test
VOLAR OR PALMAR FLEXED INTERCALATED SEGMENT INSTABILITY (VISI)
D: - Lunate rotating in palmar/ volar direction on triquetrum bone
- Related with lunotriquetral (LT) ligament injury
- Triquetrum destabilized
MoI: Wrist hyperextension or extension & radial deviation
S&S: - Ulnar sided wrist pain, getting worse with pronation & ulnar deviation
- Tenderness on LT joint
ST: LT ballottement test
OA OF 1st CMC JOINT: def, mechanism of injury, signs & symptoms, special tests
D: - Affects up to 11% and 33% of men & women in their 50s & 60s - Particularly affecting post- menopausal women (33% of population)
- Prevalence increases with age
MECHANISM OF INJURY:
- Excessive repetitive use of CMC joint of thumb - Subluxation
- Lesion of ligaments
- Fracture
- Laxity of CMC joint
SIGNS & SYMPTOMS:
- Pain, tenderness & stiffness at base of thumb with gripping, pinching, or clasping something between thumb & index fingers - Reduced grip strength
- Swelling around base of thumb
- Deformity- enlarged joint
SPECIAL TESTS: axial load test / grind test
TFCC INJURY: description, mechanism of injury, signs & symptoms, special tests
D: = Load-bearing structure between lunate, triquetrum & ulnar head
- Function: act as stabilizer for distal radioulnar joint (DRUL)
- Prevalence: increases with age
- In one study, authors found 49% prevalence in patients aged 70 or older & prevalence of 27% in patients aged 30 or younger
MoI: Traumatic injury: most common, fall on extended wrist with forearm pronated.
- Chronic injuries
S&S: - Ulnar prominence
- Tenderness on Palpation: ulnar sided wrist pain that often gets worse with activity
- Weakness in grip, instability, or clicking
- Turning key in door painful
ST: TFCC load test & Chair press test
