Common Pathologies Of Upper Limb

Question 1

Rotator cuff is made of…

Answer 1

Supraspinatus, infraspinatus, teres minor and subscapularis

Question 2

What do rotator cuff muscles do?

Answer 2

Hold head of humerus in the small glenoid fossa.
They have some physiological movements:
Supraspinatus is abduction
Infraspinatus is lateral rotation and ADDUCTION
Teres minor is lateral rotation, ADDUCTION and extension
Subscapularis is medial rotation

It is thought they do not all work together - posterior is more for flexion and anterior more for extension

Question 3

Rotator cuff related shoulder pain is umbrella term for what?

Answer 3

SIRRLS

Subacromial pain syndrome
Impingement
Rotator cuff tear
Rotator cuff tendinopathy

Issues with long head of biceps tendon and subacromial bursitis

Question 4

Describe theories related to rotator cuff tendinopathy

Answer 4

Tendon compression in subacromial space between the acromion and humoral head. Irritates tendon and causes changes, pain and dysfunction.

Intrinsic factors that cause tendon compression are overload, overuse and underuse of the tendon.

Another theory is that acromion process irritates superior part of rotator cuff tendons causing inflammation and damage.

Studies show damage is within the tendon or inferior to it

Newer accepted theory is tendon compressed between greater tuberosity and superior aspect of glenoid fossa. It causes excessive superior sliding of numeral head in the glenoid fossa

Genetics

Nutrition

Over 50s

Diabetics

People who work with shoulder above 90 degrees

Question 5

CLINICAL PRESENTATION OF ROTATOR CUFF TENDINOPATHY

Answer 5

Pain and impairment of shoulder movement and function occurring in shoulder elevation (flexion or abduction) or on lateral rotation.

Slow working lower fibres of trapezius causing scapula to elevate and rotator superiorly earlier than it should do.

Increased superior glide of head of humerus in glenoid fossa.

Painful arc- flex or abduct with no pain and then pain occurs between 90-120 degrees and then less painful into full ROM

Rotator cuff tendinopathy if you have excessive or mal adaptive loads.

Rotator cuff normally stabilises head of humerus into the glenoid fossa.

Question 6

Management of rotator cuff tendinopathy

Answer 6

Surgery to re attach the tendon or adjust it to attach to numeral head

Physio intervention can give exercises to improve scapulohumeral rhythm and increase strength of lower fibres of trapezius to improfe strength and mobility of the shoulder.

Educate patient about condition and the help we can give

Modify loads gradually to improve strength at shoulder

Evidence claims physio and surgery have similar outcomes

Steroid injections
Ice = reduce swelling and pain
Stretching to increase flexibility of shoulder
Heat= reduce shoulder stiffness

Question 7

LATERAL EPICONDYLITIS / Tennis elbow

Answer 7

Can also be called lateral epicondylalgia as no inflammation.

Can affect radial nerve as it goes between two heads of supinator.

Most common overuse tendinopathy of the elbow caused by tendinopathy to the extensor muscles of the forearm.

Question 8

Prevalence and incidence

Answer 8

Affects 1-3% of people

Male and females are equal

Around 90% improve within a year and recurrence rate is about 8% and may need surgery if it keeps happening.

Prognosis - most cases self limiting

2 risk factors are obesity and smoking

Question 9

What is most commonly affected tendon?

Answer 9

ECRB followed by ECRL, supinator, ED, EDM and ECU

Often caused by repetitive use eg, musicians, c9puter users, manual users and racquet sports

Question 10

Clinical presentation of tennis elbow

Answer 10

Pain at lateral epicondyle in line with the extensor tendon and pain can radiate into extensor muscles

Varying pain - intermittent, constant, high or low severity

Aggravated by wrist and finger extension, supination and grip

Stretching tendon can compress common extensor tendon and causes symptoms again

Middle finger extension may be painful as it adds extra stress to ECRB by fixating third metacarpal for middle finger extension.

Question 11

Management of lateral epicondylitis

Answer 11

Load management- don’t over or underuse
Exercises- to load tendon safely
Taping and bracing- to reduce symptoms so we can increase loads safely 
Educate patient about condition and treatment 
NSAIDs- ibuprofen and naproxen 
Corticosteroid injections
Shock wave therapy 
Surgery

Question 12

Medial epicondylitis

Answer 12

Can be called golfers elbow

An overuse tendinopathy affecting the common flexor tendon at medial epicondyle for the flexors and pronators of the forearm.

It can involve the ulna nerve between two heads of Pronator teres

Question 13

Incidence of medial epicondylitis

Answer 13

Less common than lateral (10% incidence)

Aged 40-60

Incidence is 0.3-1.1% and more in females and males

Associated with golfers and manual workers

Usually involves tendon of FCR and pronator teres

Question 14

Clinical presentation of medial epicondylitis

Answer 14

Pain on medial aspect of elbow and tender to palpate

Aggravated by resisted wrist flexion or pronation, valgus stress and stretching the tendons FCR and pronator teres

Aggravated by throwing or gripping and reduce grip strength

Can involve the ulna nerve (20%) so there is pins and needles a new numbness in little finger and half of fourth finger.

Question 15

Management of medial epicondylitis

Answer 15

Education 
Exercises 
Gradually increase the load to stress the tendons 
Offload tendon using taping or bracing to cope with increased loads 
NSAIDs 
Corticosteroid injections 
Shock wave therapy 
Surgery 

About 60-90% recover with conservative management and don’t need surgery

Question 16

De Quervain’s syndrome

Answer 16

A reactive thickening of the tendon sheaths of EPB and APL

It can occur as idiopathic or overuse of the thumb

Overuse may include eccentric lowering of the wrist into ulna deviation with load

More common in women than men

Common in new mothers as they lift baby into radial deviation and then lower baby down into ulna deviation with the weight of baby in the hands

Age is 40-50

Incidence in women is 1.3% and men it is 0.5%

Question 17

Describe the pathophysiology of De Quervain’s

Answer 17

There’s inflammation of synovial sheaths around EPB and APL.
This leads to swelling, fibrosis and thickening of the sheath.
Adhesions develop between the tendon and its sheath so the tendon normally slides easily within it but adhesions limit tendon movement.
Enclosed tendons are constricted and compressed so there is some more inflammation.

Question 18

Clinical presentation of De Quervain’s

Answer 18

Pain on radial side of the wrist and pain radiates into the thumb

Aggravated by radial deviation of wrist and resisted thumb extension or abduction as the tendons bring on pain.

Stretching tendons will hurt

Finkelstein’s test: tuck thumb into the fist and ulna deviate which produces pain in the tendons and confirms this problem.

Painful when you palpate the tendons

Question 19

Management of this condition

Answer 19

Splinting- can immobilise the thumb for rest but when they take it off it may hurt again, so we need to rest and use load management.

Exercises

Load management

Education

Corticosteroid injections

NSAIDs

Surgery

Question 20

Define a strain

Answer 20

Strain is an injury to a muscle or tendon caused by over contracting or over lengthening leading to tears of the collagen.

Question 21

Describe grade 1 strain

Answer 21

A grade 1 is mild.

The muscle or tendon is overstretched with micro tears in the collagen

Localised pain and tenderness

No visible bruising

Minimal swelling

Minimal loss of function

Strength and ROM are intact

Question 22

Grade 2 strain

Answer 22

Grade 2 is moderate.

Partial tear of muscle or tendon.

Immediate cardinal signs of inflammation.

Pain is poorly localised

Moderate bruising

Moderate swelling

Decreased strength and pain on resisted testing

Painful ROM or slight reduction in ROM

Question 23

Grade 3 strain

Answer 23

Grade 3 is severe

Complete rupture of a tendon or a muscle

Inability to contract muscle

Separation may be evident

Pop or crack noise

Immediate pain, swelling and bruising

As you progress the pain may be less than grade 2

Question 24

Where would you see a strain?

Answer 24

Most commonly in 2-joint muscles because a movement of one joint can increase tension of the muscle and overstretch it or eccentric contractions of the muscle.

Mainly in muscles with more type 2 twitch muscle fibres - fast twitch with high contraction speeds.

Question 25

Management of strains

Answer 25

Depending on severity and healing times

POLICE or PRICE

Mobilise injury as early as possible for maximal healing

Once ROM is back, work on strength and loading of the muscle

Proprioception

Endurance training- the type we do depends on patient goals

Grade 3 needs surgery but the physio management after is the same

Question 26

Define sprain

Answer 26

A stretch or tear of a ligament

Usually caused by the joint being forced outside of normal ROM and in elastic collagen fibres will stretch too far and tear.

Most common are ankle sprains and has grades 1,2 and 3

Prognosis = most recover with conservative management but in very severe cases surgery needs to reconstruct the ligament

Question 27

How are sprains managed?

Answer 27

Depending on severity and healing times, POLICE or PRICE

Early mobilisation 
Early WB
Exercises to maintain loads 
Education 
Return to sport if appplicable 

Severe cases use surgery

Question 28

Carpal tunnel formation

Answer 28

Flexor retinaculum is the roof and the contents are tendons of FDS, FDP and FPL plus median nerve.

Flexor retinaculum attaches at high points of carpal bones so this is pisiform, hook of hamate, scaphoid tubercle and ridge of trapezium,

Question 29

Carpal tunnel syndrome

Answer 29

The most common peripheral nerve entrapment.

The median nerve is compressed in the tunnel.

Compression may be caused by oedema, inflammation of tendon, hormonal changes or repetitive manual activity. Anything that reduces the space compresses median nerve.

1 in 10 people get it

More common in females than males and the difference increases with age

Question 30

Name 6 risk factors for carpal tunnel syndrome

Answer 30

Obesity
Pregnancy
Hypothyroidism 
Arthritis 
Menopause 
Diabetes

Question 31

Prognosis

Answer 31

Mild to moderate is resolved with conservative management

Severe needs surgery

Question 32

Clinical presentation of carpal tunnel

Answer 32

Intermittent nocturnal paraesthesia- pins and needles and numbness during the night and increases in frequency over time and into daylight hours too

Loss of sensation

In severe cases, the median nerve provides minimal motor supply to muscles it supplies eg, thenar eminence wasting of muscles (atrophy) and these muscles are weaker.

Pain

Symptoms likely to follow path of median nerve then more distributed

Progresses to difficulty with fine motor tasks

Question 33

What would we do to test if someone has carpal tunnel syndrome?

Answer 33

Test the thumb strength in resisted abduction , ADDUCTION and flexion, which would be reduced if motor fibres are affected.

Test sensory changes in the hand using light and deep touch and sharp and blunt sensations

Tinel’s sign= tap the part of tunnel where median nerve passes to see if symptoms are reproduced

Phalen’s test= put hand into position where median nerve is compressed and hold to see if symptoms reproduced

Question 34

How do we manage carpal tunnel syndrome?

Answer 34

Education- maybe life style modifications?

Load management

Splints- at night especially to reduce compression

Exercises

Corticosteroid injections

Surgery

If the carpal tunnel syndrome is mild it should improve in 6 weeks of conservative management, then they are referred for a second opinion.