E4- Lateral Epicondylitis-TMJ Flashcards
what is the average functional range of the elbow
130 avg arc
what is the average functional range for pronation and supination
103
what is the average functional range for keyboarding
65 deg pronation
what is the average functional range for opening a door
77 deg supination
what can cause lateral elbow pain
tendinopathy
trauma
radial n entrapment
what are the RF for lateral elbow pain
dominant arm> non dominant
forceful activities
repetitive activities
smoking
poor posture
35-54 yrs of age
what are the primary tendons involved with lateral epicondylitis
ECRL
ECRB- most common
ED
EDM
what are the hallmark signs of tendinitis
TTP
pain with lengthening in ROM
pain with RST especially in lengthened position
what are the ROM signs of lat epicondylitis
pain and limitation with lengthening during wrist FLX w/ or w/out elb EXT
what are the RST signs of lat epicondylitis
pain with wrist EXT, R. dev, especially in lengthened position
possible weakness
pain with gripping
abnormal m activation
where can be TTP with lat epicondylitis
common extensor tendon
how do we treat lat epicondylitis
tendinitis RX
sport specific correction - tennis swing or larger grips
cuff, scapular, trunk, and LE m coordination, endurance, and strength
what about lat elbow pain without overuse at the elbow of a laborer or tennis player
tendinosis
abducted elbow
radial n entrapment
how might C5-6 regional interdependence affect the elbow
C5-6 hypermobility
over recruited wrist EXt creating CET tension
n is hypersensitive not impinged
what symptoms of regional interdependence can be present that affects the elbow
no change in activity
nociplastic pain
FHP
trauma
age- ARJC
what can happen with C6 n impingement in the elbow
creates decreased activation of wrist extensors and lowers supply
what are the S&S of sp n impingement
paresthesia with head movement
DTR hyperactive
sensation loss
80% conduction loss for myotomes
how do we treat C6 spinal n impingement that is affecting the elbow
tendinosis- MT, pt edu,, MET- heavy, eccentric
neck- mechanical traction, thoracic manip, postural edu, neural mob, MET- aerobic, local m stabilization
where is lat tendinosis most often
degeneration most often at musculotendinous junction
what are the S&S of lateral tendinosis at the elbow
persistent 4-6 wks, decrease tendon tolerance
ROM- limited and painful mostly EXT
RST- painful, mostly EXT
Palpation - tender at CET
(+) Mill’s test for CET scarring
what do we need to edu the patient on for lat elbow tendinitis/osis
soreness rule
load managent - ergonomic corrections
what does bracing/taping do for elbow tendinitis/osis
unload tendon and decrease lever arm
decrease wrist motion= decrease load on extensors (shorten tendon)
what are benefits of cervical JM for elbow tendinitis/osis
improve pain and grip strength
what are benefits of cervical and elbow JM for elbow tendinitis/osis
better than either alone
what are benefits of thoracic JM for elbow tendinitis/osis
increase grip strength
what are benefits of Mill’s JM for elbow tendinitis/osis
improve pain and function
pulling apart scar tissue
what is the MET for elbow tendinitis/osis
tendon proliferation and possible cervical stabilization
tendinosis prescription
eccentric
Where do you start with exercises for tendinitis/osis
isometric in shortened position
isotonic in neutral to shortened position
isotonic in lengthened position
WB
plyometric
why do cortisone injections have poor outcomes
weakens structures
what is the prognosis of lateral tendinitis/osis in the elbow
prone to recurrent bouts
avg year
what can happen to cause abducted elbow
trauma- FOOSH
leads to medially fixated olecrannon
what can you see in a SCAN for abducted elbow
ob- increased carrying angle
ROM- limited elbow FLX and sup, wrist FLX and R dev
RST- pain in wrist EXT and R dev
AM- limited lat glide at HU jt
palpation- CET TTP
what complications can occur with abducted elbow
carpal fx
subluxation
how do we treat abducted elbow
correct lat glide with manip
stabilization MET
tendinosis RX
what are common symptoms of radial tunnel syndrome
dorsoradial forearm and hand pain/paresthesia
wrist and finger extension weak and painful
what is wartenberg syndrome
compression of superficial sensory radial n between brachioradialis and ECRL
where can wartenberg syndrome have sensory symptoms
paresthesia over dorsoradial 1st 3.5 digits
what sp test are important for diagnosing radial n entrapment
ULTT
resist supination
how do we treat a n branch injury
POLI (C)ED
STM/JM/Splinting eliminate compression
MET neural motion/flossing
what structures are involved with medial tendinitis/osis
pronator teres
FCR
FCU
FDS
FDP
who can have med tendinitis/osis
throwers, little league, or golfers
what are hallmark signs of med tendinitis/osis
TTP at common flexor tendon
Pain with wrist ext
Pain with resisted sup, wrist FLX, U dev
what is med epicondyle apophysitis
bone growth exceeds wrist flexor and pronator lengthen
increased tendon tension
growth plate weak spot
inflammation
what are complications of med epicondyle apophysitis
avulsion and or premature closure
UCL sprain
what are symptoms of med epicondyle apophysitis
gradual onset of overuse
pop - maybe indicates trauma or avulsion
grows out of clothes
pitches or throws a lot
what is in a scan for med epicondyle apophysitis
ROM- loss of ext
RST- weak and painful muscles attach to CFT
palpation- TTP over medial epicondyle
what sp tests can we do to assess for med epicondyle apophysitis
UCL sprain tests
TTP at CFT
how do we treat med epicondyle apophysitis
Pt edu- load management
POLICED
MET
proper stretching
throwing progressions
what is the MET for med epicondyle apophysitis
trunk, cuff, scapular, and LE impairments
what sp test can stress the UCL
valgus stress test at 0 and 90 deg
UCL instability
what can be found in scan for a sprain
ROM- limited/painful with lengthen, AROM=PROM
RST- strong/painful
CM- inconsistent
ST- (+) for distraction
what would we do in our BE if we suspect a sprain
stability tests- more stress on lig
sp test- (+) for lig, laxity — late, soft, empty end feel
AM- hyper
palpation
how can we sprain the elbow
trauma (FOOSH)
repetitive stress like overhead sports
a 13 yr old pt reports a pop in his elbow while he was pitching. He is tender to palpation, has pain with lengthening and RST, What do you suspect and what do we do?
avulsion of growth plate
send to imaging and immobilize
what structure is injured with varus stress overload
RCL or LCL
how do we treat sprains
POLICED
immobilization
bracing/taping
MET
how might an MD fix a UCL sprain
direct repair or reconstruction with palmaris longus
12-18 months
described a pushed dislocation
FOOSH
radial head is pushed proximal out of annular lig
fx of distal radius and ulna
describe a pulled dislocation
radial head is pulled distally out of annular lig
forceful traction
what complications can occur during a humeroulnar dislocation
3 major n
brachial artery disruption
radial head fx
how do we treat dislocations
like ligamentous sprains
stabilization and tissue integrity
what is a condylar fx complication
volkmann’s ischemic FLX contracture due to brachial a damage
emergency referral
what position is an olecrannon fx casted in
no flexion >90 deg for 2 months
what motion is hard to regain after an olecrannon fx
ext
what are the sp test of elbow fx after trauma
lack of ext ROM
other motions are restricted
lack of sup ROM
lack of pro ROM
how do we treat a fx
POLICED- ice even with a cast
isometrics while immobilized
Exercise non-immobilized parts to prevent secondary impairments
STM/JM to improve ROM
MET with optimal stresses
where can ulnar n entrapment be
cubital tunnel at elbow
FCU heads
Guyons canal in hand
what symptoms are present with cubital tunnel syndrome
medial hand/finger paresthesia
weak grip
what can cause ulnar n entrapment at cubital tunnel
OA/Trauma
what is in a scan for cubital tunnel syndrome
ROM- limited elbow FLX with paresthesia, possible limited ext
RST- weak wrist and 4/5th finger FLX, thumb ADD, and grip
Neuro- possible diminished sensation over ulnar cutaneous distribution
what sp test would be positive for cubital tunnel syndrome
elbow flexion test
tinels
wartenbergs sign
how can Palpation tell us it is the ulnar n
provocation with ulnar n pressure up to 60 sec
possible ulnar n subluxation
what is different about FCU heads causing ulnar n entrapment than cubital tunnel syndrome
etiology
ROM- elbow WNL
palpation- no paresthesia or ulnar n subluxation
what causes Guyon’s canal
cyst/repetitive stress with hand and onto hook of hamate carpal bone
what does Guyon’s canal scan look like
ROM- elbow WNL
RST- hand but no wrist weakness
Palpation- no paresthesia or ulnar n subluxation
what is the functional ROM for drinking activities
6-24 deg ext
what is the functional ROM for using a telephone
40 deg ext
what is the functional ROM for turning a doorknob
40 deg ext
40 deg flx
30 deg ulnar dev
what is the functional ROM to rise from a chair
60 deg ext
25 deg ulnar dev
what is the ideal functional ROM for the wrist
30-50 flexion
60 deg ext
20 deg radial dev
40 deg ulnar dev
what is the optimal position for strength and precision in the wrist
slightly hyperextended
2-5 fingers- slightly flexed
thumb opposition
what can cause a de quervains tenosynovitis
repetitive thumb use with ulnar dev and gripping
what is de quervains tenosynovitis
inflammation or thickening of tendons/sheath just prox of snuff box
decreased grip and pinch strength at thumb
what sp test can be used for de quevains tenosynovitis
(+) finkelstein
what is the Rx for de quervains tenosynovitis
POLICED
workplace ergonomics
tendinosis MET
tendon glides
thumb splint
what can cause mallet finger
tendon rupture or avulsion fx of the extensor hood at DIP
what is the mallet finger
results in DIP flexion contracture
what can cause a boutonniere deformity
rupture or stretch of extensor tendon at PIP
what is boutonniere deformity
PIP flexion with DIP extension
what can cause swan neck deformity
rupture of volar plate at PIP
what is a swan neck deformity
hyperextension at PIP and flexion at DIP
how does a wrist sprain occur
hyperextension with a FOOSH
what is skier’s/gamekeepers thumb
excessive valgus with hyperextension ABD during FOOSH, UCL at MCP
what is the function of fibrocartilage
primary stabilizer
resist tension
shock absorption
resist compression
how can the TFCC be injured
sprains/fx
repetitive U dev
prolonged U dev
what is the Rx for articular disc
POLICED
tissue proliferation
stabilization due to laxity
bracing
what can cause dupuytren’s contracture
disease affecting the collagen formation of palmar fascia or aponeurosis
what are the S&S of dupuyren’s contracture
flexion contracture- limited ROM/AM into ext
elastic/firm end feel
in 4/5 digit
palpation- non-painful nodules
what is the PT Rx for dupuytren’s contracture
MT
MET- elasticity/mobility
splinting/bracing- mobility- at night
what are we emphasizing with MT for dupuytren contracture
emphasizing mobility
improve ROM and function with 8 wks of 2 min ea of multiplanar TFM and max finger EXt
what is the most common mononeuropathy entrapment
carpal tunnel syndrome
what are the RF for CTS
obesity
>45 yrs of age
female gender
forceful hand activity
what can cause CTS
local inflammation at wrist
systemic inflammation
benign ganglion cyst
what are the factors of local inflammation at the wrist that can cause CTS
repetitive/forceful use
age-related jt changes
trauma- subluxation
what are the factors of systemic inflammation that can cause CTS
autoimmune conditions
circulatory conditions
what structures are involved with CTS
FCR
FPL
FDS
FDP
median n
all under the transverse carpal lig
what is the distribution of the median n
sensation to volar surface of the first 3.5 fingers/dorsal tips
NOT ENTIRE PALM
what does the median n innervate
1/2nd lumbrical
opponens pollicis
ABD pollicis brevis
flexor pollicis brevis
what are the symptoms of CTS
gradual onset of tingling/numbness 1st 3.5 digits
worse at night, prolong/repetitive activities, especially FLX
weaken grip, tip, pinch strength
what function is lost with CTS
limited dexterity- fine motor control
what can you find in a SCAN for CTS
ob- thenar atrophy
ROM- symptoms with prolong wrist FLX and EXT
neuro- diminished sensation of peripheral n
what can AM look like due to CTS
hypo or hyper in carpal, RC, distal RU jts due to immobilization or trauma
what sp test can be performed for CTS
wainners CPR- 4 or 5/5
two point discrimination - >6mm
monofilament testing- 2.83-3.22
what are the passive treatments for CTS
Pt. edu - work ergonomics, RF
POLI(C)ED
modalities
orthotics
what physical treatments can we do for CTS
JM- neck, FA, wrist
neural glides
MET- lack evidence
combo of stretching and orthoses
what is the Rx/prognosis of CTS
combo of STM and neural/tendon glides
what are the MD rx for CTS
cortisone injection
CTS sx
what happens in CTS sx
cutting of transverse carpal lig
what is the ape hand
degeneration of median n
what can we observe with ape hand
weakness in thenar m
thenar atrophy causing hand to be in the same plane
inability to FLX, oppose, or ABD
what is the result of ulnar n damage
claw hand
what can you observe with claw hand
hypothenar atrophy
deficient interossei m
claw deformity
what is a colles fx
most common
distal radius displaces dorsally
what is a smith fx
distal radius displaces proximally
FOOSH on dorsal side
describe a scaphoid fx
most common carpal fx
wrist hyperextension with ulnar dev
pain at snuff box
what are sp test for scaphoid fx
pain with thumb to index pinch
pain with wrist ext and pronation
stethoscope test
what is a boxers fracture
neck of 2,3,4 or 5
most common in fingers
what is a bennett fx
most common fx of thumb
subluxation of prox MC
describe scapho-lunate
most common instability
watsons
what is the resting position of TMJ
lips closed, teeth not touching, and tongue resting on roof of mouth
what are the opening m of TMJ
digastric
lateral pterygoid
hyoids
what are the swallowing m of TMJ
hyoids
digastric
what are the closing m of TMJ
temporalis
masseter
medial and lateral pterygoid
what m do lateral dev of TMJ
massester
pterygoids
temporalis
what hx may indicate a TMJ disorder
thumb sucking
nail/ice biting
excessive teeth grinder
gum/smokeless tobacco chewer
what S&S of TMJ disorder
ob- FHP
localized pain and/or crepitus
trigeminal n sensitization
impaired motor/function
what is and when could acute capsular pattern of TMJ occur
earlier dev with loss of function after recent trauma
dev would be toward painful side
what is and when could chronic capsular pattern of TMJ occur
earlier dev with loss of function due to past trauma
dev away from hypermobile TMJ
AM limited on side of dev
what are the S&S of TMJ with earlier dev without loss of function
hx of trauma
dev away from UNILATERAL hypermobility
click at end range
what are the S&S of TMJ with end range dev without loss of function
no hx of trauma
gradual and less hypermobility developed bilaterally due to FHP
click at end range
what can FHP influence of TMJ
increased tension/lengthening of m and lig
anterior displacement
what occurs in FHP assessment of TMJ
opening in neutral and FHP
Swallowing in neutral and FHP
what is the hx of pt with anterior displacement
FHP
trauma sudden opening
excessive opening
what can be found for S&S with ant displacement
full opening/no dev
likely pain and limitation with closing
how do we treat for ant displacement of TMJ
distx with posterior glide
MET for stabilization of TMJ and neck
what is the hx of pt with posterior displacement of TMJ
hx of trauma with closing
what can be found for S&S with post displacement
likely pain and limitation on opening
full closing
how do we treat for post displacement of TMJ
distx with anterior glide
sleep with small neck roll for slight neck extension
avoid excessive chewing
possible night splint to maintain opening
what is the PT Rx for TMJ disorder
POLICED
Posture edu
Oral habit modification
diaphragmatic breathing
activity modification
MT
MET
