Elbow Flashcards
What are the key diagnostic factors of lateral epicondylalgia?
Pain over the lateral epicondyle
Pain with gripping activities
Pain with wrist extension
Where might there be symptom contribution from for lateral epicondylalgia?
Neck (57%), Shoulder, thoracic spine, wrist
-think regional interdependence
What areas to perform manual therapy on for lateral epicondylalgia?
Elbow
Wrist
Cervicothoracic
What is NOT beneficial in the treatment of tennis elbow?
Extracorporeal shock wave therapy
What are the effects of cortisone on lateral epicondylalgia?
Better effects at 6 weeks, poorer outcomes in the long term, high recurrence rates (47 of 65 successes regressed)
What is the CPR for mobilization with movement for lateral epicondylalgia?
-Age <49 years
-Pain-free grip on affected side >25.2 #
-pain-free grip on the unaffected side >75.5#
Levek IV evidence, not good
What are some exercises to assign with lateral epicondylalgia?
-Lower Trap
-Serratus Anterior
-Rotator Cuff
-Pec Minor Stretching
-Wrist Extensor and Flexor Stretching
-Wrist Extensor Strengthening
-Radial/Ulnar Deviation
-Grip strengthening
-Self Mobilization With Movement
What are some manual therapy techniques to use on the scapula with lateral epicondylalgia?
Superior and inferior gliding
Upward and downward rotation
Distraction
10 reps with 30 second break
Which directions are the hands mobilizing with movement performed for lateral epicondylalgia?
Top hand (humerus) into medial direction
Bottom hand (ulna) into lateral direction
What is a concept for prevention of tendinopathy?
EdUReP
-Education
-Unloading Tissue
-Reloading Tissue
-Prevention
What are mechanisms of nerve injury?
Acute ischemia
Segmental demyelination
Axonal degeneration
What are the classifications of nerve injury?
Neurapraxia
Axontomesis
Neurotmesis
What results from neurapraxia?
Temporary palsy, possibly an ischemic block
What is Axontomesis
Loss of axons such as a crush or a lysis
What is a neurotmesis
Cutting of the nerve
At what level of tissue is the most severe peripheral nerve classification?
Myelin - full
What is the reference standard for peripheral nerve issue diagnosis?
EMG/Nerve Conduction Study
What are signs of a mononeuropathy?
Motor and sensory deficits limited in distribution
What are signs of a polyneuropathy?
-Bilateral and fairly symmetric deficits
-Effect large fibers distally first
-Sensory loss precedes motor
What are clinical features of peripheral nerve injury?
-Mononeuropathy
-Polyneuropathy
-Tendon Hyporeflexia
-Tremor
-Autonomic dysfunction
What are signs of distorted motor/sensory activity?
-Fibrillation potentials
-Fasciculations
-Abnormal sensations (numbness, tingling, prickling, “pins & needles)
-Pain (burning, intractable, primarily distal)
What are 3 main neuropathies of the median nerve?
Pronator Teres Syndrome
Anterior Interosseous Syndrome
Carpal Tunnel Syndrome
What are clinical features of pronator teres syndrome?
-Pain and TTP over pronator teres, increasing with activity
-Sensory changes over thenar eminence, D1-3, and possibly D4
-Motor involvement of Flexor pollicis longus, flexor digitorum profundus, pronator quadratus, abductor pollicis brevis, opponens pollicis, 1/2 flexor pollicis brevis; pronator teres may be spared
-Positive pronator teres syndrome test
-Positive tinel’s in forearm
-Negative Phalens
(pronator teres syndrome test is resisting into pronation while extending the elbow)
What are clinical features of anterior interosseous syndrome
-Proximal forearm pain
-No sensory loss, but aching
-Motor loss of flexor pollicis longus, flexor digitorum profundus I/II, pronator quadratus
-No “OK” sign
What are clinical features of carpal tunnel syndrome?
-Hand dominance & bilaterally
-Painful parasthesias with use and at night
-Sensory deficits in median distribution sparing thenar eminence
-Atrophy of thenar muscles
-May have pain radiating from wrist to shoulder
-May report “dropping” things
-Positive tinel’s at the wrist
-Positive phalen’s and reverse phalens
What is the carpal compression test?
Applying pressure directly over the carpal tunnel for 30 seconds
Positive with pain or parasthesias
What is the clinical prediction rule for carpal tunnel syndrome?
-Hand shaking improves the symptoms
-Wrist-ratio index >0.67 (wrist should be a fair amount wider than thick)
-Symptoms severity score >1.9
-Diminished sensation in median sensory field 1 (thumb)
-Age >45
What is better? Surgery or splinting; surgery or steroid injection for carpal tunnel syndrome?
Surgery has better outcomes than splinting; more research needed to determine surgery over steroid injection.
Considered a “good surgery”
What is the evidence for exercise and mobilization for carpal tunnel syndrome
Very low quality evidence; appears to be some benefit for short term, not known for long term
What is Cubital Tunnel Syndrome?
Ulnar nerve injury at the elbow from repetitive trauma, prolonged compression, or immobilization
What are clinical features of cubital tunnel syndrome?
Sensory deficits to 5th and 1/2 of 4th digit
Vague pain
Atrophy of ulnar intrinsics
Positive Elbow Flexion Test
Positive Tinel’s at cubital tunnel
What is the elbow flexion test?
A test for cubital tunnel syndrome:
Flex both elbows and extend both wrists (“I don’t know position”) and hold for 3-5 minutes
Positive with symptoms
What is compression at Guyon’s canal?
A compression of the ulnar nerve at the wrist with symptoms mimicing Cubital Tunnel Syndrome, but limited to the palm.
At what locations are sensory or motor or both impacted with compression at Guyon’s canal?
At pisiform: both
At base of the 5th metacarpal: motor only
Distal to base of the 5th metacarpal: sensory only
What are the special tests for compressoin at Guyon’s Canal?
Phalens/Reverse Phalens
Tinels at Guyon’s tunnel
Froment’s Sign
Wartenber’s Sign
What is Froment’s Sign?
A test for Guyon’s Canal Compression performed by:
Have the individual try to pull apart a piece of paper with notable inability to properly pinch the thumb and index finger cause by palsy of the ulnar nerve to the thumb adductor.
What is the Wartenberg’s special test?
A test for Guyon’s Canal Compression noted by:
Drift of the pinky finger
What is good intervention for Guyon’s Canal Compression?
Avoidance of positions of discomfort
Ultimately, not enough available evidence to identify the best treatment
What might cause an upper arm lesion of the radial nerve?
Fracture/Trauma
Crutch Palsy
Saturday Night Palsy
Where can there be an upper arm lesion of the radial nerve?
At the spiral groove or proximal to the spiral groove
What is the clinical features of an upper arm lesion of the radial nerve at the spiral groove?
Sensory loss to the dorsum of the hand and digits 1 & 2
Weakness distal to the triceps causing complete wrist drop
What is the clinical features of an upper arm lesion of the radial nerve proximal to the spiral groove?
Sensory loss to posterior arm, posterior 1/3 of forearm, dorsum of the hand, and webspace
Tricep impacted and all distal radial n innervated muscles
What is Saturday night palsy?
A compression of the radial nerve caused by when people would fall asleep on their arm and lose the ability to extend their wrist
What is the prognosis of an upper arm lesion of the radial nerve?
If it recovers, it will happen in 4-8 months
What is posterior interosseous syndrome?
A compression of the radial nerve at the arcade of Frohse, between 2 heads of the supinator
What are clinical features of posterior interosseous syndrome?
Lateral elbow pain that subsides quickly with onset of weakness
Weakness of wrist extensors
No metacarpal phalangeal extension except if wrist is flexed
No sensory deficits
What are clinical features of radial tunnel syndrome?
Lateral elbow pain usually 4-6 cm below the epicondyle without sensory deficits and rarely motor weakness
What is Wartenburg’s Syndrome?
Compression of the superficial brance of the radial nerve; usually from chronic pressure, repetitive provocation, direct trauma (hand cuffs)
What are clinical features of Wartenburg’s Syndrome?
Numbness and/or pain in dorsal-radial wrist and hand
Symptom exacerbation wtih pronation, wrist/finger flexion, and ulnar deviation
Symptom exacerbation possible with forced grip and resisted pronation
What are common deformities of the median nerve, ulnar nerve, combined median/ulnar nerves, and radial nerve?
Median: Ape hand (inability to move thumb away/abduct)
Ulnar: Bishop’s (benediction) hand (when asked to make a fist, index and middle finger do not flex)
Combined Median/ulnar: Claw or intrinsic minus hand (fingers curved or bent)
Radial: Wrist Drop
What are nerve injuries around the shoulder?
Thoracic outlet syndrome
Axillary nerve
Suprascapular nerve
Long Thoracic nerve
Dorsal Scapular Nerve
Other brachial plexus injury
What interventions for Thoracic Outlet Syndrome?
Posture Education
Stretching/Strengthening to improve posture
Provocate the symptoms with bad posture then bring them out of it for buy in
What are signs and symptoms of axillary nerve compression?
Sensory deficit at the axillary patch
Motor deficits of teres minor and deltoid
Atrophy of the deltoid
Shoulder/deltoid pain
Possibly weakness of external rotation
What are clinical features of suprascapular nerve entrapment?
Deep burning increased with horizontal adduction
Tender over suprascapular or spinoglenoid notches
Motor weakness of rotator cuff
Atrophy of supra and infraspinatus fossa
What are clinical features of long thoracic nerve injury?
Scapular winging
Aching (or maybe painless)
Secondary shoulder symptoms from the winging
What are brachial plexus birth injuries?
Erb’s Palsy (most common)
Klumpke’s Palsy (less common)
Total Brachial Plexus Involvement (less common)
What is the prognosis of brachial plexus birth injuries?
Greater than 80% attain near-normal function, those who show evidence of biceps function before 6 months have near-normal to excellent function
What is Erb’s Palsy?
“tip hand”
What is Horner’s syndrome?
Ptosis (unequal eyelid drooping)
Miosis (unequal pupils)
Anhydrosis
What are non-operative treatment options of shoulder area nerve injuries?
Education
Pain Control
Maintain ROM/strength
Monitor compensations/posture
Support/brace as needed
What are general rehab principles for shoulder area nerve injury?
Evidence of improvement with nonsurgical rehab
If denervated, support those muscles with splinting, AAROM exercises
Electrical stimulation not shown to be beneficial
Recovery can be lengthy and uncertain outome; so be patient and do no harm
Control inflammation
Do not overstretch denervated muscles
Do not stretch injured nerves or pressure over the nerve
Prevent digit contractures by maintaining range of motion
Perform low-load strengthening exercises without muscle fatigue or failure
Increase strengthening dosage as voluntary muscle power returns
Between anterior interosseous nerve entrapment and prontator syndrome, which does not have sensory loss?
Anterior interosseous nerve entrapment
