Elbow and downwards

Question 1

Conditions of the elbow/forearm

Answer 1

OA elbow
Tennis elbow
Golfer’s elbow
Ulnar neuritis/entrapment
Olecranon bursitis

Question 2

Tennis elbow - clinical features

Answer 2

 What is it? –overuse (very occasionally traumatic) enthesopathy of the wrist extensors
 Pain lateral elbow with Hx of overuse/unaccustomed use, esp repetitive movts of fingers or static posns of wrist eg typing, gripping. Eased by rest
 Possible night pain and early morning stiffness
 Full painless ROM all joints
**  Pain resisted wrist/middle finger extension + gripping**
 Tenderness, often exquisite, common ext orig
 Possible +ve Mills’s test

Question 3

Golfers elbow - clinical features

Answer 3

What is it? –overuse (very occasionally traumatic) enthesopathy of the wrist flexors
 Pain medial elbow with Hx of overuse/unaccustomed use, esp lifting and hitting eg moving home, hammering
 Eased by rest
 Possible night pain and early morning stiffness
 Full painless ROM all joints
 Pain resisted wrist flexion
 Tenderness, often exquisite, common flexor orig

Question 4

Wheres the origins of common extensor and flexor tendons

Answer 4

Anterior facet of epicondyles

Question 5

Treatment of tennis/golfers elbow

Answer 5

 As always, Rx will be influenced by chronicity and severity
 Of primary importance is to remove the causative factor(s). Other than in very mild cases, if the patient persists in repeating the irritative action, your Rx will not work
 Selective rest –splint
 Ergonomics
 Stretching
 Eccentric strengthening
 Possible acupuncture
 Injection

Question 6

Ulnar neuritis/entrapment - clinical features

Answer 6

Sharp pain medial elbow + paraesthesia in 4th/5thdigits, often assoc with repetitive elbow extension in a valgus elbow
 Often assoc with contact pressure eg leaning on elbow at
desk, leaning on window ledge in car, cyclists
 Painless resisted movts
 Swelling around medial elbow
 Tenderness of ulnar groove
 Possible wasting medial forearm/hypothenar eminence
 Possible weakness esp ulnar deviation and 5thdigit abd
 +ve Tinel’s sign

Question 7

What is ulnar neuritis/entrapment

Answer 7

inflam/impingement of ulnar nerve at the elbow

Question 8

What is golfers elbow

Answer 8

Overuse (very occasionally traumatic)
enthesopathy of the wrist flexors

Question 9

What is tennis elbow?

Answer 9

Overuse (very occasionally traumatic)
enthesopathy of the wrist extensors

Question 10

Treatment of ulnar neuritis/entrapment

Answer 10

May need nerve conduction studies to confirm diagnosis
Selective rest from causative factor normally settles condition
Ulnar n is superficial at elbow, so topical agents –ice, gels etc –may have some beneficial effect
Appropriate mobilisation –ULTT 3
Maintenance exercises to affected muscles
 Injection
 If entrapment suspected or Rx ineffective, may require surgery

Question 11

Olecranon bursitis - clinical features

Answer 11

Obvious golf ball-like swelling posterior elbow
May be hot and/or red –commonly infected
Full painless ROM of elbow should be present
Often only mild/no tenderness
Pt often c/o bursa being space-occupying –getting in the way -rather than painful

Question 12

What is olecranon bursitis

Answer 12

Inflam of olecranon bursa, normally as
a result of contact pressure, either overuse or traumatic

Question 13

Treatment of olecranon bursitis

Answer 13

Usually you simply need to remove causative factor and it will settle
NSAIDs. Local and topical agents can be
effective, esp ice
 If any signs of infection –antibiotics are
imperative
 If bursa is esp painful –this is particularly true after trauma when there is often bleeding in to the bursa –or fails to resolve, then aspiration +/ injection can be performed
Avoidance of recurrence with ergonomic advice and/or splinting/padding

Question 14

Conditions of the wrist/hand

Answer 14

OA dist rad/ulnar jt
OA radiocarpal jt
TFCC –triangular fibrocartilage complex
Carpal tunnel syndrome
Arthropathy 1st CMC jt
Tenosynovitis –de Quervain’s, extensor
Trigger finger/thumb

Question 15

What is carpal tunnel syndrome?

Answer 15

Compression of median nerve as it passes
through carpal tunnel

Question 16

Causes of carpal tunnel syndrome

Answer 16

↑ pressure in tunnel due to ↓ volume, often resulting from ↑ peripheral oedema eg obesity, pregnancy, overuse,
thyroid, renal/cardio-vas problems, or positional trauma esp at night

Question 17

Carpal tunnel contains…

Answer 17

Median nerve and 9 tendons

• Four tendons of the flexor digitorum superficialis
• Four tendons of the flexor digitorum profundus
• The tendon of the flexor pollicis longus

Question 18

Clinical features of carpal tunnel syndrome

Answer 18

 Pain, paraesthesia, numbness in wrist + hand. Classically the palmar surface of 3.5 radial digits, but in practice, the Sx can be in all digits + occasionally dorsal surface as well
Worse with overuse + esp at night, when pt has to shake arm to ease
 Possible wasting of thenar eminence m. Poss weakness of thenar eminence m. Resisted thumb abd/add is the discriminating test (abd –median n, add –ulnar n)
 +ve Phalen’s test. +ve Tinel’s sign

Question 19

Vast majority of carpal tunnel patients are diagnosed…

Answer 19

Symptomatically

Question 20

Treatment of carpal tunnel syndrome

Answer 20

 If diagnosis uncertain, may need nerve
conduction studies to clarify
Rx depends upon causative factor(s) –weight loss, medical review, ergonomics, night splint, education
Proximal restriction of median nerve may be a factor. Posture, Cx/Tx mobs, ULTT 1+2 mobs, neural glides
 Injection
Surgery

Question 21

What position –> carpal tunnel in least tension

Answer 21

30 degrees wrist flexion/ neutral

Question 22

Arthopathy/arthritis of 1st CMC- what is it

Answer 22

Degenerative changes to/inflam of 1st
carpometacarpal jt

Question 23

Arthropathy of 1stCMC joint
Clinical features

Answer 23

Can be traumatic, but usually OA
Pain around base of thumb, worse on
gripping/dexterous movts
Pain on add/ext test (cf de Quervain’s)
Painful stiffness acc movts CMC jt
Painful weakness of grip + thumb opposition
X-Rays often show OA
Visible/palpable OA changes

Question 24

Treatment of 1stCMC jt arthropathy

Answer 24

Mobilisations CMC + other affected joints
Stretching exs
Strengthening exs for thumb m, esp grip + opposition
Advice re NSAIDs/analgesics
Resting splint
? TENS/acupuncture
 Injection
 If severe, surgery

Question 25

De Quervain’s tenosynovitis- what is it?

Answer 25

inflam of Abductor pollucis longus/Extensor pollucis longus tendon sheath due to overuse

Question 26

Clinical features of De Quervain’s tenosynovitis

Answer 26

Pain +/-crepitus around radial styloid on repetitive thumb movts
Swelling radial side wrist
Pain res thumb abd/ext, but painless pass add/ext
+ve Finkelstein’s test
Can also get tenosynovitis of extensor tendons of wrist, giving pain on dorsal surface of wrist + often gross crepitus. Common in typists, rowers, canoeists

Question 27

Treatment of de Quervain’s/extensor
tenosynovitis

Answer 27

Overuse condition, so pt MUST stop overusing it or your Rx is doomed to failure
Splinting –thumb spica de Q, wrist splint ext teno
Stretching often beneficial
Tendon sheaths superficial, so ice, gels etc will help
Advice on NSAIDs/analgesics
? DTF
 Injection
Very occasionally surgery

Question 28

What is trigger finger/thumb

Answer 28

Nodule in flexor tendon which catches
in flexor pulley system causing digit to ‘lock’ in flexion + forcing pt to manually extend digit

Question 29

Trigger finger/thumb - clinical features

Answer 29

Nearly always due to overuse
Palpable flexor nodule with palpable
catching/release
** Must be able to demonstrate triggering for diagnosis to be made. Often confused with ‘sticking’ due to OA digital joints**