Elbow and Forearm Flashcards
what is the desired ROM for elbow flexion/extension to complete most daily activities
~130 degrees
what is the desired ROM for forearm pronation/supination to complete most daily activities
~100 degrees
what is the etiology of lateral elbow pain
tendinopathy (tendinosis/tendinitis)
trauma - abducted elbow
radial nerve entrapment
repetitive stress
what population is lateral elbow pain most common
tennis players
laborers - overuse of hand tasks
what are the risk factors of lateral elbow pain
dominanr arm > non-dominant arm
forceful/repetitive activities
smoking
poor posture
25-54 years of age
what are the primary involved tendons/muscles with lateral epicondylitis
which is the highest incidence
ECRL
ECRB
ED
EDM
ECRB is the highest incidence
what is the pathogenesis of lateral epicondylitis
tendinitis aka tennis elbow
what are the hallmark signs of tendinitis
TTP
P! with lengthening/use
what would the hallmark signs of tendinitis at the lateral elbow
pain distal to lateral epicondyle
how would you distinguish tendinitis from tendinosis with your patient
how long have you experienced the pain?
what would you expect to observe with lateral epicondylitis during ROM
P!/limited with lengthening during wrist flexion with/without elbow extension
what would you expect to observe with lateral epicondylitis during resisted/MMT
pain with wrist extension, possible 3rd finger ext, radial deviation especially in lengthened position
possible weakness
pain with gripping
abnormal muscle activation patterns
what would you expect to observe with lateral epicondylitis during palpation
common extensor tendon (CET) TTP
t/f
lateral epicondylitis will not become nociplastic pain
false
lateral epicondylitis can become nociplastic pain
what would be your Rx with pts with lateral epicondylitis with tendinitis
modify activity
decrease inflammation
treat neck/shoulder (most likely stabilization)
what would be your Rx for a patient with lateral epicondylitis
tendinitis RX
sport specific corrections
cuff, scap, trunk, and/or LE muscle coordination, endurance, strength training to decrease elbow stress
what is the etiology of tendinosis at the lateral elbow
recurrent tendinitis
regional interdependence
cervical nerve impingement
what factors could contribute to lateral epicondylitis in laborers or tennis players
tendinosis etiology
abducted elbow
radial nerve entrapment
what is the etiology of C5,6 regional interdependence
C5,6 hypermobility/instability d/t FHP, hypomobility of the thoracic region, age-related changes, hx/trauma
describe the effect of inaccurate C5,6 innervation
excitation of the nerve
over recruitment when muscles are asked to contract
overuse of the muscle without change in activity
describe the pathomechanics of C5,6 regional interdependence
over-recruited wrist extensors creating increased CET tension and compression
how does C6 spinal nerve impingement affect muscles at the wrist
creates decreased activation of wrist extensors and lowers supply
what are the signs and symptoms of nerve impingement
decreased sensation/paresthesias in dermatome
muscle weakness in myotome
what is the pathogenesis of lateral tendinosis
degeneration most often at musculotendinous junction
what are the signs and symptoms of tendinosis
TTP
tendon appears large if superficial d/t fat infiltration
persistent symptoms >4-6 weeks
pain/limitation in lengthened position
decreased tendon tolerances
what is the PT Rx for tendinitis/tendinosis
Pt education - soreness rule, load management
POLICED
bracing/taping
what provides a greater pain relief, wrist extension splint or elbow strap
wrist extension splint
stops wrist from moving, decreases muscle contractions
what is the recommendations for modalities for tendinitis/tendinosis
not very definitive
what is more beneficial, STM/exercise/injections with tendinitis/tendinosis
exercise and injections are more beneficial
how does cervical JM affect tendinitis/tendinosis of the elbow
manipulation is effective with pain and grip strength
fewer visits and equal success compared to elbow Rx
how does elbow and wrist JM affect tendinitis/tendinosis of the elbow
effective
Mill’s manipulation for P!/function and pulling apart scarring
t/f
cervical and elbow JM together is better than cervical and elbow JM alone
true
what is the effect of thoracic manipulation with tendinitis/tendinosis
not effective with pain but increases grip strength
what is the primary purpose of MET with tendinitis/tendinosis
tendon proliferation and possible cervical stabilization
are eccentric or concentric exercises better for tendinitis/tendinosis
eccentrics same or better as concentrics
additive benefit with isometrics
wrist extended or flexed
t/f
greater weekly exercise frequency provides greater pain control with tendinitis/tendinosis
true
what is an example of isometric loading without compression from lengthening
wrist hyper/extension in a shortened position
what is an example of isotonic loading without compression from lengthening
wrist hyper/extension from neutral to a shortened position
what is an example of isotonic loading with compression from lengthening
wrist hyper/extension from a lengthened position
what is an example of isometric loading in weight-bearing for the wrist
planks on hands or push ups
what is an example of plyometric loading in the UE
throwing
what is the prognosis of cortisone injections with elbow tendinitis/tendinosis
associated with poorer outcomes and higher recurrrence rates
more effective than TFM and STM
what surgery would be needed with elbow tendinitis/tendinosis
what is the purpose of the surgery
arthroscopic procedure to promote inflammation with tendinosis not responding to PT
what is the prognosis of tendinitis/tendinosis
prone to recurrent bouts
6-24 months - average 1 year
89% recover
what is the mechanism of abducted elbow
trauma - FOOSH
leads to medially fixated olecranon
what would you observe with a pt that has abducted elbow
increased carrying angle
what ROM limitations are expected with abducted elbow
elbow flexion and forearm supination d/t lack of lateral ulnar glide
wrist flexion, radial deviation d/t radius shifting distally from contact with capitulum
what are the resisted testing/MMT, accessory motion expected with abducted elbow
RST/MMT: wrist extension and radial deviation painful
AM: limited lateral glide at humeroulnar joint
palpation: CET TTP
what complications of abducted elbow are common
carpal fracture
subluxation
what is the PT Rx for abducted elbow
correct lateral glide with manipulation
stabilization with MET
what are the other names for radial nerve entrapment
radial tunnel syndrome
posterior interosseous nerve syndrome (PINS)
wartenberg syndrome
describe the radial nerve course
off posterior cord from brachial plexus
passes inferior to teres major
posterior to brachial artery in posterior arm
travels just anterior to lateral epicondyle before entering posterior forearm
what condition is often confused with lateral elbow tendinopathy but provocation more distal than lateral elbow tendinopathy
radial tunnel syndrome
what is the site of radial tunnel syndrome
begins where deep radial nerve branch courses over radiohumeral joint and ends at distal edge of supinator
what symptoms are common with radial tunnel syndrome
dorsoradial forearm pain/parethesias
wrist extension weak and painful
what is the cause of wartenberg syndrome
compression of superficial sensory radial nerve between brachioradialis and ECRL
what symptoms are common with wartenberg syndrome
Only sensory symptoms or paresthesia’s and P! over 1st 3 ½ digits of dorsoradial forearm and HAND
what special tests are used to confirm radial nerve entrapment
what are examples of these tests
radial nerve dural mobility
ULTT
resisted supination test
what is the Rx for terminal nerve branch injury
POLI (no C) ED
STM/modalities for inflammatory phase
STM/JM/Splinting to assist with eliminating compression
MET
why is compression not used during POLICED of terminal nerve branch Rx
compression is the cause of the symptoms with the injury
what is the focus of MET for terminal nerve branch injury
create neural motion/flossing
eliminate compression
what structures are involved with medial tendinitis/tendinosis
pronator teres
FCR
FCU
FDS
FDP
what are the hallmark S&S of medial tendinitis/tendinosis
pain with lengthening - wrist flexion/supination
TTP over medial epicondyle
what is the PT Rx for medial tendinitis/tendinosis
modify activity
decrease inflammation
treat neck/shoulder (most likely stabilization)
what complications are common with medial tendinitis/tendinosis
medial epicondyle apophysis in adolescent overhead throwers
what is another name for medial epicondyle apophysitis
little league elbow
what population is most commonly diagnosed with medial epicondyle apophysitis
adolescent males
mostly overhead throwers and racquet sports
what is the etiology of medial epicondyle apophysitis
growth with high activity
what are the pathomechanics of medial epicondyle apophysitis
bone growth exceeds wrist flexor and pronator lengthening
increased tendon tension
most often inflammation
what structure is considered the weak spot in adolescents and adults in regards to medial epicondyle apophysitis
adolescents - growth plate
adults - tendon
what are common complications of medial epicondyle apophysitis
avulsion and/or premature closure
what are symptoms of medial epicondyle apophysitis
gradual onset with overuse
“pop” may indicate trauma/avulsion
possible loss of velocity
what ROM is expected with medial epicondyle apophysitis
possible loss of extension
what RST/MMT is expected with medial epicondyle apophysitis
possibly weak/painful muscles that attach to common flexor tendon
what is expected during palpation of medial epicondyle apophysitis
TTP over medial epicondyle
what is expected during special test of medial epicondyle apophysitis
UCL possible +
what is the PT Rx for medial epicondyle apophysitis
Pt education - soreness rule, load management, movement cues
POLICED
what is the mechanism of valgus stress overload
trauma (FOOSH)
repetitive stress like overhead throwing or racquet sports
what structure is involved with valgus stress overload
ulnar collateral ligament
what are the S&S of sprains
pain with motions that cause lengthening
+ distraction
when would you preform a stability test with a possible sprain
before accessory motion to confirm sprain
what special tests would be performed for a sprained ligament at the elbow
valgus stress test @ 0 and 90 degrees
UCL instability
describe valgus
distal segment (forearm) goes lateral
joint goes more medial
describe the medial/ulnar collateral ligament
triangular shaped
medial epicondyle to coronoid to olecranon process
provides medial stability/prevents valgus stress
what structure is involved in varus stress overload
radial collateral ligament (RCL)
what S&S are common with varus stress overload
S&S of sprains
what special tests would be used for varus stress overload
varus stress test 0 and 90 degrees
describe the lateral/radial collateral ligament
triangular shaped
lateral epicondyle to annular ligament to lateral radius
provides lateral stability/prevents varus stress
what is the PT rx for sprain
POLICED
bracing/taping prm
MET
what is the goal of MET for sprains
ultimate emphasis on stabilization and increase integrity
what are the MD Rx for sprains
reconstructive surgery - Tommy John surgery for the UCL
12-18 month recovery
describe radial head proximal/pushed subluxation/dislocation
radial head goes through annular ligament
what is the mechanism of radial head proximal/pushed subluxation/dislocation
FOOSH
t/f
radial head proximal subluxation/dislocation can also cause a fracture of distal radius and ulna
yes
what is a colles fracture
fracture of distal radius and ulna
how does radial head distal or pulled subluxation/dislocation
forceful traction through lateral forearm
mostly caused by pulling on distal arm
describe the annular ligament
attaches anteriorly and posteriorly on the radial notch
encompasses radial head and holds it against ulna
describe humeroulnar dislocation
primarily in males and usually on non-dominant side
can injure major nerves or brachial artery
frequent loss of terminal extension
what is the PT rx for subluxation/dislocation
like ligamentous sprains for greater hypermobility/instability
what are condylar fracture complications
volkmann’s ischemic flexion contracture d/t brachial artery damage
emergency referral
t/f
its common for difficulty when regaining full extension with olecranon fractures
true
what are the special tests performed after fractures
lack of extension ROM - high sensitivity
other motions restricted - high specificity
lack of supination ROM - LR+ = 14
lack of pronation ROM - LR+ = infinity
when is PT started with fracture
after clinical union occurs
between 4-8 weeks
t/f
any pain that is experienced after clinical union is formed is typically from bone
false
any pain that occurs after the clinical union is formed not due to bone
what is the focus of PT after fractures
focuses more on the consequences of prolonged immobilization where every tissue is negatively influenced
t/f
elbow is immobilized in flexion after all fractures/surgery making the regaining of full extension difficult
true
where is the ulnar nerve typically entrapped
medial condyle
where is the radial nerve typically entrapped
lateral condyle
where is the median nerve typically entrapped
at wrist
what is the second most common compression neuropathy seen by hand surgeons
ulnar nerve entrapment
what are the locations where the ulnar nerve is commonly entrapped
cubital tunnel at elbow
FCU heads in proximal forearm
Guyon’s canal in hand
what is the etiology of ulnar nerve entrapment at cubital tunnel
OA
trauma
age-related changes (not common at elbow)
what are the symptoms of ulnar nerve entrapment at the elbow
medial hand/finger paresthesia’s
weak grip
what are the signs of ulnar nerve entrapment at the elbow (ROM, RST, neuro)
ROM - limited elbow flexion with possible paresthesia’s, possible limited extension
RST - weak wrist and 4th and 5th digit flexion, thumb adduction, grip
neuro - possible diminished sensation over ulnar cutaneous distribution
__% of neurological conduction is lost resulting in muscle weakness
80%
what special tests are used for ulnar nerve entrapment at the elbow
elbow flexion test
tinel’s
wartenberg’s sign
what would palpation show with ulanr nerve entrapment
provocation with ulnar nerve pressure up to 60 seconds
possible ulnar nerve subluxation
what would palpation show with ulanr nerve entrapment
provocation with ulnar nerve pressure up to 60 seconds
possible ulnar nerve subluxation
what is the difference of ulanr nerve entrapment at the elbow
ROM - elbow WNL
palpation - no paresthesia’s or ulnar nerve subluxation in cubital tunnel
what is ulnar nerve entrapment at the elbow called
cubital tunnel syndrome
what is ulnar entrapment at the hand called
guyon’s canal
what is the difference of cubital tunnel syndrome vs guyon’s canal
etiology - cyst/repetitive stress with hand and onto hook of hamate
ROM - elbow WNL
RST - hand but no wrist weakness
palpation - no paresthesia’s or ulnar nerve subluxation in cubital tunnel
why is there wrist weakness but no hand weakness with ulnar nerve entrapment at guyon’s canal
entrapment is at hand
entrapment causes symptoms/weakness distally from the entrapment
what is the Rx for terminal nerve branch injury
POLI (no C) ED - compression is the issue
STM/modalities - inflammatory phase
STM/JM/Splinting - decreases compression
MET - neural motion, decreases compression
