Elbow and Post Op shoulder

Question 1

Throwers elbow
Non-op early goals

Answer 1

Wrist and elbow ROM focus, particularly on regaining elbow extension

Elbow is predisposed to flexion contractures due to anterior capsule adhesions, joint capsule tightness, brachialis scarring

Question 2

Humeroulnar Joint mobilization to improve elbow extension

Answer 2

Posterior glides

Question 3

Non-op thrower elbow acute goals

Answer 3

Weeks 0-2

Improve ROM, reduce risk of elbow flexion contractures, reduce pain/inflammation, reduce atrophy

Question 4

Non-op thrower elbow sub-acute goals

Answer 4

Week 2-4
Normalize motion, improve strength, power, endurance

Question 5

Non-op thrower elbow intermediate phase

Answer 5

Week 4-6
Prep athlete for return to functional structures (swinging drills, light plyo, throwers 10)

Question 6

Non-op thrower elbow return to activity stage

Answer 6

Week 6+
Throwing program, functional drills, ongoing strength and flexibility focus

Emphasis of eccentric elbow flexion (deceleration during throwing), concentric elbow extension (acceleration during throwing)

Question 7

Non-op Epicondylitis treatment

Answer 7

Iontophoresis, cryotherapy, stretching, very light strengthening

Question 8

Non-op epicondylosis treatment

Answer 8

Cross friction massage, stretching, eccentric strengthening with gradual load progression, warm modalities

Question 9

Common secondary pathology of UCL insufficiency

Answer 9

Ulnar neuropathy

Question 10

Valgus extension overload treatment focus

Answer 10

Eccentric elbow flexion strength to control rapid elbow extension

Question 11

Non-op UCL injury treatment

Answer 11

Inflammation mgt with modalities
ROM in non painful arc of motion (10-100deg) with increase of 5-10deg per week- elbow flexion/extension encouraged for collagen formation and alignment
Isometrics of shoulder, elbow, wrist

Question 12

Osteochondritis dissicans of elbow
Stage 1

Answer 12

Lateral elbow pain upon palpation or valgus stress but no evidence subchondral detachment or articular cartilage fracture

May be treated conservatively

Question 13

Osteochondritis dissicans of elbow
Stage 2

Answer 13

Lesions show evidence of subchondral detachment or articular cartilage fracture

Warrants surgery but long term sx results seem unfavorable, suggesting prevention or early detection is best

Question 14

Osteochondritis dissicans of elbow
Stage 3

Answer 14

Detached osteochondral fragments or loose bodies present

Warrants surgery but long term sx results seem unfavorable, suggesting prevention or early detection is best

Question 15

Non-op osteochondritis dissicans treatment

Answer 15

Relative rest and immobilization until elbow symptoms have resolved

Question 16

Ulnar nerve transposition treatments

Answer 16

Early immobilization with posterior splint at 90deg flexion to reduce tension on nerve from excessive extension
After week 2, Light ROM
After week 4, isotonic strengthening
Week 8 plyo and aggressive strengthening

Question 17

Posterior olecranon osteophyte excision treatment

Answer 17

Regain elbow ROM, but elbow extension slightly more conservative sure to post op pain and synovial joint inflammation
Rehab focus is similar to valgus extension overload treatment with focus of eccentric elbow flexion and dynamic stabilization of medial elbow

Question 18

Neurapraxia

Answer 18

Most benign form of peripheral nerve injury, usually a temporary palsy resulting from prolonged ischemia that induces conduction block

No loss of myelin or axons

Question 19

Axonometsis

Answer 19

Peripheral nerve injury involving loss of axons and nerve fibers, sometimes due to crush injury or laceration

Wallerian Degeneration occurs, followed by Axonal Regeneration phase

Question 20

Neurotmesis

Answer 20

Severe peripheral nerve injury involving loss of axons and connective tissue
Poor recovery potential

Wallerian Degeneration occurs, followed by Axonal Regeneration phase

Question 21

Median nerve neuropathies

Answer 21

Pronator teres syndrome (uncommon)
Anterior interosseous syndrome (uncommon)
carpal tunnel syndrome (very common)

Question 22

Pronator teres syndrome
Clinical features

Answer 22

Pain and tenderness over pronator teres, increased with activity
Sensory changes over thenar eminence, palmar digits 1-3, sometimes 4
Motor weakness thenar muscles, flexor policies longus, FDP i/ii, PQ, 1/2 FPB. Pronator teres may be spares

Sparing of FCR, PL, FDS

Question 23

Pronator teres special testing

Answer 23

(+) pronator teres syndrome test
(+) tinels in forearm
(-) phalens test

Question 24

Anterior interosseous syndrome
Clinical features

Answer 24

No sensory loss!! But aching present
Motor weakness FPL, FDP digits 1-2, pronator quadratus
Kiloh nevin sign: cannot perform dip flexion of digits 1-2 thus cannot make “OK” sign

Question 25

Kiloh nevin sign

Answer 25

Seen with anterior interosseous syndrome due to motor weakness FPL, FDP digits 1-2 Canot make "ok" sign

Question 26

Carpal tunnel syndrome Prevalence

Answer 26

40-60 years old Female > males Can be associated with RA due to thickening of tendon sheath

Question 27

Carpal tunnel syndrome Clinical features

Answer 27

Sensory deficits anterior palm digits 1-3, sometimes 4 but sparing thenar eminence. Sensory deficits dorsal and distal digits 1-3 Motor weakness of thenar muscles

Question 28

Carpal tunnel syndrome Special testing

Answer 28

(+) tinels sign at wrist (+) phalens and reverse phalens --- Nerve conduction velocity testing is gold standard, BC phalen's and tinel's signs found to have higher sensitivity and specificity for tenosynovitis vs carpal tunnel

Question 29

Carpal tunnel syndrome CPG

Answer 29

Hand shaking improves symptoms Wrist-ratio index > 0.67 (rounder wrists) Decreased sensation median sensory field 1 (thumb) Age> 45 Symptom severity score > 1.9 90% post-test probability if 5/5 positive 70% post-test probability if 4/5 positive Wrist ratio index has highest sensitivity (0.93)

Question 30

Ulnar nerve entrapment areas

Answer 30

Cubital tunnel syndrome Guyons canal

Question 31

Tardy ulnar nerve palsy

Answer 31

Aka cubital tunnel syndrome Second most common peripheral nerve compression injury

Question 32

Cubital tunnel syndrome Clinical features

Answer 32

Sensory deficit of palmar AND dorsal digit 5, 1/2 digit 4 Motor weakness or atrophy of hand intrinsics (especially interossei)

Question 33

Cubital tunnel syndrome Special testing

Answer 33

+ elbow flexion test + tinels @ cubital tunnel

Question 34

Differentiating factor for cubital tunnel syndrome vs guyons canal entrapment

Answer 34

Sensory deficits are dorsal and palmar for cubital tunnel syndrome Dorsal digit 4-5 sensation spared with guyons canal entrapment

Question 35

Froment's sign

Answer 35

Indicative of ulnar neuropathy Inability to use adductor pollicis to grab piece of paper thus you see IP flexion

Question 36

Wartenburg's sign

Answer 36

Indicative of ulnar neuropathy Pinky drifts apart from all other fingers, remains abducted due to weakness of palmar intrinsic

Question 37

Upper arm radial nerve lesion Clinical features

Answer 37

Sensory loss dorsum of hand, digits 1-2 Complete wrist drop Weakness distal to tricep (if lesion is proximal to spiral groove, tricep also affected)

Question 38

Posterior interosseous syndrome

Answer 38

Radial nerve entrapment. May occur at arcade of frohse, between 2 heads of the supinator

Question 39

Posterior interosseous syndrome Clinical features

Answer 39

No sensory deficits Motor weakness of extensor digitorum longus, ECU (supinator, ECRB, ECRL intact so radial deviation can still occur),

Question 40

Wartenburg's syndrome

Answer 40

Compression of superficial branch of radial nerve

Question 41

Ape hand

Answer 41

Indicative of (distal) median nerve lesion Atrophy thenar eminence where thumb is permanently rotated and adducted

Question 42

Bishop's sign

Answer 42

Indicative of ulnar nerve lesion Patient is asked to make a fist. Digit 4-5 able to flex but digits 2-3 unable to flex at MTP or IP joints Ulnar paradox: sign is worse if lesion is lower

Question 43

Axillary nerve injury

Answer 43

Can result from shoulder dislocation or fracture of the surgical neck of humorus Clinical features: Loss of sensation at axillary patch Motor weakness teres minor and deltoid

Question 44

Erb's palsy

Answer 44

C5 and c6 brachial plexus involvement involving upper trunk of because plexus (More common than total brachial plexus involvement and klumpke involvement)

Question 45

Klumpke's palsy

Answer 45

Brachial plexus disorder involving c7-t1 nerve roots Affect hand function

Question 46

Erb's palsy clinical features

Answer 46

Shoulder is extended, adducted, internally rotated Shoulder may be posteriorly subluxed Elbow may be involved

Question 47

Klumpke's palsy

Answer 47

May have associated Horner's syndrome Intrinsic hand weakness, weakness of long finger flexors and extensors Sensory deficit medial arm, forearm, hand

Question 48

Peripheral nerve injury treatments

Answer 48

Education!! Pain control Maintain rom/strength with consideration to antagonist relationships. Do not overstretch denervated muscle. LOW LOAD strengthening to avoid axonal fatigue Sometimes bracing or splinting E-stim questionable

Question 49

Ulnar collateral ligament tear

Answer 49

Medial elbow injury associated with repetitive overhead throwing. Repetitive valgus stress can lead to ligamentous injury Paresthesias or associated cubital tunnel syndrome possible

Question 50

Posterior interosseous syndrome

Answer 50

Peripheral nerve entrapment of posterior interosseous nerve, branch of radial nerve. No sensory deficits but will note weakness of extensor muscles of thumb, wrist, and digits

Question 51

Wartenburg's syndrome or handcuff palsy

Answer 51

Peripheral nerve entrapment of superficial radial nerve. No motor deficits. Sensory deficits of dorsal hand and wrist but fingertips spared

Question 52

Moving valgus stress test

Answer 52

More sensitive than standard valgus stress test for small, mildly symptomatic years of UCL Good for athletes with small partial tears

Question 53

Fat pad sign

Answer 53

Radiographic finding indicative of intra-articular fracture

Question 54

RTC repair Factors for good prognosis

Answer 54

Younger age Traumatic tear Smaller tear Arthroscopic repair

Question 55

Labral repair Factors for good prognosis or better outcomes

Answer 55

Non-throwing athlete OH athlete with traumatic tear > overuse injury

Question 56

TSA rehab considerations for prognosis

Answer 56

Better with OA than RA or trauma

Question 57

Monteggia fracture

Answer 57

Proximal ulna fracture. Often has radial head involvement. Results from FOOSH

Question 58

Galeazzi fracture

Answer 58

Fracture of distal 1/3 radius, along with dislocation or instability of distal radioulnar joint