Elbow and Post Op shoulder Flashcards
Throwers elbow
Non-op early goals
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
Humeroulnar Joint mobilization to improve elbow extension
Posterior glides
Non-op thrower elbow acute goals
Weeks 0-2
Improve ROM, reduce risk of elbow flexion contractures, reduce pain/inflammation, reduce atrophy
Non-op thrower elbow sub-acute goals
Week 2-4
Normalize motion, improve strength, power, endurance
Non-op thrower elbow intermediate phase
Week 4-6
Prep athlete for return to functional structures (swinging drills, light plyo, throwers 10)
Non-op thrower elbow return to activity stage
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)
Non-op Epicondylitis treatment
Iontophoresis, cryotherapy, stretching, very light strengthening
Non-op epicondylosis treatment
Cross friction massage, stretching, eccentric strengthening with gradual load progression, warm modalities
Common secondary pathology of UCL insufficiency
Ulnar neuropathy
Valgus extension overload treatment focus
Eccentric elbow flexion strength to control rapid elbow extension
Non-op UCL injury treatment
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
Osteochondritis dissicans of elbow
Stage 1
Lateral elbow pain upon palpation or valgus stress but no evidence subchondral detachment or articular cartilage fracture
May be treated conservatively
Osteochondritis dissicans of elbow
Stage 2
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
Osteochondritis dissicans of elbow
Stage 3
Detached osteochondral fragments or loose bodies present
Warrants surgery but long term sx results seem unfavorable, suggesting prevention or early detection is best
Non-op osteochondritis dissicans treatment
Relative rest and immobilization until elbow symptoms have resolved
Ulnar nerve transposition treatments
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
Posterior olecranon osteophyte excision treatment
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
Neurapraxia
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
Axonometsis
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
Neurotmesis
Severe peripheral nerve injury involving loss of axons and connective tissue
Poor recovery potential
Wallerian Degeneration occurs, followed by Axonal Regeneration phase
Median nerve neuropathies
Pronator teres syndrome (uncommon)
Anterior interosseous syndrome (uncommon)
carpal tunnel syndrome (very common)
Pronator teres syndrome
Clinical features
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
Pronator teres special testing
(+) pronator teres syndrome test
(+) tinels in forearm
(-) phalens test
Anterior interosseous syndrome
Clinical features
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
Kiloh nevin sign
Seen with anterior interosseous syndrome due to motor weakness FPL, FDP digits 1-2
Canot make “ok” sign
Carpal tunnel syndrome
Prevalence
40-60 years old
Female > males
Can be associated with RA due to thickening of tendon sheath
Carpal tunnel syndrome
Clinical features
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
Carpal tunnel syndrome
Special testing
(+) 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
Carpal tunnel syndrome
CPG
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)
Ulnar nerve entrapment areas
Cubital tunnel syndrome
Guyons canal
Tardy ulnar nerve palsy
Aka cubital tunnel syndrome
Second most common peripheral nerve compression injury
Cubital tunnel syndrome
Clinical features
Sensory deficit of palmar AND dorsal digit 5, 1/2 digit 4
Motor weakness or atrophy of hand intrinsics (especially interossei)
Cubital tunnel syndrome
Special testing
+ elbow flexion test
+ tinels @ cubital tunnel
Differentiating factor for cubital tunnel syndrome vs guyons canal entrapment
Sensory deficits are dorsal and palmar for cubital tunnel syndrome
Dorsal digit 4-5 sensation spared with guyons canal entrapment
Froment’s sign
Indicative of ulnar neuropathy
Inability to use adductor pollicis to grab piece of paper thus you see IP flexion
Wartenburg’s sign
Indicative of ulnar neuropathy
Pinky drifts apart from all other fingers, remains abducted due to weakness of palmar intrinsic
Upper arm radial nerve lesion
Clinical features
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)
Posterior interosseous syndrome
Radial nerve entrapment. May occur at arcade of frohse, between 2 heads of the supinator
Posterior interosseous syndrome
Clinical features
No sensory deficits
Motor weakness of extensor digitorum longus, ECU (supinator, ECRB, ECRL intact so radial deviation can still occur),
Wartenburg’s syndrome
Compression of superficial branch of radial nerve
Ape hand
Indicative of (distal) median nerve lesion
Atrophy thenar eminence where thumb is permanently rotated and adducted
Bishop’s sign
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
Axillary nerve injury
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
Erb’s palsy
C5 and c6 brachial plexus involvement involving upper trunk of because plexus
(More common than total brachial plexus involvement and klumpke involvement)
Klumpke’s palsy
Brachial plexus disorder involving c7-t1 nerve roots
Affect hand function
Erb’s palsy clinical features
Shoulder is extended, adducted, internally rotated
Shoulder may be posteriorly subluxed
Elbow may be involved
Klumpke’s palsy
May have associated Horner’s syndrome
Intrinsic hand weakness, weakness of long finger flexors and extensors
Sensory deficit medial arm, forearm, hand
Peripheral nerve injury treatments
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
Ulnar collateral ligament tear
Medial elbow injury associated with repetitive overhead throwing. Repetitive valgus stress can lead to ligamentous injury
Paresthesias or associated cubital tunnel syndrome possible
Posterior interosseous syndrome
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
Wartenburg’s syndrome or handcuff palsy
Peripheral nerve entrapment of superficial radial nerve.
No motor deficits.
Sensory deficits of dorsal hand and wrist but fingertips spared
Moving valgus stress test
More sensitive than standard valgus stress test for small, mildly symptomatic years of UCL
Good for athletes with small partial tears
Fat pad sign
Radiographic finding indicative of intra-articular fracture
RTC repair
Factors for good prognosis
Younger age
Traumatic tear
Smaller tear
Arthroscopic repair
Labral repair
Factors for good prognosis or better outcomes
Non-throwing athlete
OH athlete with traumatic tear > overuse injury
TSA rehab considerations for prognosis
Better with OA than RA or trauma
Monteggia fracture
Proximal ulna fracture. Often has radial head involvement.
Results from FOOSH
Galeazzi fracture
Fracture of distal 1/3 radius, along with dislocation or instability of distal radioulnar joint
