Elbow & Forearm - Final Exam Flashcards
what is the avg. functional ROM for the elbow?
130 deg (out of 142 deg)
with flexion & extension
what is the avg. functional ROM for the forearm?
103 deg with pronation and supination
what is functional ROM for max pronation? for what activity?
what is functional ROM of max supination? for what activity?
65 deg with keyboarding
77 deg with opening a door
what is the most common injury site for lateral elbow pain?
common extensor tendon
what are the 3 causes of lateral elbow pain?
tendinopathy - tendinitis, tendinosis
trauma - abducted elbow
radial n. entrapment
_______% of population gets lateral elbow pain
______% of laborers with overuse of hand tasks
______% of tennis players/racket sports
1-3%
15%
up to 40%
what are risk factors for lateral elbow pain?
dominant arm > non-dominant
forceful activities
repetitive activities
smoking (circulatory issue)
poor posture
35-54 years of age
what are the primary tendons/muscles involved in lateral epicondylitis? (4)
which has the highest incidence? why?
extensor carpi radialis longus
extensor carpi radialis brevis
extensor digitorum
extensor digiti minimi
highest incidence: ECRB - radially deviates and extends wrist
cause of lateral epicondylitis?
overuse
pathogenesis of lateral epicondylitis?
tendinitis aka tennis elbow
hallmark signs of tendinitis are:
- TTP
- tendon doesn’t like to be used/resisted
- tendon doesn’t like to be lengthened
what would these signs be at the lateral elbow?
P! with gripping
P! with extension
tender at distal lateral epicondyle (ECRB)
- tendon is inflammed
what are hallmark signs of lateral epicondylitis?
ROM?
Resisted/MMT?
Palpation?
nociplastic Pain?
- P! and limitation with lengthening during wrist flexion with/without elbow extension
- P! w/ wrist ext & possible 3rd finger ext, radial deviation esp. in lengthened position. possible weakness. P! with gripping. abnormal muscle activation patterns, including scapular muscles
- common extensor tendon TTP –> all come into CET.
- may become nociplastic p!
Rx for lateral epicondylitis?
tendinitis Rx (pt education, POLICED, NSAIDS, bracing)
possible sport specific corrections (i.e. tennis swing or larger grips)
cuff, scapular, trunk, and/or LE muscle coordination, endurance, and strength training to decrease elbow stress
if patient has lateral elbow pain but not from overuse of a laborer or tennis player, what could be some causes?
tendinosis etiologies (most common)
– recurrent tendinitis
– regional interdependence
– cervical n. impingement
abducted elbow
radial nerve entrapment
what is the cause of C5,6 regional interdependence?
C5, 6 hypermobility/instability
most common segment
Patient has lateral elbow pain and reports they haven’t done anything different to their routine. You suspect C5, 6 regional interdependence led to pain. Why?
over recruited wrist extensors created increased common extensor tendon tension and compression
** normally we only recruit the muscle fibers in the tendon needed to pick up the weight of the intended object. If we over recruit, increased tension/compression can cause pain
C6 spinal nerve impingement creates ?
decreased activation of wrist extensors and lowers supply –> overuse/lower supply of wrist extensors, even without activity change
S&S of C6 spinal n. impingement?
neuro S&S
Rx for C6 spinal n. impingement?
tendinosis Rx
in a patient with lateral tendinosis, where does the degeneration most often occur at?
musculotendinous junction
Which special test may be positive for lateral tendinosis?
Mill’s test for CET scarring
what is PT Rx for lateral tendinosis/tendinitis?
patient education (soreness rule, load management)
POLICED
bracing/taping (elbow strap)
modalities (LASER, TENS & shockwave therapy - need more evidence)
stretching - need more evidence
dry needling - short term P!
what would you target with cervical JM for lateral tendinitis/tendinosis?
effective with pain and grip strength
fewer visits and equal success compared to elbow Rx
what would you target with elbow & wrist JM for lateral tendinitis/tendinosis?
mill’s manipulation for P!/function & pulling apart scarring
*cervical and elbow together better evidence
what does thoracic manipulation increase for lateral tendinitis/tendinosis?
grip strength
what is the primary purpose of MET for lateral tendinitis/tendinosis?
tendon proliferation
cervical stabilization
what are the 5 loading MET parameters for lateral tendinitis/tendinosis?
- isometric loading without compression from lengthening i.e. in shortened position
- isotonic loading without compression from lengthening i.e. neutral to a shortened position
- isotonic loading with compression from lengthening i.e. lengthened position
- isometric loading in weight bearing (push ups)
- plyometric loading (throwing)
** 4&5 may not apply to everyone
MD Rx for lateral tendinitis/tendinosis?
cortisone injections
surgery (5-10%)
prognosis of lateral tendinitis/tendinosis?
6-24 months w/ avg of 1 year
how does an abducted elbow happen? leads to?
trauma / FOOSH
leads to medially fixated olecranon
what would you observe with someone with an abducted elbow?
increased carrying angle
what are ROM limitations of an abducted elbow?
elbow flx & FA sup - lack of lateral ulnar glide
wrist flx & R. Dev - radius shifting distally from contact with capitulum
what would a PT find with an abducted elbow?
resisted testing:
accessory motion:
palpation:
wrist ext & radial dev painful
limited lateral glide at HU joint
CET TTP
what are two complications with an abducted elbow/
carpal fx or subluxation
how do you treat abducted elbow?
correct lateral glide with manipulation
stabilization with MET
treat for tendinosis possibly (if it’s been there a while)
what is the course of the radial nerve with radial n. entrapment?
off posterior cord of brachial plexus
passes inferior to teres major
posterior to brachial a. in post. arm
travels anterior to lateral epicondyle before entering post. forearm
radial tunnel syndrome locations of:
site & TTP:
P!/paresthesia’s:
weak & painful:
begins where deep radial n. branch courses over RH jt and ends at distal edge of supinator
dorsoradial forearm & hand
wrist & finger ext
what is radial tunnel syndrome often confused with? what is the difference/
lateral elbow tendinopathy
provocation more distal than lateral elbow tendinopathy
what is Wartenberg syndrome?
where does it experience sensory symptoms?
compression of superficial sensory radial n. between brachioradialis and ECRL
** no motor innervation
sensory symptoms or paresthesia’s over dorsoradial hand (first 3.5 digits)
what are special tests used to determine radial n. entrapment?
radial n. dural mobility (+)
resisted supination test (relieve pressure on nerve)
how do you treat a terminal n. branch injury?
POLI( no C) ED - don’t create more compression
splinting to assist w/ eliminating compression & motion
MET w/ optimal stresses to create neural motion/flossing and elimination of compression
what structures are involved with medial tendinitis/tendinosis? what is this also known as?
pronator teres, FCR, FCU, FDS, FDP
thrower’s/little league/golfer’s elbow
S&S of medial tendinitis/-osis
P! w/ wrist ext
P! at medial epicondyle
P! in flex/sup
how do you treat medial tendinitis/-osis
like lateral tendinitis/-osis
what is the main complication of someone with medial tendinitis/-osis
medial epicondyle apophysitis in adolescent overhead throwers
who usually gets medial epicondyle apophysitis & how does it grow?
male overhead throwers/racquet sports
growth with high activity
medial epicondyle apophysitis:
bone growth exceeds:
increased:
growth plate is:
inflammation?
complications:
wrist flexor and pronator lengthening
tendon tension
weak spot (as opposed to tendon in adult)
yes
avulsion and/or premature closure & UCL sprain
symptoms of medial epicondyle apophysitis
gradual onset w/ overuse
pop may indicate trauma or avulsion
possible loss of velocity
what would PT see with medial epicondyle apophysitis?
ROM:
resisted:
palpation:
special tests:
possible loss of ext
possibly weak and/or P!ful muscles that attach to CFT
TTP over medial epicondyle
those for UCL sprain possible (+)
medial epicondyle apophysitis Rx:
patient education
– soreness rule, load management, movement cues
POLICED
careful w/ prolonged stretching
MET
– for trunk, cuff, scap & LE impairments
– caution w muscle/tendons attached to growth plate
RTP - throwing progression program
what is the prognosis for someone with medial epicondyle apophysitis?
1/3 return to sport
growth plate fuses around 15 years old
can become recurrent/persistent
how does a valgus stress overload sprain happen?
trauma (FOOSH)
repetitive stress like overhead throwing
what structure is involved with a valgus stress overload sprain?
UCL
S&S of elbow sprains?
ROM:
resisted:
stress tests:
special tests:
painful w/ lengthening; AROM = PROM
P! in lengthening, strong & painful
P! with distraction, compression relieving
valgus stress test at 0 & 90, UCL instability
how can there be differential Dx with medial epicondyle apophysitis?
easily misdiagnosed with a growth plate problem because common in children
sprains are more protected due to ligaments
MCL/UCL:
shaped?
runs from _____ to ______ to ______
provides:
lengthened w:
triangular shaped
medial epicondyle to coronoid to olecranon processes
medial stability/prevents valgus stress
extreme ER
what structure is involved with a varus stress overload sprain? (less common)
RCL
LCL/RCL:
shaped?
runs from _____ to ______ to ______
provides:
triangular
lateral epicondyle to annular ligament to lateral radius
lateral stability/prevents varus stress
PT Rx for sprains:
POLICED
possible brief period of immobilization
bracing/taping prn
MET - emphasis on stabilization & tissue integrity
MD Rx for sprains:
direct repair vs reconstruction with palmaris longus graft
reconstructive Sx AKA tommy john sx for UCL
12-18 month recovery
how does a pushed subluxation/dislocation happen? what happens when this happens?
** radial head proximal
FOOSH
fall on radial side & pushes radial head up through annular ligament
what is a colles fx? how may it be caused?
fx of distal radius and ulna
may be caused from pushed subluxation/dislocation
what happens if a pulled subluxation/dislocation occurs? example?
forceful traction through lateral forearm
pulls radius distally
** grabbing child’s arm
where does the annular ligament attach and what does it encompass?
attaches anteriorly and posteriorly on radial notch
encompasses radial head and holds it against ulna
what does the interosseous membrane do?
keeps radius and ulna together
serves as muscle attachment for forearm and wrist muscles
how are RU articulations held together?
annular ligament
interosseous membrane
what kind of dislocation is most common in males on non-dominant side & can injure any of the 3 major nerves or brachial artery?
humeroulnar dislocation
Frequent loss of ____________ with HU dislocation?
terminal extension
how do you treat a subluxation/dislocation?
like ligamentous sprains for greater hypermobility/instability
always some period of immobilization
where would a fracture be located for a supracondylar fracture?
above condyle
distal humeral segment
where would a fracture be located for a intercondylar fracture?
in between condyles
what could be a complication of a condylar fracture? referral type?
Volkmann’s ischemic flexion contracture due to possible brachial artery damage
emergency referral
why would someone with a olecranon fracture have difficulty regaining extension?
immobilized 6-8 weeks
no flexion > 90 for 2 months
what would you see with elbow special tests after trauma?
lack of ext ROM
other motions restricted
lack of supination
lack of pronation
Rx for fractures:
POLICED
isometrics when immobilized
STM/JM to improve ROM after prolonged immobilization
MET w/ optimal stresses, focus on consequences from immobilization
pain from bone not typically an issue after bone is healed
regain full extension - can be difficult
2nd most common compression neuropathy seen by hand surgeons:
ulnar n. entrapment
where are the locations we see ulnar n entrapment at?
cubital tunnel at elbow
FCU heads in proximal forearm
guyon’s canal in hand
how does cubital tunnel syndrome happen?
OA/trauma, age related changes
symptoms of cubital tunnel syndrome, regarding the hand?
medial hand/finger paresthesias (1/2 4th digit & 5th digit)
weak grip
what would a PT see w cubital tunnel syndrome?
ROM
resisted testing:
neuro:
special tests:
palpation in cubital tunnel:
- limited elbow flx w possible paresthesias & limited ext
- weak wrist, 4th&5th digit flx, thumb abd & grip
- possibly diminished sensation over ulnar cutaneous distribution (start w neck & move to hand/wrist)
- elbow flx test, Tinel’s, Wartenberg’s sign
- provocation w ulnar n pressure up to 60 sec, possible ulnar n subluxation
Ulnar n entrapment at FCU heads in forearm S&S are same as cubital tunnel syndrome except:
ROM elbow WNL
palpation: NO paresthesias or ulnar n. subluxation in cubital tunnel
Ulnar n entrapment at Guyon’s canal in hand S&S are same as cubital tunnel syndrome except:
etiology:
ROM:
Resisted testing:
P!/parenthesis:
- cyst/repetitive stress w hand and onto hook of hamate carpal bone
- elbow WNL
- hand but no wrist weakness because the entrapment is at the hand & distal
- no paresthesia’s or ulnar n subluxation in cubital tunnel
