Elbow, Forearm, Wrist & Hand Assessment (Lowe)

Question 1

Single-Plane Movements

Answer 1

• Elbow:

-flexion and extension occur in the sagittal plane at the humeroulnar and humeroradial joints

-flexion occurs as the forearm is brought toward the upper arm from anatomical position: 150°

-extension occurs when the forearm is in anatomical position

• Forearm:
  -pronation and supination occur in the transverse plane at the proximal and distal radioulnar joints
  -pronation occurs as the forearm rotates in a medial direction: 80°
  -supination occurs as the forearm rotates in a lateral direction: 80°
• Wrist:

-flexion and extension (sagittal plane), radial deviation and ulnar deviation (frontal plane) occur at the radiocarpal joint (with some accessory motion at the carpal bones)
-flexion occurs as the palm is brought toward the anterior surface of the forearm: 80°
-extension occurs as the back of the hand is brought toward the posterior surface of the forearm: 70°
(hyperextension)
-radial deviation (abduction) occurs when the radial side of the hand is moved in a laterally: 20°
-ulnar deviation (adduction) occurs when the ulnar side of the hand is moved in a medially: 30°

• Thumb:

-movements occurs at the carpometacarpal (CMC), metacarpophalangeal (MCP) and interphalangeal
(IP) joints
-flexion and extension occurs in the frontal plane
-flexion (CMC & MCP) occurs when the thumb is brought across the palm (requires slight degree of abduction): 15°
-extension occurs when the thumb moves in a lateral direction: 20°
-flexion (IP) occurs when the tip of the thumb is brought toward the anterior surface of the palm: 80°
-extension occurs when the tip of the thumb is brought back to anatomical position: not calculated
-abduction and adduction (CMC & MCP) occur in the sagittal plane
-abduction occurs as the thumb moves anterior from the palm: 70°
-adduction is the return of the thumb from an abducted position: not calculated

• Fingers:

-movements occur at the metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints
-flexion and extension occur in the sagittal plane
-flexion (MCP) occurs as the finger is brought toward the anterior surface of the palm: 90°

• Extension occurs as the finger is brought back to anatomical position
  -hyperextension occurs as the finger is brought past full extension: 30° (more passive motion)
  -flexion (PIP & DIP) occurs as tip of finger is brought toward anterior surface of palm: 100° (PIP); 85-90-
  (DIP)
  -extension occurs as finger held in anatomical position
  -abduction and adduction (MCP) occurs in the frontal plane
  -abduction is movement away from the midline of the hand versus midline of body
  -adduction is return to anatomical position

Question 2

Capsular Patterns

Answer 2

Elbow: flexion more limited than extension
Forearm Radioulnar joints: pronation and supination usually equally limited
Wrist: flexion and extension equally limited; possible slight limitation in radial and ulnar deviation
Thumb CMC joint: abduction most limited; extension limited after abduction
Thumb MCP & IP joints: flexion more limited than extension
Fingers MCP, PIP & DIP joints: flexion limited most, followed by extension

Question 3

Range of Motion

Answer 3

AROM: demonstrate the movement to be performed; have patient perform the movement
-pain indicates problems in either the contractile or inert tissues
-factors prematurely limiting active movement include ligamentous or capsular damage, muscle contractures, pain from nerve compression or tension, tendinosis, tenosynovitis, fibrous cysts or joint disorders (arthritis)
PROM: establish the joint’s normal end feel, have patient relax as much as possible, use gentle and slow movements
-predominantly implicates inert tissues; muscles and tendons that contract in the opposite direction are stretched at end range

Question 4

Resistive Tests

Answer 4

MRT: test one action at a time, position should isolate the action/muscles involved; if pain is suspected, start in a mid-range position; patient using a strong, but appropriate amount of effort
-pain indicates that one or more of the muscles and/or tendons performing that action are involved
-may be weakness due to lack of use, fatigue, reflex muscular inhibition and possibly, a neurological pathology

Question 5

Elbow MRT

Answer 5

Elbow
Resisted Flexion: standing/seated, elbow flexed to 90°; therapist places a hand on posterior distal end of patient’s humerus, other hand at distal forearm; patient holds position as therapist attempts to push patient’s forearm into extension
Resisted Extension: prone, humerus abducted to 90° and supported by table and elbow at table’s edge; patient’s arm brought into full or partial extension; therapist places a hand on patient’s distal forearm and patient holds position while practitioner attempts to push patient’s arm into flexion

Question 6

Forearm MRT

Answer 6

Resisted Pronation: standing/seated, therapist grasps patient’s hand as if shaking hands; therapist’s other hand stabilizes patient’s forearm; patient holds position as therapist attempts to pronate patient’s forearm (tests supination)

Resisted Supination: standing/seated, therapist grasps patient’s hand as if shaking hands; therapist’s other hand stabilizes patient’s forearm; patient holds position as therapist attempts to supine patient’s forearm (tests pronation)

Question 7

Wrist MRT

Answer 7

Resisted Flexion: seated with forearm supinated and supported by table with wrist at table’s edge; therapist grasps patient’s hand with one or both hands; patient’s forearm is supinated and patient holds hand stationary while therapist attempts to pull wrist into extension

Resisted Extension: seated with forearm pronated and supported by table with wrist at table’s edge; therapist grasps patient’s hand with one or both hands; patient’s forearm is pronated and patient holds hand stationary while therapist attempts to pull wrist into flexion

Resisted Radial Deviation: seated with forearm in neutral, supported by table with wrist at edge; therapist grasps patient’s hand with one hand; patient holds wrist stationary while therapist attempts to pull wrist into radial deviation (to test ulnar deviation)

Resisted Ulnar Deviation: seated with forearm in neutral, supported by table with wrist at edge; therapist grasps patient’s hand with one hand; patient holds wrist stationary while therapist attempts to pull wrist into ulnar deviation (to test radial deviation)

Question 8

Thumb MRT

Answer 8

Resisted Flexion: seated with forearm and hand supported by table, therapist uses one hand to stabilize patient’s hand while other hand offers resistance to patient’s thumb; patient attempts to pull thumb medially across palm

Resisted Extension: seated with forearm and hand supported by table, therapist uses one hand to stabilize patient’s hand while other hand offers resistance to patient’s thumb; patient attempts to pull thumb away from palm

Resisted Abduction: seated with forearm and hand supported by table, forearm is supinated so hand rests on table; therapist uses one hand to stabilize patient’s hand with other hand offers resistance to patient’s thumb as pull thumb upwards away from table as therapist pushes against thumb

Resisted Adduction: seated with forearm and hand supported by table, forearm is supinated so hand rests on table; therapist uses one hand to stabilize patient’s hand with other hand positions patient’s thumb in abduction, patient pulls thumb downwards towards table as therapist resists movement

Question 9

Fingers MRT

Answer 9

Resisted Flexion: seated with forearm and hand supported by table; therapist uses on hand to stabilize patients hand while other controls motion of finger; forearm is supinated and therapist brings patient’s finger into partial flexion at MCP joint; patient holds position as therapist attempts to push finger into extension

Resisted Extension: seated with forearm and hand supported by table; therapist uses on hand to stabilize patient’s hand while other controls motion of finger; forearm is pronated and patient’s finger in partial extension at MCP joint; patient holds position as therapist attempts to push finger into flexion

Resisted Abduction: seated with forearm and hand supported by table, forearm pronated or supinated; therapist uses one hand to stabilize patient’s wrist and other to control finger motion; hold fingers apart; therapist attempts to push fingers together as patient resists

Resisted Abduction: seated with forearm and hand supported by table, forearm pronated or supinated; therapist uses one hand to stabilize patient’s wrist and other to control finger motion; hold fingers apart; patient attempts to pull fingers back together while therapist resists

Question 10

1. Excessive Cubital Valgus

Structural and Postural Deviations

Answer 10

Characteristics: in anatomical position there is a natural angulation of the forearm (cubital valgus/carrying angle) which allows the forearm to swing away from the body during normal walking stride
-valgus angulation: lateral deviation of the distal end of a bony segment; approx. 5-15°
-excessive carrying angle is greater than 15°
-no specific symptoms but can lead to cubital tunnel syndrome, medial epicondylitis, apophysitis and myofascial trigger points
-usually results from genetics, can be caused by injury (fracture); injury can also cause cubital varus or gunstock deformity

History: ask about pain/symptoms; ask about injuries/fractures; ask whether aware of deviation; identify nature of injury and damage to adjacent structures

Observation: see when patient is standing in anatomical position; compare angulations of both sides; measure with goniometer

Palpation: no significant findings; irritation of ulnar nerve or attachment sites of flexor muscles may cause tenderness; injury may produce residual tenderness

Range of Motion and Resistance Testing

AROM: not impaired unless results from traumatic injury; pain or irritation may develop near end of full flexion as ulnar nerve and flexor tendons stretched

PROM: as with AROM MRT: no unusual findings

Suggestions for Treatment: no treatment unless soft-tissue disorders occur; if nerve impairment or recurrent nerve pain, refer to physician

Question 11

2. Dupuytren’s Contracture

Structural and Postural Deviations

Answer 11

Characteristics: fibrosis of the palmar fascia that affects the tendons of the fingers (flexion contractures) that force fingers to curl into flexion at MCP, PIP or DIP joints; usually affects both hands but can have different degrees of severity

Proliferative phase: myofibroblasts develop
Involutional phase: myofibroblasts align along tension lines
Residual phase: tissue becomes acellular and leaves thick bands of collagen
-begins with loss of ROM in fingers and progresses as the flexion contractures develop leading to loss of finger extension
-fingers are held in constant, but varied, degree of flexion; pronounced in 4th and 5th digits
-causes not well understood
-factors that increase risk: diabetes, seizure disorders, smoking, drinking alcohol excessively
-may have a genetic predisposition; more likely in men

History: thickening sensations just under skin on palm, pain or tightness and loss of motion in fingers; depends on developmental stage; ask about physician involvement; identify history of seizures or diabetes; ask about smoking/drinking; ask about familial history

Observation: thickening of palmar fascia; fibrosis gathers around flexor tendons which look cord-like; pitting and loss of mobility in the skin of the palm evident during some hand movements

Palpation: fibrous nodules may be present in palm or joints of fingers; can develop into cord-like structures; skin feels firm or tight

Range of Motion and Resistance Testing:

AROM: flexion and extension impaired
PROM: crepitus or stiffness; flexion can be limited; extension limited due to contractures MRT: weakness with flexion and extension; reduced grip strength, flexion may cause pain
Differential Evaluation: stenosing tenosynovitis, nerve compression, pathologies, rheumatoid arthritis, synovial ganglions, tumours or fibrositic processes in the hand

Suggestions for Treatment: splinting, ultrasound, stretching, flexibility exercises, injection therapy; surgery; stripping and myofascial techniques help to reduce fibrosis and increase ROM

Question 12

3. Rheumatoid Arthritis

Structural and Postural Deviations

Answer 12

-a systemic autoimmune disorder that is polyarticular; hands and feet affected most frequently; may affect other tissue other than joints with advanced stages; viruses, bacteria or fungi are involved and may be the cause; may be genetic or environmental factors; rheumatoid factor is usually present

Characteristics: immune system erroneously attacks the lining of the synovial membrane surrounding the joints through an enzymatic reaction that causes articular degeneration
-progressive
-initially, inflammation and proliferation of fibrous tissue causes swelling, heat, puffiness and fibrin deposits that cause movement pain; ROM decreased due to stiffness and pain; sores in the morning due to accumulation of fluid in synovial tissues; fever, fatigue and anemia may be present
-symptoms are intermittent because the disease can flare up and then go into remission
-during flare-up, the joints become stiff and sore bilaterally
-degree of swelling and deformity in the hands distinguishes it from osteoarthritis
-can produce stenosing tenosynovitis (trigger finger) due to inflammation in the synovial sheaths of flexor tendons
-as it progresses, continued thickening of synovial membranes which can lead to tendon adhesions and ruptures, loosening of joint capsules, subluxations and permanent deformities
-temporary/permanent deformities at MCP joints; held flexed or laterally/medially (ulnar drift)
-can also deviate in swan-neck (PIP extension, DIP flexion) and boutonniere (DIP flexion, PIP extension)
deformities
-occurs in older individuals, women more than men; oral contraceptives and pregnancy decrease risk; smoking, obesity, blood transfusions increase risk

History: swelling and pain in various joints (hands and feet); bilateral pain more often; pain at rest, magnified by movement; joint stiffness and limited ROM pronounced in the morning; deformities in hands; fatigue and periodic fever may be reported

Observation: enlarged joints with visible nodules, skin may be puffy, red or shiny during initial inflammatory reaction; look for ulnar drift, swan-neck or boutonniere deformity

Palpation: heat, swelling or nodules, painful with palpation; stiffness due to fibrosity

Range of Motion and Resistance Testing:

AROM: any motion may be painful; not painful if not flared-up; limited motion due to pain and/or fibrosity
PROM: as with AROM
MRT: weakness due to neurological inhibition and fibrositic changes in muscle-tendon unit; may produce pain if engage muscles acting on affected joints

Differential Evaluation: stenosing tenosynovitis, Dupuytren’s contracture, osteoarthritis, degenerative joint disease, gout, peripheral nerve compression, tendinosis, tenosynovitis

Suggestions for Treatment: refer to and receive clearance from physician; palliative care; relaxing massage; massage contraindicated in acute stages; primary goals are to manage symptoms, prevent further inflammation and reduce risk of permanent joint damage

Question 13

Lateral Epicondylitis ( Tennis elbow) ( extensor carpi radialis)

Common Injury Conditions

Answer 13

Characteristics: chronic collagen degeneration in the extensor tendons and enthesopathy (irritation of the attachment site) at the lateral epicondyle of the humerus
-repeated tensile stress on tendons leads to collagen degeneration and enthesopathy
-extensor carpi radialis brevis (ECRB) is most affected; all other wrist extensor muscles may be involved
-pain aggravated by actions that engage extensor muscles in a contraction (concentric, isometric or eccentric)
-wrist flexion produce pain due to extensor tendons being stretched
→ uncomfortable
-in acute cases, pain results from fibre tearing in tendon or periosteal tears at ECRB tendon attachment
-sports, occupations or hobbies that require repetitive grasping; also repetitive supination or pronation
-uni or bilateral
-other conditions can co-exist: myofascial trigger points can cause extensor muscles to be hypertonic, create an excess tensile load on tendons

History: pain in lateral elbow region, radiates into forearm; aching or sharp pain; ask about gradual or sudden; ask about activities requiring repetitive gripping or static contractions of forearms or wrist; may have difficulty grasping or lifting a smaller item

Observation: hot inflammatory ( n: may be a bit, but must not → no heat); unless perfostealtear or enthesitis (but not visible)

Palpation: tenderness and pain at extensor tendon attachment at lateral epicondyle; wrist extensors feel hypertonic; pain increased if wrist put in flexion and muscles/tendons palpated; fibrotic or ropy feel; may be referrals from trigger points near elbow or forearm when forearm muscles palpated; entrapped posterior interosseous nerve could produce pain down forearm

Range of Motion and Resistance Testing:

AROM: pain may or may not be present with wrist extension; pain at end range of flexion as extensors stretched
PROM: pain at end range of flexion as tendons stretched
MRT: pain with wrist extension; weakness due to reflex muscular inhibition; weakness can also be from compression of posterior interosseous nerve compression

Special Tests:
(N: MRT+ press)

Tennis Elbow Test; standing or seated; therapist wraps one hand around patient’s elbow so thumb is pressing on extensor tendons distal to lateral epicondyle of humerus; therapist’s other hand grasps patient’s hand and uses it to resist patient’s wrist extension; offer resistance only, do not push; contracting wrist extensors causes pain as affected tendons pulled near attachment site; pressing on tendons while in contraction, stress to damaged tissues is exaggerated

Differential Evaluation: radial tunnel syndrome, myofascial trigger point activity, ligament damage near elbow, radial neuropathy, cervical radiculopathy, joint pathology of elbow, medial epicondylitis

Suggestions for Treatment: treated conservatively; ultrasound, stretching, ROM exercises and electrical stimulation; anti-inflammation medications during early stages; deep friction applied directly to affected tendons to stimulate collagen production in damaged fibers; deep longitudinal stripping, myofascial approaches and active engagement beneficial to restore optimum function

Question 14

Medial Epicondylitis ( Golfer’s elbow)

Common injury conditions

Answer 14

Characteristics: affect wrist flexors where they attach to the medial epicondyle of the humerus; not inflammatory; excessive tensile stress on the flexor tendons causes chronic collagen degeneration (tendinosis) and enthesopathy at the attachment site
-repetitive or prolonged contractions of the wrist flexors
-often due to manipulation of tools and equipment with the hands or throwing actions
-may derive from repetitive supination and pronation of forearm (stresses pronator teres); proximity of its attachment at medial epicondyle cause it to be involved
-concentric, isometric or eccentric contractions aggravate pain
-pain may also occur in motions requiring wrist extensions where flexor tendons are stretched
-pain during activity, subsides after activity ceased ..
-poor conditioning is another cause
-may result from injury leading to chronic tendon irritation; may be some initial inflammation with minor tendon fibre tearing
-other conditions seen along with ME are carpal tunnel syndrome, ulnar nerve pathology

History: pain on medial side of elbow, radiates into forearm, general aching or sharp pain; gradual onset; ask about activities of repetitive gripping or static contractions of forearm and wrist; identify ergonomic factors that overuse flexors; ask about sudden changes in activity level (poor conditioning); may be pain with shaking hands; ask about symptoms related to nerve pathologies (cubital or carpal tunnel syndromes or pronator teres syndrome)

Observation: not inflammatory; unless periosteal tear or enthesitis (but not visible); may se cubital
valgus but structural not necessarily a symptom

Palpation: tenderness and pain at flexor tendon attachment at medial epicondyle; wrist flexors feel hypertonic; pain increased if wrist put in extension and muscles/tendons palpated; fibrotic or ropy feel; may be referrals from trigger points near elbow or forearm when forearm muscles palpated (n: deep papation)

Range of Motion and Resistance Testing:

AROM: pain possible with wrist flexion if severe; as condition worsens, less force required to cause pain; pain at end ROM with extension as tendons stretched; pain may also occur at end range of supination as pronator teres stretched
PROM: pain at end range with wrist hyperextension as tendons stretched and end range of supination if pronator teres involved
MRT: pain with wrist flexion; pain with pronation if pronator teres involved; weakness possible due to reflex muscular inhibition

Special Tests:
( n: MRI+press)

Golfer’s Elbow Test:standing/seated; therapist grasps patient’s elbow so thumb presses on flexor tendons distal to attachments at medial epicondyle; therapist’s other hand offer resistance to patient’s wrist flexion; offer resistance only, do not push; engaging wrist flexors causes pain at medial epicondyle as tensile force added; pressing on tendons while in contraction, stress to damaged tissues is exaggerated

Differential Evaluation: arthritis, pronator teres strain, cubital tunnel syndrome, cervical radiculopathy, pronator teres syndrome, median nerve compression near elbow, thoracic outlet syndrome, ulnar collateral ligament injury; osteochondritis dissecans, epicondylar apophysitis, stress fractures, ulnar nerve pathology, flexor muscle strain

Suggestions for Treatment: treated conservatively; ultrasound, stretching, ROM exercises and electrical stimulation; anti-inflammation medications during early stages; deep friction applied directly to affected tendons to stimulate collagen production in damaged fibres; deep longitudinal stripping, myofascial approaches and active engagement beneficial to restore optimum function

Question 15

Olecranon Bursitis

Common injury conditions

Answer 15

Characteristics: olecranon bursa is superficial to olecranon process of ulna to protect it and reduce friction between bony prominence and overlying skin; primary cause of bursitis is compression of the bursa, followed by inflammation; may be acute injury (direct blow) or chronic compressive loads over time

-can be caused by infection, systemic disorders or medical procedures (kidney dialysis)

History: pain with various movements; if acute, ask about traumatic event; if chronic ask about chronic compression; otherwise consider systemic disorder and refer to physician if not already diagnosed

Observation: large lump on posterior side of elbow; redness and inflammation

Palpation: tender to touch even with mild pressure; excess fluid around elbow; warmth due to inflammation

Range of Motion and Resistance Testing:

AROM: flexion or extension may be painful, more common at end of flexion
PROM: as with AROM

MRT: increase in pain not likely

Differential Evaluation: rheumatoid arthritis, olecranon process fracture, ligament sprain of elbow, synovial cyst, ulnar nerve compression

Suggestions for Treatment: PRICE, avoid compression in treatment, anti-inflammatories and/or antibiotics; no direct massage treatment to bursa

Question 16

Cubital Tunnel Syndrome = flexor Carpi ulnaris + Unar Nerve

Common injury conditions

Answer 16

Characteristics: cubital tunnel is located where the ulnar nerve passes between the two heads of flexi carpi ulnaris (FCU); one head blends with flexor tendon attachments at medial epicondyle of humerus; other head originates on medial aspect of olecranon process; tunnel is spanned by an aponeurotic band connecting the two heads; syndrome results when ulnar nerve is compressed between two heads of FCU of by the aponeurotic band

-during elbow flexion, space within tunnel decreases up to 55% and ulnar nerve is pulled taut; subluxation of ulnar nerve as elbow flexes can also produce symptoms

-acute or chronic compression of elbow; biomechanical factors (excessive cubital valgus) can also play

-can also occur due to bone spurs synovial ganglions, fibrous bands within muscles, mechanical compression during flexion, hypertonicity of FCU
- ulnar nerve is increasing y sensitive to cores huni more proximal nerve compression pathologies
exist (double crush phenomenon) (n: cubical tunnel + guyon)

-pain, burning, tingling, paresthesia; more men affected

-weakness or atrophy are likely (intrinsic hand muscles)

History: pain, aching, burning sensation, paresthesia in ulnar distribution; weakness, clumsines in hand, difficulty performing precise movements with thumb and fingers; ask about repetitive or static flexion of elbow; night symptoms with sleeps with elbow flexed

Observation: may be excessive cubital valgus; muscle atrophy in intrinsic hand muscles (adductor pollicis)

Palpation: pressure on cubital tunnel elicits patients symptoms; assess when elbow neutral and full flexion; may feel bone spurs or synovial masses; tenderness /hypertonicity throughout FCU muscle

Range of Motion and Resistance testing:

AROM: symptoms increase with elbow flexion, decrease with extension; may not be felt if elbow brought rapidly into full flexion and immediately returned to neutral; if held in flexion for more than a minute, symptoms usually felt
PROM: as with AROM
MRT: pain not expected; palpating cubital tunnel during wrist flexion exacerbates symptoms; symptoms may occur if flexion is performed while elbow flexed; ( n: w+e : exaggerate); weakness possible with adduction or flexion of thumb

Special Tests:

Elbow Flexion Test: standing/seated; bring both elbows into full flexion with forearms supinated and wrists hyperextended; bilaterally; if symptoms reproduced within 60 seconds, compression of ulnar nerve in cubital tunnel likely; puts tensile stress on ulnar nerve while decreasing space within cubital tunnel

Froment’s Sign: see Guyon’s Canal Syndrome

Upper Limb Neurodynamic Test: see General Neuromuscular Pathologies

Differential Evaluation: Guyon’s canal syndrome, thoracic outlet syndrome, carpal tunnel syndrome, other regions of ulnar nerve compression or tension, systemic disease, space-occupying lesions in elbow, ligament damage, cervical radiculopathy, myofascial trigger point referral, diabetic neuropathy, osteophytes

Suggestions for Treatment: relieve pressure on affected nerve; eliminate activities that keep elbow cal
flexed for long periods or apply pressure to cubital tunnel; splints for at night to keep elbow extended;(n: we can wrap the towel around); a surgery; massage to decrease muscular hypertonicity in FCU; deep stripping or active engagement to reduce tension and compression of ulnar nerve; caution with direct compression over ulnar nerve at
FCU ( n: pin & stretch)

Question 17

Pronator Teres Syndrome = Pronator teres + Median Nerve

Common injury conditions

Answer 17

Characteristics: develops from compression of the median nerve by pronator teres muscle; as median nerve passes the elbow it runs between two heads of pronator teres where it can be compressed (hypertonicity or fibrous bands); anatomical anomalies (nerve traveling deep to both heads) can also be a cause

-results from repetitive motions that cause pronator teres hypertonicity; occupational activities cause overuse of pronator teres
-symptoms felt in the anterior forearm and median nerve distribution in the hand; women affected more
-pain can radiate proximal or distal to nerve compression
-exacerbated by repetitive elbow flexion; symptoms in forearm and hand
-atrophy possible in thenar muscles
-can be double or multiple crush phenomenon to median nerve (? + carpal tunnel
-fibrous band (lacertus fibrosus/bicipital aponeurosis) from biceps brachii can also compress median nerve (connects distal portion of biceps to ulna)
-pronator teres compression may affect anterior interosseous nerve (AIN) instead of median nerve

History: aching, shooting or sharp electrical pain, paresthesia in median nerve distribution of hand; may be felt in anterior forearm also; pain aggravated when using pronator teres against resistance; ask about repetitive elbow movements, night pain not usual ( n: not stress + compress more)

Observation: may cause atrophy of forearm and hand muscles supplied by median nerve

Palpation: tenderness and hypertonicity in forearm flexors and pronator teres; symptoms aggravated when palpating pronator teres

Range of Motion and Resistance Testing:

AROM: rarely causes discomfort unless condition is advanced; slight discomfort at end of supination if wrist hyperextended and elbow extended (stretching of pronator teres and median nerve)
PROM: supination produces pain if wrist hyperextended and elbow extended (stretching of pronator teres and median nerve)
MRT: pain with forearm pronation and possibly with elbow flexion; weakness in flexors of hand/fingers due to impaired motor function of median nerve

Special Tests:

Pronator Teres Test: standing with elbow flexed to 90°; therapist places one hand on patient’s elbow for stability and other hand grasps patient’s hand in a handshake; patient holds position as therapist attempts to supinate patient’s forearm (forcing pronator teres contraction); therapist also extends patient’s elbow; if pain reproduced, good chance median nerve compression by pronator teres (elbow should stay relaxed); pronator teres engaged in isometric contraction which increases compression of median nerve; muscle is then forcefully lengthened into extension producing greater potential nerve compression

Pinch Grip Test: patient firmly pinches tips of thumb and index finger together; if patient is unable to do this without hyperextending DIP joint of index finger, anterior interosseous nerve compressed near elbow; innervates flexor digitorum profundus that flexes DIP of index finger; weakness causes patient to be unable to prevent DIP hyperextension

Differential Evaluation: carpal tunnel syndrome, other median nerve entrapment sites, cervical radiculopathy, thoracic outlet syndrome, tumors or space-occupying lesions of anterior elbow, medial epicondylitis, medial apophysitis, myofascial trigger point referrals, diabetic neuropathy

Suggestions for Treatment: reduce compression of median nerve; massage directly to pronator teres; static compressions to treat trigger points, deep stripping and pin-and-stretch, stretching to decrease nerve compression

Question 18

Radial Tunnel Syndrome = Supinator + Radial Nerve (Posterior interosseus Nerve)

Common injury conditions

Answer 18

-aka resistant tennis elbow because it causes pain in the same region as tennis elbow but does not improve with standard epicondylitis treatment

Characteristics: compression of a branch (posterior interosseous nerve) of the radial nerve that travels through several fibro-osseous tunnels in the elbow region; symptoms are weakness or atrophy; pain or paresthesia in forearm

-caused by anatomical relationship between posterior interosseous nerve (PIN) and supinator
-supinator is composed of a superficial head which is more proximal, arises from the lateral epicondyle of the humerus, radial collateral and annular ligaments; deep head originates on the supinator crest and the fossa of the ulna
-the PIN runs between the divisions of the supinator (arcade of Frohse)
compression of the PIN
-in some cases, fibrous bands or hypertonicity from trigger point pain in the supinator produce
-can also be compressed by cysts or other soft-tissue masses
-pain felt near lateral epicondyle of humerus, can radiate into anterior and lateral forearm

History: pain, paresthesia or numbness near lateral epicondyle of humerus, aching, extends distally into anterior/lateral forearm; may radiate proximally; ask about activities of prolonged isometric contractions of forearm muscles (n: supinator); may report weakness when gripping/holding objects

Observation: no visual characteristics; motor impairment during some movements or positions; may be able to extend wrist but difficult or impossible to fully hyperextend fingers at MCP or finger joints because of weakness

Palpation: pressure directly on supinator distal to lateral epicondyle of humerus reproduces pain; can differentiate between lateral epicondylitis due to location

Range of Motion and Resistance Testing:

AROM: unlikely to be painful; pain may occur at end of full pronation when supinator is pulled taut against underlying nerve (n: stretch)

PROM: as with AROM

MRT: supination may aggravate symptoms and increase pain; preformed with elbow extended to decrease contribution from biceps brachii; weakness possible in al muscles innervated by the PIN

Special Test:

Upper Limb Neurodynamic Test #3: no specific for radial tunnel syndrome; helpful to identify various compression or tension pathologies that affect radial nerve

Differential Evaluation: lateral epicondylitis, tumors or synovial masses in elbow, ligament sprains in elbow, cervical radiculopathy, thoracic outlet syndrome, myofascial trigger point referrals, other proximal radial nerve lesions, diabetic or other systemic neuropathies

Suggestions for Treatment: massage and soft-tissue therapy; address radial nerve entrapment in wrist and finger extensors in forearm and supinator; deep longitudinal stripping to free restrictions in distal region of radial nerve; deep broadening techniques for wrist extensors; pin-and-stretch to supinator to reduce nerve compression near the PIN and arcade of Frohse

Question 19

Carpal Tunnel Syndrome

Common injury conditions

Answer 19

Characteristics: carpal tunnel located at the base of the hand with the dorsal aspect created by the carpal bones and the palmar border of the transverse carpal ligament; transverse carpal ligament attaches to the pisiform and hamate on the medial side and spans the tunnel to connect to the trapezium and scaphoid on the lateral side; tunnel contains the median nerve, tendons from flexor digitorum superficialis, flexor digitorum profundus and flexor pollicis longus; tendons are enclosed in a common synovial sheath

-CTS involves compression of the median nerve under the transverse carpal ligament (aka flexor retinaculum)
-develops when the space decrease within the tunnel and the nerve is compressed
-tenosynovitis of the flexor tendons is a common cause; inflammatory reaction between tendon and its sheath occur from overuse and compress the nerve further; fibrosis and tendon thickening eventually occur if compression not relieved; fibrous proliferation may also tether the median nerve to adjacent structures
-occupational causes due to repetitive flexion and extension of wrist; women affected more
-can result from acute injury; crushing trauma to median nerve (Volkmann’s contracture: CTS results from acute injury that causes edema and increased pressure with forearm compartments)

-structural changes can cause CTS: due to fluid retention during pregnancy, osteophytes, structural anomalies, tumors in the wrist or obesity
-other causes are systemic conditions (gout, nerve ischemia, diabetes, alcoholism, rheumatoid arthritis, vitamin B6 deficiency and kidney failure)
-pressure causes varying stages of demyelination of the median nerve (Neurapraxia, axonotmesis, neurotmesis)
-sensory symptoms felt in the hand along cutaneous median nerve innervation

History: ask about repetitive wrist or hand activities; paresthesia, numbness or pain in median nerve distribution of hand and fingers; symptoms can appear suddenly or gradually, more often sensory than motor; decrease in tactile sensitivity in fingertips, clumsiness, loss of dexterity, weakened grip strength; if chronic symptoms appear gradually; ask about recent injuries to wrist or systemic disorders; night symptoms with flexed wrist

Observation: thenar muscles may be atrophied; square shaped wrist more prone to CTS

Palpation: tenderness and reproduction of sensory symptoms likely when area over carpal tunnel palpated; hypertonicity in wrist and finger flexors; myofascial trigger points may contribute to tightness; fluid retention at wrist; atrophy of thenar muscles

Range of Motion and Resistance Testing:

AROM: reproduce symptoms near end range of wrist flexion or extension, may reduce available range; flexion reduces space at wrist, extension stretches median nerve
PROM: as with AROM
MRT: pain or weakness with wrist flexion, finger flexion or thumb abduction; pain reduced or neutral if wrist held in neutral during test

Special Tests:

Phalen’s Test: patient presses back of hands together so wrists are flexed to 90°; if sensory symptoms of pain, paresthesia or numbness in the median nerve distribution reproduced within 60 seconds, test is positive; can be performed passively; full flexion decreases space within carpal tunnel and compresses median nerve
Variation: reverse Phalen’s: wrists placed in full hyperextension and held for 60 seconds (adjunct to no replacement)

Tinel’s Sign: therapist lightly taps on carpal tunnel; neurological symptoms indicate CTS; places sudden compressive force on median nerve

Tethered Median Nerve Stress Test: active or passive: wrist held in extension while index finger is pulled into hyperextension; held for 60 seconds; space in carpal tunnel decreased with wrist extension; hyperextension of index finger pulls median nerve taut

Differential Evaluation: cervical radiculopathy, thoracic outlet syndrome, myofascial trigger point referrals, pronator teres syndrome, medial epicondylitis, other proximal median nerve lesions, rheumatoid arthritis, Guyon’s tunnel syndrome, diabetic neuropathy, Volkmann’s contracture

Suggestions for Treatment: conservative approaches, splints stretching, anti-inflammatories; massage to reduce hypertonicity in wrist and finger flexors; deep longitudinal stripping and active engagement to wrist and finger flexors in forearm; mofascial methods to stretch fascial tissues lying over carpal tunnel

Question 20

Ganglion Cyst

Common injury conditions

Answer 20

-most common tumors of the hand and wrist

Characteristics: a fibrous swelling that occurs near joints; located near and often attached to the joint capsule or tendon sheaths; can be growths on the tendon retinacula, knots of dysfunctional tissue or herniations of the synovial sheath of an associated joint; cysts contain a clear mucinous fluid different from synovial fluid; may result from mucoid degeneration of collagen and connective tissue, ligament stress, subluxation of local joints or other lesions

-most are dorsal wrist ganglions and develop as a herniation or extension of the joint capsule or tendon sheath; often connected to the scapholunate ligament with a fibrous stalk; some are volar wrist ganglions while others develop in other regions of the body
-occur more in women
-majority are benign cystic tumors; often not painful; can cause pain due to location and can interfere with hand activities because of pain
-can be sole cause or contributing factors for nerve compression
-can cause nerve compression of ulnar nerve in Guyon’s canal or median nerve in carpal tunnel

History: weakness, paresthesia, dull, aching pain in region of cyst; pain when cyst is struck or compressed; pain with flexion/extension as cyst is pulled or compressed, not felt when wrist in neutral; intermittent and directly related to motions of wrist; cyst changes in size or appearance; ask about trauma

Observation: bump that appears near the wrist; few centimetres wide; may not be visible (occult ganglions)

Palpation: tender, out of proportion to amount of pressure used; may feel soft or firmer if advanced

Range of Motion and Resistance Testing:

AROM: may cause pain, worse when further compress cyst
PROM: as with AROM

MRT: does not aggravate cyst unless compressed or pulled; ex. dorsal ganglion painful during resisted extension if fully hyperextended; no pain with flexion

Differential Evaluation: distal nerve compression pathologies, tenosynovitis, tendinosis, localized infection, carpal fracture if acute, carpal ligament sprain

Suggestions for Treatment: massage may temporarily relieve overall achy pain; may be aspirated to remove excess fluid, surgically removed, may recur

Question 21

Guyon’s Canal Syndrome

Common injury conditions

Answer 21

-develops when the ulnar nerve is compressed in Guyon’s canal (tunnel) on the medial side of the wrist (aka ulnar tunnel syndrome)

Characteristics: flexor retinaculum (transverse carpal ligament) splits into two bands near middle of wrist; on the ulnar side it attaches to the pisiform and hamate; on the radial side it attaches to the scaphoid and trapezium; the space between the two is called Guyon’s canal
-ulnar nerve and artery pass through
-results from external pressure on palm; internal compression can also derive from ganglion cysts
-three variations:
Type 1 compression: proximal to Guyon’s canal, involves both superficial and deep branches of ulnar nerve (mixed sensory and motor symptoms): weakness and atrophy in hypothenar muscles and adductor pollicis; paresthesia and numbness in ulnar nerve distribution
Type 2 compression: most common: involves the deep branch of the ulnar nerve (motor symptoms); atrophy and weakness
Type 3 compression: involves the superficial branch of the ulnar nerve (sensory symptoms); compressed by palmaris brevis
-occupational disorders are primary cause (tight grip)
-may occur due to acute injury; fall on outstretched hand; carpal fractures or dislocations

History: pain and paresthesia in ulnar nerve distribution of the hand; may be felt proximally in forearm (not common); pain worsens with certain motions, exacerbated with additional pressure on base of hand; weakness in grip strength; ask about sudden force to base of hand, space-occupying lesion or cyst that may compress ulnar artery or vein would lead to cold intolerance, swelling, fullness, puffiness or coldness in hand and fingers

Observation: atrophy of hypothenar eminence and adductor pollicis; may see cyst or other mass on volar aspect of medial wrist near base of hand

Palpation: can be painful over canal, reproduce symptoms; pressure on ulnar nerve (proximal and distal) can increase symptoms

Range of Motion and Resistance Testing:

AROM: wrist extension painful or reproduce neurological symptoms at end range as ulnar nerve stretched through tunnel; also at end of wrist flexion as ulnar nerve compressed
PROM: as with AROM
MRT: pain unlikely to increase; weakness in adductor pollicis

Special Tests:
Froment’s Sign: patient holds piece of paper between thumb and base of index finger (as if holding a key); therapist tries to pull paper out; positive test if can easily pull paper away; adductor pollicis may be weak

Upper Limb Neurodynamic Test #4: see General Neuromuscular Pathologies
Differential Evaluation: carpal tunnel syndrome, cubital tunnel syndrome, synovial ganglion cysts, carpal ligament damage, other regions of ulnar nerve pathology, thoracic outlet syndrome, cervical radiculopathy, myofascial trigger point pain referrals, diabetic neuropathy
Suggestions for Treatment: remove external compression; wrist splints; surgery; massage gives some symptomatic relief if neural tension in other regions of ulnar nerve

Question 22

De Quervain’s Tenosynovitis

Common injury conditions

Answer 22

Causes: slide

Characteristics: abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons are surrounded by a synovial sheath as they course under the extensor retinaculum on the radial side of the wrist (called the anatomical snuff box)
-repetitive or overuse activities involving the thumb can lead to tendon irritation and the subsequent inflammation can cause thickening and adhesions between the tendons and their synovial sheath
-may result from anatomical anomalies (septum or fascial wall between APL and EPB tendons)
-occurs in occupations where the hands are used extensively
-if local inflammation presses on radial nerve, may cause paresthesia along thumb dorsum of hand or index finger

History: localized pain in distal radial forearm near wrist, may refer to nearby areas; pain during activities where thing is pinched between thumb and fingers (tendons stabilize base of thumb); may cause reflex muscular inhibition and muscle weakness in thumb or hand; gradual onset of symptoms

Observation: no significant visible factors

Palpation: tenderness in anatomical snuff box; proximal and distal may also be tender; pain may be present at proximal attachments of APL and EPB on radius due to enthesopathy; palpable edema is possible around retinaculum near styloid process of radius; fibrous thickening of tendons possible

Range of Motion and Resistance Testing:

AROM: painful at end of thumb extension as tendons pulled against retinaculum; pain/discomfort may occur at end of ulnar deviation of wrist or flexion of thumb as tendons stretched
PROM: as with AROM

MRT: pain and/or weakness due to reflex muscular inhibition apparent in thumb gripping and extension or abduction of thumb

Special Tests:
Finkelstein Test: patient pulls thumb into full flexion across anterior face of palm; fingers wrap over thumb to hold in position; either actively/passively move wrist into unar deviation; positive or likely if pain reproduced near styloid process of radius at end ROM; bringing thumb across anterior surface of palm stretches affected tendon; ulnar deviation extends the stretch

Differential Evaluation: carpal tunnel syndrome, rheumatoid arthritis, distal radial nerve entrapments, myofascial trigger point referrals, tendinitis, osteoarthritis, enthesitis of affected tendons (n: pulling of the tendon at the attachment), carpal bone or ligamentous injury, distal radial styloid injury

Suggestions for Treatment: deep friction massage to address fibrous adhesions between tendon and sheath (transverse to fibre direction); reduce tension in affected muscles APL and EPB with deep longitudinal stripping and active engagement (n: tap the tendons, mm w activities, stretch: start only wrist Finkelstein)

Self care: slide

Question 23

Trigger finger

Common injury conditions

Answer 23

-develops when tendon thickening prevents free movement of the tendon within its synovial sheath

Characteristics: tendons of flexor digitorum superficialis and flexor digitorum profundus are surrounded by synovial sheaths to enhance mechanical function during finger flexion; there are thickened sections call pulleys, close to the joints; the pulley closest to the MCP joint is the Al pulley (frequent location for a fibrous nodule binding on the tendon)
-during flexion and extension, the tendon slides back and forth under the pulley
-trigger finger develops when a fibrous nodule or thickening develops on the surface of the tendon and prevents smooth gliding
-as finger extended, nodule gets caught proximal to pulley preventing finger from completing motion until it snaps under the pulley (like a trigger); may occur with flexion also
-may be due to systemic diseases; diabetes, hypothyroidism, gout, rheumatoid arthritis
-affects women more (45-60 years old)
-no association with repetitive activity or overuse

History: locking or catching sensation in finger during flexion/extension; may be painful, if pain, felt in palm or affected digit; usually only in one finger but can occur in more; gradual onset

Observation: nodule may be visible; finger may be held in flexion

Palpation: nodule palpable, tender to touch, crepitus during flexion and extension may be felt; may be fibrous feeling to fascia on palm or fingers

Range of Motion and Resistance Testing:

AROM: painful and limited in finger flexion/ extension; catching or snapping
PROM: as with AROM; if severe may be greater PROM than AROM

MRT: flexion or extension may be painful if nodule pulled against edge of pulley during contraction; weakness may occur as pain causes reflex muscular inhibition (n: Uc Chế phan xa)

Differential Evaluation: carpal tunnel syndrome, other median nerve entrapments, gout, rheumatoid arthritis, Dupuytren’s contracture, diabetes mellitus, ganglion cysts

Suggestions for Treatment: corticosteroid injections and anti-inflammatories even though not inflammatory; physical therapy to encourage movement; surgical release; get physician consent

Question 24

Lateral epicondylitis ( tennis elbow)

Common injury conditions

Answer 24

Characteristics: chronic collagen degeneration in the extensor tendons and enthesopathy (irritation of the attachment site) at the lateral epicondyle of the humerus
-repeated tensile stress on tendons leads to collagen degeneration and enthesopathy
-extensor carpi radialis brevis (ECRB) is most affected; all other wrist extensor muscles may be involved
-pain aggravated by actions that engage extensor muscles in a contraction (concentric, isometric or eccentric)
-wrist flexion produce pain due to extensor tendons being stretched
-in acute cases, pain results from fibre tearing in tendon or periosteal tears at ECRB tendon attachment
-sports, occupations or hobbies that require repetitive grasping; also repetitive supination or pronation (wheel chair athletes, tennis)
-uni or bilateral
-other conditions can co-exist: myofascial trigger points can cause extensor muscles to be hypertonic, create an excess tensile load on tendons

History: pain in lateral elbow region, radiates into forearm; aching or sharp pain; ask about gradual or sudden; ask about activities requiring repetitive gripping or static contractions of forearms or wrist; may have difficulty grasping or lifting a smaller item

Observation: not inflammatory; unless periosteal tear or enthesitis (but not visible)
Palpation: tenderness and pain at extensor tendon attachment at lateral epicondyle; wrist extensors feel hypertonic; pain increased if wrist put in flexion and muscles/tendons palpated; fibrotic or ropy feel; may be referrals from trigger points near elbow or forearm when forearm muscles palpated; entrapped posterior interosseous nerve could produce pain down forearm

Range of Motion and Resistance Testing:

AROM: pain may or may not be present with wrist extension; pain at end range of flexion as extensors stretched
PROM: pain at end range of flexion as tendons stretched
MRT: pain with wrist extension; weakness due to reflex muscular inhibition; weakness can also be from compression of posterior interosseous nerve compression

Special test:

Tennis Elbow Test: standing or seated; therapist wraps one hand around patient’s elbow so thumb is pressing on extensor tendons distal to lateral epicondyle of humerus; therapist’s other hand grasps patient’s hand and uses it to resist patient’s wrist extension; offer resistance only, do not push; contracting wrist extensors causes pain as affected tendons pulled near attachment site; pressing on tendons while in contraction, stress to damaged tissues is exaggerated

Differential Evaluation: radial tunnel syndrome, myofascial trigger point activity, ligament damage near elbow, radial neuropathy, cervical radiculopathy, joint pathology of elbow, medial epicondylitis

Suggestions for Treatment: treated conservatively; ultrasound, stretching, ROM exercises and electrical stimulation; anti-inflammation medications during early stages; deep friction applied directly to affected tendons to stimulate collagen production in damaged fibres; deep longitudinal stripping, myofascial approaches and active engagement beneficial to restore optimum function

Question 25

Medial Epicondylitis: (Golfer’s elbow)

Common injury conditions

Answer 25

Characteristics: affect wrist flexors where they attach to the medial epicondyle of the humerus; not inflammatory; excessive tensile stress on the flexor tendons causes chronic collagen degeneration (tendinosis and enthesopathy at the attachment site
-repetitive or prolonged contractions of the wrist flexors and pronators (golf, overhead tennis serve)
-often due to manipulation of tools and equipment with the hands or throwing actions
-may derive from repetitive supination and pronation of forearm (stresses pronator teres); proximity of its attachment at medial epicondyle cause it to be involved
-concentric, isometric or eccentric contractions aggravate pain
-pain may also occur in motions requiring wrist extensions where flexor tendons are stretched
-pain during activity, subsides after activity ceased
-poor conditioning is another cause
-may result from injury leading to chronic tendon irritation; may be some initial inflammation with minor tendon fibre tearing
-other conditions seen along with ME are carpal tunnel syndrome, ulnar nerve pathology (passes through hiatus in the Flexor carpi ulnaris)

History: pain on medial side of elbow, radiates into forearm, general aching or sharp pain; gradual onset; ask about activities of repetitive gripping or static contractions of forearm and wrist; identify ergonomic factors that overuse flexors; ask about sudden changes in activity level (poor conditioning); may be pain with shaking hands; ask about symptoms related to nerve pathologies (cubital or carpal tunnel syndromes or pronator teres syndrome)

Observation: not inflammatory; unless periosteal tear or enthesitis (but not visible); may see cubital valgus but structural, not necessarily a symptom

Palpation: tenderness and pain at flexor tendon attachment at medial epicondyle; wrist flexors feel hypertonic; pain increased if wrist put in extension and muscles/tendons palpated; fibrotic or ropy feel; may be referrals from trigger points near elbow or forearm when forearm muscles palpated

Range of Motion and Resistance Testing:

AROM: pain possible with wrist flexion if severe; as condition worsens, less force required to cause pain; pain at end ROM with extension as tendons stretched; pain may also occur at end range of supination as pronator teres stretched

PROM: pain at end range with wrist hyperextension as tendons stretched and end range of supination if pronator teres involved
MRT: pain with wrist flexion; pain with pronation if pronator teres involved; weakness possible due to reflex muscular inhibition; weak grip possible

Special Tests:

Golfer’s Elbow Test: standing/seated; therapist grasps patient’s elbow so thumb presses on flexor tendons distal to attachments at medial epicondyle; therapist’s other hand offer resistance to patient’s wrist flexion; offer resistance only, do not push; engaging wrist flexors causes pain at medial epicondyle as tensile force added; pressing on tendons while in contraction, stress to damaged tissues is exaggerated

Differential Evaluation: arthritis, pronator teres strain, cubital tunnel syndrome, cervical radiculopathy, pronator teres syndrome, median nerve compression near elbow, thoracic outlet syndrome, ulnar collateral ligament injury; osteochondritis dissecans, epicondylar apophysitis, stress fractures, ulnar nerve pathology, flexor muscle strain

Suggestions for Treatment: treated conservatively; ultrasound, stretching, ROM exercises and electrical stimulation; anti-inflammation medications during early stages; deep friction applied directly to affected tendons to stimulate collagen production in damaged fibres; deep longitudinal stripping, myofascial approaches and active engagement beneficial to restore optimum function

Symptom Picture: Acute

There is a gradual onset, with tenderness, local to the tendon, one or two days after activity.
Initially, pain diminishes with renewed activity. This progresses to pain during activity as the severity increases. Micro tearing occurs with adhesion formation as the tendon attempts to heal.
Repetitive use tears these new adhesions causing more inflammation and a cycle of re-injury.
Inflammation, heat and swelling develop along the tendon or tendon sheath.
Crepitus may develop with tenosynovitis and para tendinitis
There is decreased range of motion of the affected muscle(s).

Symptom Picture: Chronic
Pain occurs during and after activity.
Chronic inflammation, fibrosis and adhesions are present
Chronic swelling or thickening may be observed if the tendon is superficial enough Crepitus may be present
There is decreased range of motion and decreased strength Flareup to the acute stage may occur with repeated overuse
The tendon may degenerate to such a degree that tendon rupture occurs

Treatment Goals: Acute
Reduce inflammation
Reduce pain
Decrease sympathetic nervous system firing
Treat any compensating structures
Reduce edema
Reduce hypertonicity and trigger points
Maintain range of motion
Mobilize hypomobile joints

Treatment Plan: Acute
Positioning: limb is elevated and pillowed securely
Hydrotherapy: cold
Diaphragmatic breathing
Trunk and unaffected limbs treated using effleurage and petrissage
Lymphatic drainage
Unidirectional effleurage, stationary circles, local techniques proximal to tendon Address trigger points proximal to tendon; effleurage, muscle stripping Decrease hypertonicity in antagonists of affected muscles; segmental petrissage
Decrease hypertonicity in affected muscles; Golgi tendon organ release on unaffected tendon of affected muscles; vibrations on site
Pain-free PROM to proximal and affected joint to maintain ROM
Gentle joint play to hypomobile joints in affected limb

Treatment goals: Chronic
Decrease, sympathetic, nervous system firing
Treat compensatory structures
Reduce facial restrictions
Reduce any chronic oedema
Reduce hypertonicity and trigger points
Improve tissue health
Reduce adhesions
Mobilize hypomobile joints
Restore range of motion
Stretch shortened muscles

Treatment Plan: Chronic
Positioning: patient comfort
Hydrotherapy: deep moist heat to soften adhesions and increase local circulation
Diaphragmatic breathing
Fascial glide to assess and fascial techniques to treat adhesions
Reduce hypertonicity and trigger points proximally; rhythmic techniques, effleurage, repetitive petrissage, ischemic compressions
Treat antagonists; skin rolling, long effleurage, petrissage
Treat affected muscles with similar techniques; work towards lesion

Reduce adhesions in affected tendon; skin rolling, fascial spreading, muscle stripping, frictions, myofascial release with passive lengthening Frictions followed by passive stretch to re-align fibres, ice Distal limb treated with effleurage, petrissage to increase venous return Joint play on hypomobile joint in affected limb
PROM to affected joints
Passive stretch to affected muscles and antagonists

Self-care goals: Acute
Educate the patient regarding activities
Stretch shorten muscles
Strengthen weak muscles

Self-care plan: Acute
Relative rest from activity that causes pathology
Hydrotherapy: ice
Slow, pain-free stretch of affected muscles and antagonists to regain flexibility Regain full strength in affected muscles to prevent re-injury
Progressive strengthening when no pain on activity and when full, pain-free stretch is obtained (isometric)

Self-care goals: Chronic
Educate the patient regarding activities
Stretch shortened muscles
Strengthen weak muscles
Educate the patient regarding activities
Refer the patient

Self-care plan: Chronic
Hydrotherapy: contrast, ice after activity Self-massage
Stretching to maintain flexibility
Strengthening using isometric, then isotonic exercises (once full PROM is pain-free)
Eccentric, isotonic exercise is slow, gradual increase in speed Modify sport or occupational activities
Contraindications
Frictions are avoided if the patient is on anti-inflammatory medication