Evaluation - E/W/H Flashcards
Evaluation - Diagnostic Classification:
- Patho-anatomical = ?
- Movement System = ?
- Treatment Response = ?
Evaluation - E/W/H
Evaluation - Diagnostic Classification:
(a) Patho-anatomical:
- Health conditions are discussed in a manner similar to a physician visit.
(b) Movement System:
- Where impairments or syndromes are listed that impact the musculoskeletal, nervous, integumentary, cardiovascular, pulmonary, or endocrine systems.
(c) Treatment Response:
- Clinical prediction rules and patterned treatments classify the patient.
(d) Notes:
- Generally, the more proximal the condition, the more apt our profession is to discuss that malady in terms of movement system and treatment-based classifications.
- The more distal we get, the more we still use pathoanatomical terms and clinical prediction rules for screening.
Evaluation: Personnel
- Who’s envolved = ?
Evaluation - E/W/H
Evaluation: Personnel
(a) Who’s envolved… ?
The Patient’s Story:
- Five components to consider = ?
Evaluation - E/W/H
The Patient’s Story - Five components:
(1) Positives:
- Young Age
- Healthy Lifestyle
- No Red Flags
- Decrease Comorbidities
- Decrease Severity
- Decrease Irritability
(2) Impairments:
- Strength
- Mobility
- Coordination
- Muscle Tightness
- Pain Guarding
(3) Chief Complaint:
- Patient’s description of what brought them for therapy.
(4) Treatment:
- Two or three general types of treatment to address your selected impairments.
(5) Participation:
- Patient’s Goal for Therapy
Epicondylopathy
- Inner tendon’s three phases = ?
- The outer remains = ?
- What is usually effected more, extensors or flexors = ?
Evaluation - E/W/H
Epicondylopathy:
(a) Inner tendon’s three phases:
(1) Reactive
- 20’s
- Inflammatory
- Increase in proteoglycans
(2) Disrepair
- 30’s
- Separation & type-III collagen
- Neural ingrowth
(3) Degenerative
- 40’s+
- Breakdown
- Cell death
(b) Outer Remains Metabolically Active:
- Focus on the Donut, Not the hole!
- Increase tendon thickness on the outside
- Improve capacity to manage load
(c) Commonly:
- Extensors > Flexors
- Extensor Carpi Radialis Brevis
Epicondylopathy:
- Classifications = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Epicondylopathy:
(a) Classifications:
- Epicondylitis
- Epicondylosis
- Epicondylalgia
- Tennis Elbow (Most Common)
- Golfer’s Elbow
(b) Characteristics:
- Pain Pattern
- Localized, Distal Epicondyle
- Risk Factors
- 35-50 Years Old
- Repetitive Movements
- Women > Men
- Observation
- Avoidance of grasping or active wrist flex/ext
- Examination
- Pain: Palpation / contraction
- (+) Cozen, Maudsleys, Mills, or Medial Epicondylitis test
- (-) C Spine, nerve entrapment, & chair push-up test
- Decrease grip strength
- Patient-rated tennis elbow evaluation
(c) Manual Therapy:
- Patient Education:
- Activity reduction
- Ice ( if inflammatory )
- Orthotics
- Wrist extension
- Counterforce
- Joint Mobilization:
- Humeroradial Joint
- PRUJ
- DRUJ
- STM/MFR:
- Cross-friction Massage
- 1 Direction
- 2 min light, 2 min heavy
- Extensor Muscles
- Instrument Assisted
(d) Therapeutic Exercise:
- Motor
- Scapular Strengthening
- Hand Intrinsic Strengthening
- Tendon:
- Pain should not exceed 5/10
- Isometrics
- If pain reducing, 4-5 sets of 45 sec hold
- Eccentric Training
- 2 sets of 15, with 2RiR
- 48 Hour Rest
- Energy Storage
- Rapid Eccentrics
- Energy Release
- Rapid Concentrics
- Neurodynamics:
- Radial Nerve Glides
Distal Biceps Tear:
- Mechanism of Injury = ?
- Often Preceded by = ?
Evaluation - E/W/H
Distal Biceps Tear:
(a) Mechanism of Injury
- Rapid High Force
- Eccentric Loading
- Flexed and Supinated Forearm
(b) Often Preceded by:
- Prior Degeneration
- Repetitive Pronation
Distal Biceps Tear:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Distal Biceps Tear:
(a) Classification:
- Distal biceps tear
(b) Characteristics:
- Pain Pattern
- Localized, Non-Radicular Pain over the Biceps
- Risk Factors
- > 45 Years Old
- Repetitive Pronation
- Smoking
- Heavy Eccentric Loading
- Observation
- Displaced Biceps mmBelly
- Swelling
- Ecchymosis
- Examination
- Pain: Resisted elbow flexion
- Decrease flexion/supination strength
- (+) Biceps Squeeze Test
(c) Manual Therapy
- Patient Education
- Adherence to Protocol
- Importance of Protected Phase
- Joint Mobilization
- Humeroulnar Joint
- Humeroradial Joint
- PRUJ
(d) Therapeutic Exercise:
- Protected Phase
- Orthotic Bracing
- Spot-Treat Movement System
- Progressive Motion Phase
- ROM Exercise
- Stretching
- Strengthening Phase
- Isometric
- Isotonic
- Sport/Work-Specific
Ulnar Collateral Ligament - Injury of the Elbow:
- Common mechanisms of injury = ?
- Three bundles = ?
- Muscularly stabilized by = ?
Evaluation - E/W/H
Ulnar Collateral Ligament - Injury of the Elbow:
(a) Mechanism of Injury:
- Repetitive Trauma
- Overhead Athletes
(b) Three Bundles:
(i) Anterior Bundle:
- Anterior (0-60) and Posterior Band (60-120)
(ii) Posterior Bundle:
(iii) Transverse/Oblique Bundle:
(c) Muscularly Stabilized:
- UCL Fails at 260N
- Throwing Generates 290N
- Flexor Carpi Ulnaris
- Flexor Digitorum Superficialis
Ulnar Collateral Ligament Injury of the Elbow:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Ulnar Collateral Ligament Injury of the Elbow:
(a) Classifications:
- UCL Reconstruction
- Tommy John Surgery
(b) Characteristics:
- Pain Pattern
- Localized, distal epicondyle
- Risk Factors
- Repetitive movements
- Observation
- Decrease throwing velocity
- Examination
- Pain: Palpation
- (+) Moving Valgus Stress Test
- (-) Medial Epicondylitis Testing,
(c) Manual Therapy:
- Patient Education
- Activity Reduction
- Joint Mobilization
- Humeroulnar Joint
- Humeroradial Joint
- PRUJ
- DRUJ
- Shoulder External Rotation
- Scapula
- Thoracic Spine
- STM/MFR
- Cross-friction Massage
- 1 Direction
(d) Therapeutic Exercise:
- Motor
- Ant Core/Subscap/Grip Strength
- Flexor/Pronator Strength
- Surgical Protocol:
(i) Immediate Motion
- Pain Control
- PROM/AAROM/AROM
(ii) Intermediate
- Resistance Training = Strength/Control
- Mobilization
(iii) Advanced Strengthening
- Progress Resistance
- Power/Endurance
- Plyometrics
(iv) Progressive Return to Activity
- Neurodynamics:
- Ulnar Nerve Glides
Lateral Collateral Ligament Injury:
- Mechanisms of injury = ?
- The radius and ulna act as a unit, which results in = ?
- Frequency = ?
Evaluation - E/W/H
Lateral Collateral Ligament Injury:
(a) Mechanism of Injury
- Hyperextension force in olecranon fossa
- Levers trochlea past coronoid process
(b) Typically, Annular Ligament Remains Intact
- Radius and Ulna Act as a Unit
- Results in Posterolateral Instability
(c) Frequency
- Most Common Dislocation in < 10 yo
- 2nd Most Common > 10, After Shoulder
(d) Different From Nursemaid’s Elbow
Lateral Collateral Ligament Injury:
- Classifications = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Lateral Collateral Ligament Injury:
(a) Classifications:
- Posterolateral Rotary Instability
- Radial Head Subluxation
(b) Characteristics:
- Pain Pattern
- Localized, Distal Epicondyle
- Reports: Elbow “Giving way”
- Risk Factors
- Hx: Radial Dislocation
- Hx: Lateral Epicondylitis
- Observation
- Apprehension of Supination + Loading
- Examination
- Pain: Palpation
- Decrease in extension ROM
- (+) Chair Push-up Test
- (-) Lateral Epicondylitis Testing
(c) Manual Therapy:
- Patient Education
- Activity Avoidance
- Bracing
- Joint Mobilization
- Humeroradial Joint
- PRUJ
- DRUJ
- Shoulder Internal Rotation
(d) Therapeutic Exercise:
- Motor
- Grip/Extensor Strength
- Surgical Protocol:
(i) Immediate Motion
- Pain Control
- PROM/AAROM/AROM
(ii) Intermediate
- Resistance Training = Strength/Control
- Mobilization
(iii) Advanced Strengthening
- Progress Resistance
- Power/Endurance
- Plyometrics
(iv) Progressive Return to Activity
- Neurodynamics
- Radial Nerve Glides
Annular Ligament Injury:
- Mechanisms of injury = ?
- Radial head / annular ligament configuration is more susceptible, when = ?
Evaluation - E/W/H
Annular Ligament Injury:
(a) Mechanism of Injury:
- Longitudinal Pull on the Radius
- Full Extension and Supination
(b) Radial Head/Annular Ligament Configuration
- Children Not as Congruent and Stable as Adults
- Looser and Even More Susceptible After Injury
Annular Ligament Injury:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Annular Ligament Injury:
(a) Classifications:
- Annular Ligament Tear
- Nursemaid’s Elbow
(b) Characteristics:
- Pain Pattern
- Localized, Distal Epicondyle
- Risk Factors
- Age 2-4
- Observation
- None
- Examination
- Pain: Palpation/ROM
- Decrease in ROM
- (+) Chair Push-up Test
- (-) Lateral Epicondylitis Testing
(c) Manual Therapy:
- Patient Education
- Referral For Imaging and Potential Relocation
(d) Therapeutic Exercise:
- Motor
- Grip Strength
- Wrist Extension Strength
Elbow Arthropathy:
Evaluation - E/W/H
Elbow Arthropathy:
(a) Osteoarthritis:
- Secondary to Prior Trauma
- Chondral Degenerative Process
- Not as Common as other Large Joints
(b) Panner’s Disease:
- Disruption of Blood Supply to the Capitulum
- Repetitive Valgus Stress or Trauma (6-11)
- No Chondral Flaking
- Good Prognosis
(c) Osteochondritis Dissecans:
- Genetic Predisposition to Poor Subchondral Health / Blood Supply
- Repetitive Valgus Stress or Trauma (10-20+)
- Chondral Flaking
- Guarded Prognosis
Elbow Arthropathy:
- Classifications = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Elbow Arthropathy:
(a) Classifications:
- Osteoarthritis (OA)
- Osteochondrosis
- Panner’s Disease
- Osteochondritis Dissecans (OCD)
(b) Characteristics:
- Pain Pattern
- Deep in Elbow Joint
- Risk Factors
- Age > 55 (OA)
- Girls > Boys (OA)
- Age 6-11 (Panner’s)
- Boys > Girls (Panner’s/OCD)
- Girls > Boys (OA)
- Hx: Joint Trauma
- Hx: Heavy Joint Loading
- Observation
- Swelling
- Nodules (Osteoarthritis)
- Examination
- Pain: ROM
- Decrease in ROM
- Joint Crepitus (OA)
- Loose Bodies (OCD)
(c) Manual Therapy:
- Patient Education
- Joint Protection Principles
- Rest/Immobilization (Panners)
- Anti-inflammatory Diet (OA)
- Ice – Acute | Heat Recurrent
- Referral for Medical Management
- Joint Mobilization
- Humeroulnar Joint I-II
- Humeroradial Joint I-II
- PRUJ I-II
- DRUJ I-II
(d) Therapeutic Exercise:
- Motor
- Daily AROM
- Pain-free Grip and Elbow Strengthening
- Modalities
- Ultrasound = (1 MHz; 1W/cm2 for 5 min)
Cubital Tunnel Syndrome:
Evaluation - E/W/H
Cubital Tunnel Syndrome:
(a) Nerve Compression Injury
(i) Medial Intermuscular Septum
(ii) Cubital Tunnel
- Medial Epicondyle of the Humerus
- Olecranon of the Ulna
- Cubital Retinaculum & Flexor Carpi Ulnaris
(b) In Flexion, Olecranon Moves 1.5cm Away:
(i) ‘Roof Collapses’ as Space Becomes Narrow Oval
(ii) Pressure Goes Up Inside Space
- x7 in Full Flexion
- x20 in Full Flexion + Active Ulnar Deviation
(c) Prolonged Exposure:
- Thickening of Epineurium and Perineurium
- Microvascular Proliferation of the Endoneurium
Cubital Tunnel Syndrome:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Cubital Tunnel Syndrome:
(a) Classification:
- Ulnar Nerve Entrapment
- “Funny Bone”
(b) Characteristics:
- Pain Pattern
- Radicular Pain and Paresthesia from Medial Elbow to Medial Hand
- Risk Factors
- Prolonged Elbow Flexion
- Work/Sleep (7-20xmmHg)
- UCL Inflammation
- Examination
- (+) Tinel’s Sign
- (+) Elbow Flexion Test
- (-) C Spine, Medial Epicondylitis Testing
- Decrease in Grip Strength
- Wartenberg Sign (↓ Intrinsic)
- Froment Sign (↓ Add Pol)
- Claw Hand
(c) Manual Therapy:
- Patient Education
- Activity Reduction
- Heat
- Night Orthotics
- STM/MFR
- Flexor Carpi Ulnaris
- Cubital Tunnel Retinaculum
(d) Therapeutic Exercise:
- Stretch
- Flexor Carpi Ulnaris
- Neurodynamics
- Ulnar Nerve Glides
Elbow Fracture:
- Mechanisms of Injury = ?
- What complications does surgery present = ?
Evaluation - E/W/H
Elbow Fracture:
(a) Mechanism of Injury:
- High-force Impact
- Fall or Car Accident
(b) Multiple Classification Schemes
- Surgery is Most Common Treatment (ORIF)
- Stiffness is Common
- Early Mobility Helps
- Varus Deformity is Expected
(c) Difficult Surgery:
- Altered Kinematics
- Decreased ROM
- Close Proximity to Neurovascular Structures
- Iatrogenic Nerve Involvement
Elbow (Humerus) Fracture:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Elbow (Humerus) Fracture:
(a) Classification
- Extra-articular (A)
- Articular with Shaft Continuity (B)
- Articular without Shaft Continuity (C)
(b) Characteristics:
- Pain Pattern
- Diffuse Pain
- Risk Factors
- Men aged 12-19
- Women > 80
- Fall History
- Observation
- Swelling
- Obvious Deformity
- Examination:
- (↓) ROM
- Significant Stiffness
- (↓) Grip Strength
- (+) Elbow Extension Test
(c) Manual Therapy:
- Patient Education
- Ice
- Orthotics
- Static Progressive
- Joint Active System (JAS)
- Joint Mobilization
- Humeroulnar Joint
- Humeroradial Joint
- PRUJ
- DRUJ
- STM/MFR
- Biceps
- Triceps
- Forearm Musculature
(d) Therapeutic Exercise
Protocol:
(I) Inflammatory Phase
- 0-2 Weeks
- Manage Pain/Inflammation
- Light ROM
(II) Fibroplastic Phase
- 3-8 Weeks
- Increase ROM
- Begin Light Strengthening
(III) Remodeling Phase
- 2-6 Months
- Progress Strength
- Mobilizations
- Static-Progressive Orthotics
- Neurodynamics:
- Nerve Glides (Check All)
Carpal Tunnel Syndrome:
Evaluation - E/W/H
Carpal Tunnel Syndrome:
(a) Most Common UE Nerve Compression
(b) Etiology
- Fractures, Carpal Arthritis, Synovitis
- Forceful Grip with Wrist Flexion (Lumbricals)
(c) Pathogenesis
(i) Extra-neural Compression - Endoneurial Swelling
- 2+ Hours Extra-neural - 24 Hours Endoneurial
(ii) Prolonged Swelling
- Endoneurial Breakdown
- Nerve Fibrosis
- Demyelination
- Wallerian Degeneration
(d) Associated with Double Crush Phenomenon
Carpal Tunnel Syndrome:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Carpal Tunnel Syndrome:
(a) Classification:
- Median Neve Entrapment
(b) Characteristics:
- Pain Pattern
- Pain/paresthesia
- Lateral Hand
- Pain Worse at Night
- Risk Factors
- Age > 45, Women > Men
- Diabetes
- Observation
- Flick Sign - Shaking (↓) Sx
- Wrist Ratio > 0.7
- Thenar Atrophy
- Examination
- (+) Phalen’s, Tinel’s, Wainer CPR, Durkan’s (Compression)
- (-) Scaphoid Fx, Finkelstein, TOS, Cervical Spine
- (↓) Grip Strength/Sensation
- (↓) Coordination (Moberg)
(c) Manual Therapy:
- Patient Education
(i) Possible Injection Consult
(ii) Possible Surgical Consult
(iii) Heat
(iv) Activity Modulation
- (↓) Full MCP Flexion and Ulnar Deviation
- Work in 0-45° Pronation
- Work in slight Ext/Ulnar Dev.
(v) Orthotics
- 2 degrees Ext/Ulnar Deviation
- Night, During Heavy Work Activities, or Pregnant (not mouse work)
- STM/MFR
- Flexor Retinaculum
- Medial Arm
(d) Therapeutic Exercise:
- Neurodynamics
- Distal Median Nerve Glides
- Flexibility
- Flexor Retinaculum Stretch
- Hand Intrinsic Stretch
- Finger Flexor Stretch
- Post-Surgical (Only a few visits over 2-3 weeks are needed)
- Activity Avoidance Education
- Light Paper Taping Over the Incision
- Light Isometrics progressing to tendon glides
- Distal Median Nerve Glides
Distal Radius Fracture:
- Mechanisms of Injury = ?
- Types of Fracture = ?
Evaluation - E/W/H
Distal Radius Fracture:
(a) Mechanism of Injury
- FOOSH
- Old Age
- Activity (Skateboarding, skiing, snowboarding…etc.,).
- Contact Sports
(b) Type of Fracture
- Extra-articular is Most Common
- Colles’ = Distal Radius Displaces Dorsally
- Likely to be oversimplified
- Multitude of potential fracture patterns and classifications
- Smith’s = Distal Radius with Volar Displacement
Distal Radius Fracture:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Distal Radius Fracture:
(a) Classification:
(I) Extra-Articular
- Colle’s Fracture (Dorsal)
- Smith’s Fracture (Volar)
(II) Intra-Articular
(b) Characteristics:
- Pain Pattern
- Diffuse Wrist Pain
- Risk Factors
- (>) 50 Years Old
- Fall Risk
- Women > Men
Observation
- Avoidance of grasping or active wrist flex/ext
- S/P Examination
- (↓) ROM
- (↓) Grip/Pinch Strength
- (↓) Push-off Test Strength
(c) Manual Therapy:
- Patient Education
- Ice/Heat
- Orthotics
- Joint Mobilization
- Humeroradial Joint
- PRUJ
- DRUJ
- Radiocarpal Joint
- MCP/IPs
- STM/MFR
- Forearm Musculature
(d) Therapeutic Exercise:
- Protocol
(I) Protective Phase
- 1-6 Weeks
- Wrist Immobilization
- Monitor Pain/CRPS
- Finger/Elbow/Shoulder ROM
(II) Motion Phase
- After Immobilization
- Wrist AROM (Priority: Wrist Ext/Sup/Pro and Finger Flexion)
- Tendon Gliding
(III) Function Phase
- Starts at Bone Healing
- Strength = Isometric - Isotonic
- Mobilization
- Neurodynamics:
- Nerve Glides (Check All)
Triangular Fibrocartilage Complex (TFCC) Injury:
- Articular Disc is Mostly = ?
- Mechanisms of Injury = ?
- Causes of degeneration = ?
- Treated with = ?
Evaluation - E/W/H
Triangular Fibrocartilage Complex (TFCC) Injury:
(a) Articular Disc is Mostly Avascular
(b) Mechanism of Injury
- Trauma
- Fall Onto an Outstretched Hand
- Forced Rotation While Gripping
(c) Degeneration
- Wear - Chondromalacia - Puncture - Arthritis
- Secondary to Ulnar Malposition
- Prior Trauma
- Positive Ulnar Variance
(d) Treated With:
- Active Stabilization
- Bracing
- Injection
Triangular Fibrocartilage Complex (TFCC) Injury:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Triangular Fibrocartilage Complex (TFCC) Injury:
(a) Classification:
- Acute
- Degenerative
(b) Characteristics:
- Pain Pattern
- Localized, Distal Ulna
- Risk Factors
- Hx: Distal Forearm Injury
- Ulnar Variance (+)or(-)
- Advancing Age
- Repetitive Movements
- Observation
- Localized Swelling
- Clicking/Crepitus
- Examination
- Pain: Palpation/ROM
- (+) Ulnomeniscotriquetral Sweep
- (↓) Grip Strength
(c) Manual Therapy:
- Patient Education
- Ice
- Orthotics - Night + Vigorous Activity
- Possible Referral if Bracing/Strength are Unsuccessful - Injection or Surgery
- Joint Mobilization
- Humeroradial Joint
- PRUJ
- DRUJ
- STM/MFR
- Cross-friction Massage - 1 Direction
- ECU + FCU
(d) Therapeutic Exercise:
- Motor
- Grip Strength
- Wrist Strength
- Sensory
- Angle Reproduction - Laser on a Bat
- Reflex Reactivation - Lighter Perturbations
- Neurodynamics
- Ulnar Nerve Glides
Stenosing Tendovaginitis:
- Mechanisms of Injury = ?
- Pathogenesis = ?
- Common Sites of Pathology = ?
Evaluation - E/W/H
Stenosing Tendovaginitis:
(a) Mechanism of Injury
- Trauma and repetitive Stress
- Possible Predisposition
(b) Pathogenesis
(i) Metaplasia of Collagen and Extracellular Matrix
- Limited to No Inflammatory Element
(ii) Thickening of the Retinaculum
- Up to 3-4x its thickness
(iii) Adhesions Form Between Tendon and Sheath
(c) Common Sites of Pathology
(i) De Quervain’s Tenosynovitis
- 1st Dorsal Compartment
- Abd. Pollicis Longus & Extensor Pollicis Brevis
(ii) Trigger Finger
- A1 Pulley
Stenosing Tendovaginitis:
- Classifications = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Stenosing Tendovaginitis:
(a) Classifications:
- Stenosing Tenosynovitis
- De Quervain’s Tenosynovitis
- Trigger Finger
(b) Characteristics:
- Pain Pattern
(i) Localized Pain
- De Quervain’s: Radial Styloid
- Trigger Finger: Pulley
- Risk Factors
- Repetitive /Forceful Jobs
- Women > Men
- Observation
- Local Nodule
- AROM: Catching/Crepitus
- Examination
- Pain: Palpation/AROM
- (+) Finkelstein’s
- (↓) Strength
- (-) Scaphoid Fracture
(c) Manual Therapy:
- Patient Education
- Activity Avoidance
- Ergonomic Modifications
- Ice
- Ultrasound
- Orthotics - Rigid
- Refer for Injection - Failing Conservative Care
- STM/MFR
(i) Cross-friction Massage
- 2-Direction
- 2 min light
(ii) Involved Musculature
(d) Therapeutic Exercise:
- Motor
- Grip Strength
- Gentile Tendon Glides
- Stretching
- Strengthen Kinematic Chain
Scaphoid Fracture:
- Mechanisms of Injury = ?
- Vascular Supply = ?
Evaluation - E/W/H
Scaphoid Fracture:
(a) Mechanisms of Injury:
- Most Common Carpal Fracture
- Vulnerable Due to 45 Angulation
- Compression in Extension & Radial Deviation - Radioscaphocapitate Ligament Fx Waist (70%)
(b) Vascular Supply:
- Most Vascularization at or Distal to Scaphoid Waist
- Proximal Pole Supplied by Retrograde Intraosseous Flow/
Scaphoid Fracture:
- Classifications = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Scaphoid Fracture:
(a) Classifications:
- N/A
(b) Characteristics:
- Pain Pattern
- Localized, Distal Radius
- Risk Factors
- 15-30 Years Old
- Men > Women
- Observation
- Focal Swelling
- Examination
- Pain: Palpation
- (+) Scaphoid Compression
- (+) Snuffbox Tenderness
- (-) Finkelstein’s Test
- (↓) Grip Strength
(c) Manual Therapy:
- Patient Education
- Screening and Referral
- Ice
- Orthotics - Thumb Spica (long/short) and Progressive Orthotics
- Joint Mobilization
- Radiocarpal Distraction
- DRUJ
- Light Carpal Mobilization
- MCP Mobilization
- IP Mobilization
(d) Therapeutic Exercise:
- Protocol: Can vary greatly depending on location of fracture and surgical intervention.
(I) Protective Phase
- 2-4 Weeks
- Wrist Immobilization
- Monitor Pain/CRPS
- Finger/Elbow/Shoulder ROM
(II) Motion Phase
- After Immobilization
- Finger/Wrist AROM
- Stretching/Tendon Gliding
(III) Function Phase
- Starts at Bone Healing
- Strength (Isometric - Isotonic)
- Mobilization
- Neurodynamics:
- Median Nerve Glides
Ulnar Collateral Ligament Tear of the 1st:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Ulnar Collateral Ligament Tear of the 1st:
(a) Classification:
- Skier’s Thumb - Trauma
- Gamekeeper’s Thumb - Repetitive Stress
(b) Characteristics:
- Pain Pattern
- Localized, Medial 1st MCP
- Risk Factors
- Fall Risk
- Observation
- Focal Swelling
- Examination
- Pain: Palpation
- (+) Ulnar Collateral Ligament Test
(c) Manual Therapy:
- Patient Education
- Screening and Referral
- Ice
- Orthotics - Thumb Spica (short)
- Joint Mobilization
- DRUJ
- Carpal Mobilization
- CMC Mobilization
- IP Mobilization
(d) Therapeutic Exercise:
- Motor
- 2-8 Weeks after Immobilization
- Pinch and Grip Strength
- Wrist Strength
- Stretching
- Neurodynamics
- Median Nerve Glides
Metacarpal Fractures:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Metacarpal Fractures:
(a) Classification:
- Boxer’s Fracture
(b) Characteristics:
- Pain Pattern
- Localized, Metacarpal
- Risk Factors
- Age 22-34
- High Force Loading
- Men > Women
- Observation
- Focal Swelling
- Ecchymosis
- Guarded Movement
- Examination
- Pain: Palpation/ROM
- (↓) Strength
(c) Manual Therapy:
- Patient Education
- Referral
- Ice
- Orthotics
- ‘Rehabilitation Ready’ Splinting (MCP Flexion and IP Extension)
- Joint Mobilization
- Carpal
- MCP
- IP
- STM/MFR
- Hand Intrinsics
(d) Therapeutic Exercise:
- Protocol
(I) Protective Phase:
- 3-7 Days
- Hand Immobilization
- Monitor Pain/CRPS
- Finger/Elbow/Shoulder ROM
(II) Motion Phase:
- 7-21 Days
- Tendon Gliding
- Finger/Wrist AROM
(III) Function Phase:
- 4-8 Weeks
- Wean from Orthotic
- Strength (Isometric - Isotonic)
- Aggressive Stretching and Mobilization
Dupuytren’s Contracture:
- Pathogenesis = ?
- Cord Types = ?
Evaluation - E/W/H
Dupuytren’s Contracture:
(a) Pathogenesis:
- Unknown Etiology
- Fibromatosis of the Palmar Ligaments and Fascia
- Nodule at Distal Wrist Branches Outward
- Longitudinal Ligaments Limit Function
- MCP & PIP
- 4th & 5th Digits
(b) Cord Types:
(i) Central Cord (Pictured)
- Longitudinally Runs Palmar to Flexor Tendons
(ii) Spiral Cord (Not Pictured)
- Runs Laterally and Tethers Neurovascular Bundle
(iii) Natatory Cord (Not Pictured)
- Crosses Metacarpals, Connects Digits
Dupuytren’s Contracture:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Dupuytren’s Contracture:
(a) Classifications:
- Progressive Fibroplasia
- Dupuytren’s Disease
- Dupuytren’s Diathesis (More Severe)
(b) Characteristics:
- Pain Pattern
- Localized, Palm 4th/5th Digits
- Catching/Locking
- Risk Factors
- Alcoholism
- Diabetes
- Smoking
- Men > Women
- North European Ancestry
- Observation
- Dupuytren’s Nodule
- Obvious Deformity
- Examination
- ROM: (↓) 4th/5th MCP & IP
- (+) Tabletop Test
(c) Manual Therapy:
- Patient Education
(i) Wound Management
(ii) Orthotics
- Extension IP (pre-surgical)
- Dorsal Orthosis (I)
- Volar Orthosis (II)
- Static/Dynamic Ext. (III)
- Joint Mobilization
- Carpal
- MCP
- IP
- STM/MFR
- Forearm Musculature
- Hand Intrinsics
(d) Therapeutic Exercise:
**- Protocol **
(I) Wound Management:
- Weeks 1-2
- Orthotics
- Wound Cleaning
- Mid-range ROM
(II) Motion Phase:
- Weeks 2-3
- Progressive ROM
- Light Mobilization
- Tendon Gliding
(III) Discharge Phase:
- 4-6
- Achieve End-range ROM
- Isometric Strength
- Wean from Therapy
Wrist and Hand Tendon Pathology:
- Classifications = ?
- Mallet Characteristics = ?
- Complex Considerations = ?
- Mallet Considerations = ?
Evaluation - E/W/H
Wrist and Hand Tendon Pathology:
(a) Classifications:
- Flexor Tendon Laceration
- Extensor Tendon Laceration (Mallet Finger)
(b) Mallet Characteristics:
- Pain Pattern
- Localized, DIP
- Risk Factors
- Impact Sports or Professions
- Observation
- DIP Flexion
- PIP Extension
- Focal Swelling
- Examination
- Pain: Palpation/ROM
- (↓) Grip Strength
(c) Complex Considerations:
**- Dependent on Protocol **
- Indiana Hand Protocol Manual
- Protocol Types
- Immobilization
- Early Passive Motion
- Early Active Motion
- Protocol Dependent on
- Flexor vs Extensor Side
- Zone of Injury
- Severity of Injury
- Surgical Intervention Type
- Strength of Suture Used
- Patient:
- Age/Health
- Motivation
- Socioeconomic Factors
(d) Mallet Considerations:
- Mallet Finger Protocol
- 6 weeks Mallet Splint
- Light ROM Exercise
- Goal
- Strong Tendon
- Glides Freely
Complex Regional Pain Syndrome:
- Pathogenesis = ?
Evaluation - E/W/H
Complex Regional Pain Syndrome:
Pathogenesis:
(1) Starts with overt or covert nerve injury
(2) Genetic predisposition increases:
- Pain/Inflammatory Mediators
(3) Sympatho-afferent Coupling
- Nociceptive Fibers Grow Adrenergic Receptors
- Stress Response Triggers Pain
- Worsened by an Elevated Stress Response
(4) Decreased Regional Sympathetic Activity
- Parasympathetic Dominance
- Vasodilation (Red/Warm)
(5) Upregulation of Sympathetic Receptors
- Sympathetic Dominance
- Vasoconstriction (Blue/Cold)
(6) Prolonged Pain Produced Central Sensitization
- Changes in Somatosensory Mapping
Complex Regional Pain Syndrome:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Complex Regional Pain Syndrome:
(a) Classification:
- Type I (Reflex Sympathetic Dystrophy)
- Type II (Causalgia)
(b) Characteristics:
- Pain Pattern
- Unilateral, Non-dermatomal
- Hyperalgesia = increased pain from a stimulus that usually causes pain.
- Allodynia = Pain caused by a stimulus that doesn’t usually cause pain.
- Risk Factors
- Advancing Age
- Women>Men
- Fracture or Crush Injury
- Observation
- Warm/Red - Cold/Blue
- Edema/Sweating
- Trophic Change
- Examination
- (↓) Range of Motion
- Weakness/Dystonia
- Anxiety/Depression
- Budapest Criteria (3 of 4, 1 at eval)
- Hyperalgesia & Allodynia
- Edema/Sweating
(c) Manual Therapy:
(i) Patient Education
- Pain Neuroscience Ed.
- Relaxation Exercises
- Cardio Program
- Ice or Heat
(ii) Desensitization
(iii) Retrograde Massage
(d) Therapeutic Exercise:
(i) Guided Motor Imagery
- Limb Laterality Recognition
- Week 1
- Imagined Movements
- Week 2
(ii) Mirror Box Therapy
- Active Movements (Week 3-6)
- Two Point Discrimination
(iii) Pain Free AROM
(iv) Graded Exposure
(v) Isometric Strengthening
(vi) Push/Pull Stress Loading
(vii) Return to Work
Wrist and Hand Arthropathy – Osteoarthritis:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Wrist and Hand Arthropathy – Osteoarthritis:
(a) Classification:
- Osteoarthritis
- Bouchard’s Nodes (PIP)
- Heberden’s Nodes (DIP)
(b) Characteristics:
- Pain Pattern
- Localized, DIPs & 1st CMC
- Risk Factors
- Age > 50
- Women > Men
- Observation
- Crepitus
- Swelling
- Examination
- Pain: ROM
- (↓) Grip Strength
- (↓) ROM
(c) Manual Therapy:
- Patient Education
- Joint Protection Principles
- Anti-inflammatory Diet
- Ice: Acute
- Heat: Recurrent
- Orthotics (OtC Support)
- Joint Mobilization
- Carpal I-II
- CMC I-II
- MCP I-II
- IP I-II
(d) Therapeutic Exercise:
- Pain-Free Motor
- Daily AROM
- Hand Intrinsic Strengthening
- Isometric Grip Strength
- Forearm-Strength
Auto-Immune Systemic Inflammation of the Synovium = ?
Evaluation - E/W/H
Rheumatoid Arthritis: Auto-Immune Systemic Inflammation of the Synovium
(a) Endothelial Inflammation
(b) Synovial Hyptertrophy and Hyperplasia
- Invades Surrounding Tissue
(c) Massive Inflammatory Response
- Destroys Cartilage - Desiccation and Degradation
- Destroys Bone - Elevated Osteoclastic Activity
- Distends Capsular - associated Ligaments
- Destroys Tendons - Matrix and Venous Disruption, Tears
Wrist and Hand Arthropathy – Rheumatoid Arthritis:
- Classification = ?
- Characteristics = ?
- Manual Therapy = ?
- Therapeutic Exercise = ?
Evaluation - E/W/H
Wrist and Hand Arthropathy – Rheumatoid Arthritis:
(a) Classification:
(1) Rheumatoid Arthritis
- (I) Inflammatory
- (II) Proliferative
- (III) Destructive
- (IV) Collapse & Deformity
(2) Swan Neck Deformity
(3) Boutonniere Deformity
(b) Characteristics:
- Pain Pattern
- Diffuse, Fingers/Hands
- Risk Factors
- Family History
- Smoking/Periodontitis
- Women > Men
- Observation
- (I) Focal Swelling/Heat
- (III/IV) Obvious Deformity
- Examination
- (I) Pain: Palpation/ROM
- (↓) Grip Strength 2nd to:
- (I/II) Pain
- (III/IV) Deformity
- (III/IV) Tendon Rupture
(c) Manual Therapy:
- Patient Education
(.) Joint Protection Principles
(..) (I/II) Ice or (III/IV) Heat
(…) Orthotics
- Increasing Support for Each Stage
- (I/II) Compression Gloves
- (III/IV) Night Orthoses -
- (III/IV) Swan Neck
- (III/IV) Boutonniere
- STM/MFR
- Spot-treat (Contractures/Tightness)
(d) Therapeutic Exercise:
- Motor
- Pain-free AROM
- Isometric Strengthening
- General Conditioning
