msk final Flashcards
what movements does the humeroulnar joint help guide?
flexion and extension
what are the articulations of the HUJ?
trochlea and trochlear notch
what movement does valgus help with at the HUJ
extension
helps clear hips
what movement does varus help with at the HUJ?
flexion
helps with eating
does the HUJ follow cave on vex rules?
no
what does the deep concavity of the HUJ resrict?
traditional distraction - 45 deg
traditional cave on vex glide - posterior medial/lateral at 60 deg
what motion does posterior glide help at HRJ?
extension
what motion does anterior glide help at HRJ?
flexion
what are the articulations of HRJ?
capitulum and radial head
what movements does the humeroradial joint help guide?
flexion and extension
pronation and supination
what is the concavity of the HRJ?
cave on vex
what influence on the length of radius does the HRJ have?
posterior-medial radial head is thicker
in pronation, pushes radial distally
synkinetic with PRUJ
ext and pro go together
flex and sup go together
what are the articulations of PRUJ?
radial head and radial notch
what motions does the PRUJ help guide?
pro and sup
what is the concavity of PRUJ?
vex on cave
what motions does the DRUJ help guide?
pro and sup
how much force does TFCC absorb?
20%
what is the concavity of DRUJ?
cave on vex
least congruent in pronation
most congruent in supination
what are common disruptions of DRUJ?
colles fracture:
malalignment and RU lig dysfunction
ulnar styloid fracture:
RU lig dysfunction
what are the carpals intrinsically stabilized by?
form closure
force closure
what is the arthrokinematics of carpals?
radiocarpal - vex on cave
mid-carpal - non traditional
what is the scapholunate angle?
30-60 deg in the palmar direction
at risk during FOOSH
tapeziometacarpal joint (CMC 1)
saddle joint
cave on vex in flex/ext
vex on cave in abd/add
CMC 2&3
very rigid
CMC 4&5
complex planar joint
allows flexion and extension of MC 4 & 5
MCP joint
condyloid
allow abd and add
cave on vex
IP joints
hinge joints
only flex/ext
cave on vex
what side of arm are the flexors on?
anterior
what flexors can jeopardize the median nerve?
FDS
FDP
what flexor can crush the ulnar nerve in the cubital tunnel?
FCU
what extensor muscle connects the ulna to the hand?
ECU
what extensors are prone to lateral epicondlyopathy?
ECRB
ECRL
what extensors make up part of the snuff box?
AbdPL
EPB
what extensors form the extensor hood?
ED
EI
EDM
clinical pearl of the lumbricals
on thumb side and come off of profundus
mechanical advantage of flexion
contribute to median nerve entrapment
clinical pearl of interossei
attach on the side needed to perform their function
ulnar nerve
overview of median nerve
sensation: palmar and dorsal distal 1-3
proximally compressed at pronator teres
distally compressed at carpal tunnel
overview of radial nerve
sensation: dorsal 1-3
prox compressed at radial tunnel between two heads of supinator
overview of ulnar nerve
sensation: dorsal and palmar 4-5
prox compressed at cubital tunnel
dis compressed at guyon’s canal
what nerve is entrapped by anterior interosseous syndrome?
median
what muscles are affected by AIS?
FPL
FDP (2,3)
PQ
what is the presentation of AIS?
no snesory loss
weakness of tip pinch grasp
-unable to make ok sign
-unable to button shirts
possible pain at prox, medial forearm
what nerve is entrapped in posterior interosseous syndrome?
radial nerve
what muscles are impacted in PIS?
Supinator
ECRB
ED
EDM
ECU
AbdP
EPL
EPB
EI
what is the presentation of PIS?
no sensory loss
weakness in MCP ext, some wrist ext
possible pain at radial tunnel
inability to create full open hand motion
quickDASH
11 of 30 questions
higher scores indicate increased severity
amount of activity - kennedy stages
pain after - reduce by 0-25%
pain before and after - reduce by 25-50%
pain before during and after, perf unaffected - 50-75%
pain before during and after, perf affected - 75-100%
where are pain patterns most accurate?
more distal
frontal view observation
guarding of arm
carrying angles - should be valgus
skin appearance
swelling
hand atrophy
side view observation
attitude of hand
wrist deformities
swelling
hand deformities
nail bed changed
what is the radial nerve neural hand deformity?
wrist drop
what is the ulnar nerve neural hand deformities?
wartenburg - DM pull pinky into abd
froment - add poll impacted
claw hand
what is the median nerve neural hand deformities?
ape hand
okay sign
moberg pick up test
12 items
once with eyes open
once with eyes closed
prox radial MMT
ECRL/B
pt in wrist extension, resistance on thumb side
dis radial MMT
ED
pt 2nd digit in ext, resistance on pip
prox med MMT
FCR
pt in wrist flexion, resis on thumb side
dis med MMT
FPB
pt tumb in flexion, resistance pulls thumb up
prox ulnar MMT
FCU
pt in wrist flexion, resis on pinky side
dis ulnar MMT
Pl
pt in finger add, resistance pushed finger into abd
humeroulnar joint medial glide
for extension!
supine
arm partially supinated
push distally and medial
humeroulnar joint lateral glide
for flexion!
supine
push prox and lateral
humeroradial joint distracton
client supine
only grasp radius and distract
humeroradial joint posterior glide
client supine
drive the radius post/lateral at 60 deg
humeroradial joint anterior glide
client supine
use heel of hand to deliver force
anterior is subject to client position
distal RU dorsal glide of the radius
sitting, in 10 deg supination
push radial head posteriorly
DRUJ volar glide of the radius
sitting, in 10 deg supination
push radial head anteriorly
wrist dorsal glide
used for flexion
sitting, neutral wrist
glide prox row of carpals posterior
wrist palmar glide
used for extension
sitting, neutral wrist
glide prox row of carpals anterior
specific carpal bone posterior glide
basically palpation with overpressure
trapeziometacarpal joint dorsal glide
sitting, wrist neutral
push towards ulna for flexion
to radius for extension
dorsally for abduction
palmarly for adduction
CMC 2-5 dorsal glide
4&5 should move, 2&3 should not
posterior force goes to ceiling
MCP 1-5 glides
just grab and go for it
direction of movement is movement is helps
IP 1-5 glides
glide in respective direction
biceps squeeze test
distal biceps tear
squeeze biceps firmly with both hands
+ lack of forearm supination as biceps is squeezed
cozen’s test
lateral epicondylopathy
palpate lat epi
client extends wrist against resistance
+ reproduction of pain in lat epi
Maudsley’s lateral epicondylitis test
lateral epicondylopathy - ECRB specifically
palpate lat epi
client extends 3rd against resistance
+ reproduction of pain in lat epi
medial epicondylitis test
client sitting
palpate med epi
supinate pts forearm, extend wrist and elbow
+ pain at med epi
varus stress test
for lateral instability
palpate RCL
apply adduction force to distal forearm
+ distraction pain laterally and compression pain medially at joint line, laxity
valgus stress test
for medial instability
palpate UCL
apply abduction force to distal forearm
+ distraction pain medially and compression pain laterally at joint line, laxity
moving valgus stress test
for dynamic medial instability due to bands of UCL
valgus stress at elbow through ROM
+ pain reproduction when elbow is extended. highest level of pain should be between 70-120 deg
chair push up test
for posterior-lateral radial instability, TFCC instability
client’s fingers face out, push up from chair using arms
+ reluctance to extend elbow fully, radius pushing out laterally
elbow flexion test for cubital tunnel
client fully flexes elbow and extends wrist
hold for 3 min
adding wrist flexion for FCU tendon
+ reproduction of symptoms along ulnar nerve distribution
wrist flexion and median nerve compression
for carpal tunnel syndrom
even and constant pressure over median nerve with wrist flexed to 60 deg
+ repro of symptoms along median nerve distribution within 20-30 seconds
phalen’s test
for carpal tunnel syndrome
press dorsal surfaces of hands together for 60 seconds
+ paresthesia in cutaneous distribution of median nerve
reverse phalen’s test
for carpal tunnel syndrome
press palmar surfaces of hands together for 60 seconds
+ paresthesia in cutaneous distribution of median nerve
finkelstein’s test
for stenosing tendovaginitis (swelling of sheath)
client makes a fist and clinician ulnarly deviates fully
both sides must be done to be correct, can do one side at a time
+ pain over APL and EPB
watson scaphoid test
for scapholunate instability
thumb over scaphoid tubercle
move from ulnar dev to radial dev
release thumb
+ sublux or clunk at thumb and reproduction of pain
ulnomeniscotriquetral dorsal glide or piano key test
for UMT instability or TFCC tear
thumb on dorsal ulna, index finger on pisiform
push together to perform dorsal glide of pisiform
+ repro pain or laxity
ulnar collateral ligament test
for thumb instability
thumb into extension, apply valgus stress to MCP joint
+ valgus movement great than 30 deg
grind test
for 1st CMC arthritis
compress 1st MC into trapezium
+ pain at 1st CMC
bunnell-littler test
for hand intrinsic tightness
trial 1) MCP in extension
trial 2) MCP in flexion
flex IP
+ less PIP motion with MCP extension = tightness, need stretching
if no change, capsular problem, need mobs
bend and stretch
perpendicular load and stretch tissue
ischemic compression
press into trigger point until tissue release
myofascial release holds
picking up skin
this is done to someone with stuck skin
scar massage
wait until its healed enough that you are comfortable pulling on it
ok to be underagressive
thumbs uniform for fresher scar
once fully healed - can break adhesions
cross friction massage
for tendinopathy
finger over finger
1 direction for opathy
2 for tenovaginitis
2 min at light intensity and 2 more min more forceful
humeroulnar joint distraction in extension
for extension restriction
supine
arm in pronation
pre-positioned to full ex
distraction force in posterior-distal direction at 45 deg
30-45 sec 4x or until capsular change
humeroulnar joint mobilization in extension
sidelying with involved side down
arm in pronation
full extension
mob force post-med at 60 deg
30-45 sec 4x or until cap change
humeroulnar joint distraction in flexion
sidelying
supination
flexion limit
distraction force in post-distal direction at 45 deg
30-45 sec 4x or until cap change
humeroulnar joint mobilization in flexion
sidelying, involved side down
supination with med epi up
flexion limit
mob force in post-lat direction at 60 deg
30-45 sec 4x or until cap change
humeroradial joint and PRUJ distraction and mobilization in extension
sitting with arm on table
in supination with cubital fossa up
extension
mob force in post-lat at 60 deg
distraction force along radius as arm brought into pronation
30-45 sec 4x or until cap change
humeroradial joint and PRUJ mobilization in flexion
sitting with arm on table
in pronation with cubital fossa up
flexion
mob force in post-lat at 60 deg
distraction force along radius as arm brought into supination
30-45 sec 4x or until cap change
distal radioulnar joint mobilization in supination or pronation
sitting with arm on table
sup or pro (whichever is restricted)
SUP: mob force along volar surface of radius in posterior direction along joint line
PRO: mob force along dorsal surface of radius in anterior direction along joint line
30-45 sec 4x or until cap change
radiocarpal joint volar mobilization in extension
sitting with arm on table
in wrist extension
stabilizing force applied to distal radius and ulna
mob force applied to dorsal surface of proximal carpal row in volar direction
30-45 sec 4x or until cap change
radiocarpal joint dorsal mobilization in flexion
sitting with arm on table
in wrist flexion
stabilizing force applied to distal radius and ulna
mob force applied to volar surface of proximal carpal row in dorsal direction
30-45 sec 4x or until cap change
radiocarpal joint medial mobilization in radial deviation
sitting with arm on table and wrist off table
wrist in rad dev and slight flexion
stab force applied to distal radius and ulna
mob force applied to lateral surface of proximal carpal row in medial direction
30-45 sec 4x or until cap change
radiocarpal joint lateral mobilization in ulnar deviation
sitting with arm on table and wrist off table
wrist in ulnar dev and slight extension
stab force applied to distal radius and ulna
mob force applied to medial surface of proximal carpal row in lateral direction
30-45 sec 4x or until cap change
intercarpal joint volar/dorsal mobilization or manipulation
sitting with pt hand in yours
from neutral into flex or ex
EX: force applied to dorsal surface of hypomobile carpal with overlapping thumbs
FLEX: force applied to volar surface of hypomobile carpal with overlapping index fingers
mob: 30-45 sec 4x or until cap change
manip: 1-2 times
1st carpometacarpal distraction
pt sitting with arm on the table
stabilize distal carpal row
distraction force applied along axis of 1st MC
30-45 sec 4x or until cap change
1st carpometacarpal mobilization
sitting with arm on table
stabilization force applied to distal carpal row
mob force to base of 1st MC
- flexion: medial force to lateral surface
- extension: lateral force to medial surface
- abduction: dorsal force
- adduction: palmar force
30-45 sec 4x or until cap change
metacarpalphalangeal joint distraction or mobilization
sitting with arm on table
stabilizing force to distal MC
mob force to base of 1st phalanx
- flexion: volar force
- extension: dorsal force
- abduction: force away from 3rd finger
- adduction: force toward third finger
30-45 sec 4x or until cap change
interphalangeal joint distraction or mobilization
sitting with arm on table
stab force applied to distal portion of proximal phalanx
- flexion: volar force
- extension: dorsal force
30-45 sec 4x or until cap change
what are the three phases of epicondylopathy?
reactive - 20’s, inflam, heal on its own
disrepair - 30’s heal poorly
degenerative - 40’s, breakdown, cell death, need PT
which set of muscles are more commonly affected by epicondylopathy?
extensors - tennis elbow
esp extensor carpi radialis brevis
what is the pain pattern for epicondylopathy?
localized to distal epicondyle
what are the risk factors for epicondylopathy?
35-50 yo
repetitive movements
women>men
what will you observe with epicondylopathy?
avoidance of grasping or active wrist flexion/extension
what will an examination find with epicondylopathy?
pain with palpation/contraction
+ cozen, maudsley’s, mills or medial epicondylitis test
- c spine, nerve entrapment, and chair push up test
decreased grip strength
patient rated tennis elbow evaluation
patient education for epicondylopathy
activity reduction
ice
orthotics - wrist extension, counterforce
manual therapy for epicondylopathy
mobs: HR, PRUJ, DRUJ
STM/MFR: cross friction in 1 direction
instrument assisted for extensor muscles
ther ex for epicondylopathy
scapular strengthening
hand intrinsic strengthening
isometrics - if pain reducing
eccentric training - 2 sets of 15 with 2 RIR, 48 hr rest
rapid eccentrics
rapid concentrics
radial nerve glides
MOI for distal biceps tear
rapid high force
eccentric loading
flexed and supinated arm
what often happens before a distal biceps tear?
prior degeneration
repetitive pronation
pain pattern for distal biceps tear
localized, non-radicular pain over biceps
risk factors for distal biceps tear
> 45 yo
repetitive pronation
smoking
heavy eccentric loading
what will you observe with a distal biceps tear?
displaced biceps muscle belly
swelling
ecchymosis
what will an examination find with a distal biceps tear?
pain with resisted elbow flexion
decreased flexion/supination strength
+ biceps squeeze test
pt ed for distal biceps tear
adherence to protocol
importance of protected phase
manual therapy for distal biceps tear
mobs: HU, HR, PRUJ
ther ex for distal biceps tear
protected phase
- orthotic bracing
- spot-treat movement system
progressive phase
- ROM exercise
-stretching
strengthening phase
- isometric
isotonic
sport/work-specific
MOI of UCL injury of elbow
repetitive trauma
overhead athletes
which bundle of the UCL is most vulnerable?
anterior bundle
what two muscles keep the UCL stabilized?
flexor carpi ulnaris
flexor digitorum superficialis
what is the pain pattern for UCL injury of the elbow?
localized to the distal epicondyle
what are the risk factors for UCL injury of the elbow?
repetitive movements
what would you observe with UCL injury of the elbow?
decreased throwing velocity
what would an examination of UCL injury of the elbow reveal?
pain with palpation
+ moving valgus test
- medial epicondyle testing
pt ed for UCL injury of the elbow
activity reduction
manual therapy for UCL injury of the elbow
mobs: HU, HR, PRUJ, DRUJ, shoulder ER, scapula, thoracic spine
STM/MFR: cross friction in 1 direction
ther ex for UCL injury of the elbow
anterior core, subscap and grip strength
flexor/pronator strength
SURGICAL PROTOCOL
immediate motion:
- pain control
- PROM, AAROM, AROM
intermediate
- resistance training - strength/control
- mobilization
advanced strengthening
- progress resistance
- power/endurance
- plyometrics
progressive return to activity
ulnar nerve glides
MOI for LCL
hyperextension force in olecranon fossa
levers trochlea past coronoid process
frequency of LCL injury
most common dislocation <10 yo
2nd most common >10
pain pattern for LCL injury
localized to the distal epicondyle
reports of elbow giving way
risk factors for LCL injury
history of radial dislocation
history of lateral epicondylitis
what would an observation of LCL injury reveal?
apprehension of supination and loading
examination of LCL injury
pain with palpation
decreased extension ROM
+ chair push up test
- lateral epicondylitis testing
pt ed for LCL injury
activity avoidance
bracing
manual therapy for LCL injury
mobs: HR, PRUJ, DRUJ, shoulder IR
ther ex LCL injury
grip and extensor strength
SURGICAL PROTOCOL
immediate motion:
- pain control
- PROM, AAROM, AROM
intermediate:
- resistance training - strength and control
- mobilization
advanced strengthening
- progress resistance
- power/endurance
- plyometrics
progressive return to activity
radial nerve glides
MOI of annular ligament injury
longitudinal pull on the radius
full extension and supination
most common annular ligament injury in children
nursemaid’s elbow
pain pattern of annular ligament injury
localized to distal epicondyle
risk factors annular ligament injury
age 2-4
examination of annular ligament injury
pain with. palpation
decreased ROM
+ chair push up test
- lateral epicondylitis testing
pt ed for annular ligament injury
referral for imaging and potential relocation
ther ex for annular ligament injury
grip strength
wrist extension strength
osteoarthritis
secondary to prior trauma
chondral degenerative process
panner’s disease
disruption of blood supply to capitulum
repetitive valgus stress or trauma (6-11)
osteochondritis dissecans
genetic predisposition to poor sunchondral health/blood supply
repetitive valgus stress or trauma (10-20+)
pain pattern for elbow arthropathy
deep in elbow joint
risk factors for elbow arthropathy
OA: age >55
panner’s: 6-11
panner’s/OCD: boys<girls
OA: girls>boys
history of joint trauma
history of heavy joint loading
observation in elbow arthropathy
swelling
nodules
examination of elbow arthropathy
pain in ROM
decreased ROM
OA: crepitus
ODC: loose bodies - sharp pain and dead arm feeling
what are loose bodies?
things floating in joint
what nerve does cubital tunnel syndrome involve?
ulnar
what is the pain pattern for cubital tunnel syndrome?
radicular pain and paresthesia form medial elbow to medial hand
risk factors for cubital tunnel syndrome
prolonged elbow flexion
UCL inflam
examination of cubital tunnel syndrome
+ tinel’s, elbow flexion test
- c spine, medial epi testing
decreased grip strength
wartenburg sign
froment sign
claw
what is wartenburg sign?
abd of pinky
what is froment sing?
thumb cannot adduct so has to flex for pinching
pt ed for cubital tunnel syndrome
activity reduction
heat for sym reduction
night orthotics
manual therapy for cubital tunnel syndrome
STM/MFR
FCU
cubital tunnel retinacuclum
ther ex for cubital tunnel syndrome
stretch FCU
ulnar nerve glides
MOI for elbow fracture
high force impact
most common treatment for elbow fracture
ORIF
varus deformity expected
pain pattern for elbow fracture
diffuse pain
risk factors for elbow fracture
men aged 12-19 doing sketchy shit
women >80 due to osteoporosis
fall hx
observation of elbow fracture
swelling
obvios deformity
examination for elbow fracture
decres ROM - stiffness
decres grip strength
+ elbow extension test
pt ed for elbow fracture
ice
orthotics - static progressive or JAS
manual therapy for elbow fracture
mobs: HU, HR, PRUJ, DRUJ
STM/MFR: biceps, triceps, forearm musculature
ther ex for elbow fracture
PROTOCOL
inflam phase:
0-2 weeks
manage pain/inflam
light ROM
fibroplastic phase:
3-8 weeks
increase ROM
begin light strengthening
remodeling phase:
2-6 months
progress strength
mobilizations
static-progressive orthotics
all nerve glides
what nerve is involved with carpal tunnel syndrome?
median
pain pattern for carpal tunnel syndrome
pain/paresthesia in lateral hand
worse at night
risk factors for carpal tunnel syndrome
age > 45
women>men
diabetes
observation for carpal tunnel syndrome
flick sign - shaking decres sym
wrist ratio > 0.7
thenar atrophy
examination of carpal tunnel syndrome
+ phalen’s, tinel’s, wainer CPR, Durkan’s
- scaphoid fx, finklestein, TOS, c spine
decres grip strength/sensation
decres coordination with moberg
what is wanier CPR
age > 45
flick sign - shaking decres sym
wrist ratio > 0.7
decres grip strength
decres sensation
pt ed for carpal tunnel syndrome
possible injection or surgery consult
heat
activity mod
- decres full MCP flex/udev
- work in 0-45 deg pro
- work in slight ext/udev
orthotics
- 2 deg ext/udev
-night, during heavy work or pregnant
manual therapy for carpal tunnel syndrome
STM/MFR:
flexor retinaculum
medial arm
instrument assisted
ther ex for carpal tunnel syndrome
distal median nerve glides
flexor ret stretch
hand intrinsic stretch
finger flexor stretch
POST-SURGICAL
activity avoidance
light paper taping over incision
light isometrics progressing to tendon glides
distal median nerve glides
MOI for distal radius fracture
FOOSH
contact sports
colles fracture
dorsal displacement
smith’s fracture
volar displacement
pain pattern for distal radius fracture
diffuse wrist pain
risk factors for distal radius fracture
> 50 yo
fall risk
women > men
observation for distal radius fracture
avoidance of grasping or active wrist flexion/ext
examination of distal radius fracture
decres ROM
decres grip/pinch strength
decres push off strength test
pt ed for distal radius fracture
ice/heat
orthotics
manual therapy for distal radius fracture
mobs: HR, PRUJ, DRUJ, radiocarpal, MCP, IP
STM/MFR: forearm musculature
Ther ex for distal radius fracture
PROTOCOL
protective:
- 1-6 weeks
- wrist immob
- monitor pain/CRPS
- finger/elbow/shoulder ROM
motion:
- after immob
- wirst AROM - ext, sup, pro, finger flex
- tendon gliding
function:
- bone healing
- strength - isometric to isotonic
- mobilization
all nerve glides
MOI of triangular fibrocartilage complex injury
FOOSH
forced rotation while gripping
what is triangular fibrocartilage complex injury treated with?
active stabilization
bracing
injection
pain pattern for triangular fibrocartilage complex injury
localized to distal ulna
risk factors for triangular fibrocartilage complex injury
hx: distal forearm injury
ulanr variance
advancing age
rep mvmts
observation of triangular fibrocartilage complex injury
localized swelling
crepitus
examination for triangular fibrocartilage complex injury
pain with palpation and ROM
+ ulnomeniscotriquetral sweep
decres grip strength
pt ed for triangular fibrocartilage complex injury
ice
orthotics
possible referral if bracing not working
manual therapy for triangular fibrocartilage complex injury
mobs: HR, PRUJ, DRUJ
STM/MFR: cross fric in one direction on ECU and FCU
MOI of stenosing tenovaginitis
trauma and repetitive stress
pain pattern for stenosing tenovaginitis
localized pain
DeQ: radial styloid
trigger finger: A1 pulley
risk factors stenosing tenovaginitis
repetitive/forceful jobs
wom>men
observation of stenosing tenovaginitis
local nodule
AROM: catching/crepitus
examination of stenosing tenovaginitis
pain with palpation/AROM
+ finkelstein’s
decres strength
- scaphiod fracture
pt ed for stenosing tenovaginitis
activity avoidance
ergonomic mods
ice
US
orthotics - rigid
refer for injection
manual therapy stenosing tenovaginitis
STM/MFR
- cross fric in 2 directions
ther ex for stenosing tenovaginitis
grip strength
gentle tendon glides
stretching
strengthening kinematic chain
MOI of scaphoid fracture
most common carpal fracture
vulnerable due to 45 deg angulation
compression and extension and radial deviation
pain pattern of scaphoid fracture
localized distal radius
risk factors for scaphoid fracture
15-30 yo
men > women
observation for scaphoid fracture
swelling
examination for scaphoid fracture
pain with palpation
+ scaphoid compression, snuffbox tenderness
- finkelstein’s
decreased grip strength
pt ed for scaphoid fracture
screening and referral
ice
orthotics
- thumb spica
- progressive orthotics
manual therapy for scaphoid fracture
mobs: radiocarpal, DRUJ, light carpal, MCP, IP
ther ex for scaphoid fracture
PROTOCOL
protective:
- 2-4 weeks
- wrist immob
- monitor pain/CRPS
- finger/elbow/shoulder ROM
motion:
- after immob
- finger/wrist AROM
- stretching/tendon gliding
function:
- starts at bone healing
- strength: isometric to isotonic
- mobilization
median nerve glides
what is the pain pattern for ulnar collateral ligament tear of the 1st?
localized to the medial 1st MCP
risk factors for ulnar collateral ligament tear of the 1st
fall risk
observation for ulnar collateral ligament tear of the 1st
focal swelling
examination of ulnar collateral ligament tear of the 1st
pain with palpation
+ ulnar collateral ligament test
pt ed for ulnar collateral ligament tear of the 1st
screening and referral
ice orthotics - thumb spica
manual therapy for ulnar collateral ligament tear of the 1st
mobs: DRUJ, carpal mobilization, CMC, IP
ther ex for ulnar collateral ligament tear of the 1st
2-8 weeks after immob
pinch and grip strength
wrist strength
stretching
median nerve glides
pain pattern for metacarpal fracture
localized to MC
risk factors for metacarpal fracture
age 22-34
high force loading
men > woman
observation for metacarpal fracture
focal swelling
ecchymosis
guarded mvmt
examination for metacarpal fracture
pain with palpation
decres strength
pt ed for metacarpal fracture
referral
ice
orthotics - rehab ready splinting
manual therapy for metacarpal fracture
mobs: carpal, MCP, IP
STM/MFR: hand intrinsics
ther ex for metacarpal fracture
PROTOCOL
protective
- 3-7 days
- hand immob
monitor pain/CRPS
finger/elbow/shoulder ROM
motion
- 7-21 days
- tendon gliding
- finger/wrist ROM
function
- 4-8 weeks
- wean from orthotic
- strength - metric to tonic
- aggressive stretching and mobilization
pain pattern for dupuytren’s contracture
localized to the palm and 4/5 digits
catching/locking
risk factors for dupuytren’s contracture
alcoholism
diabetes
smoking
men > women
north european ancestry
observation for dupuytren’s contracture
dupuytren’s nodule
obvious deformity
examination for dupuytren’s contracture
ROM decres at 4/5 MCP and IP
+ table top test
pt ed for dupuytren’s contracture
wound management
orthotics
manual therapy for dupuytren’s contracture
mobs: carpal, MCP, IP
STM/MFR: forearm, hand intrinsics
ther ex for dupuytren’s contracture
PROTOCOL
wound management
- weeks 1-2
- orthotics
- wound cleaning
- mid-range ROM
motion
- weeks 2-3
- progressive ROM
- light mobs
- tendon gliding
discharge
- 4-6
- achieve end range ROM
- isometric strength
- wean from therapy
what is mallet finger?
extensor tendon laceration
pain pattern of mallet finger
localized to DIP
risk factors for mallet finger
impact sports or professions
observations for mallet finger
DIP flexion
PIP extension
focal swelling
examination for mallet finger
pain on palpation
decres grip strength
complex considerations for wist and hand tendon pathology
dependent on PROTOCOL
protocol types
- immob
- 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
mallet finger considerations
PROTOCOL
- 6 weeks mallet splint
- light ROM exercise
GOAL
- strong tendon
- glides freely
two types of CRPS
type I: reflex sympathetic dystrophy
type II: causalgia
pain pattern for CRPS
unilateral
non-dermatomal
hyperalgesia & allodynia
risk factors for CRPS
advancing age
women > men
fracture or crush injury
observation for CRPS
warm/red to cold/blue
edema/sweating
trophic change
examination for CRPS
decres ROM
weakness/dystonia
anxiety/depression
budapest criteria
what is the budapest criteria?
hyperalgesia & allodynia
warm/red to cold/blue
edema/sweating
trophic change
need 3 of 4, 1 at eval
pt ed for CRPS
PNE
relaxation exercises
cardio program
ice or heat
manual therapy for CRPS
desensitization
retrograde therapy
ther ex for CRPS
guided motor imagery
mirror box therapy
pain free AROM
graded exposure
isometric strengthening
push/pull stress loading
return to work
what joint do bouchard’s nodules occur at?
PIP
what joint do heberden’s nodules occur at?
DIP
pain pattern for wrist and hand OA
localized to DIPs and 1st CMC
risk factors for wrist and hand OA
age > 50
women > men
observation for wrist and hand OA
crepitus
swelling
examination for wrist and hand OA
pain in ROM
decres grip strength
decres ROM
pt ed for wrist and hand OA
joint protection
anti inflam diet
ice for acute and heat for recurrent
orthotics
manual therapy for wrist and hand OA
mobs: carpal, CMC, MCP, IP
ther ex for wrist and hand OA
daily AROM
hand intrinsic strengthening
isometric grip strength
forearm strength
what are the inflammatory responses of RA
destroys cartilage
destroys bone
distends capsular associated ligaments
destroys tendons
4 classes of RA
I inflammatory
II proliferative
III destructive
IV collapse and deformity
what does a swan neck deformity look like?
PIP joint goes down
what does boutonniere deformity look like?
PIP goes up
pain pattern for RA
diffuse
in fingers and hands
risk factors of RA
family hx
smoking/periodontitis
women > men
observation of RA
I focal swelling
III/IV obvious deformity
examination of RA
I pain in palpation and ROM
decres grip strength secondary to
- I/II pain
- III/IV deformity
III/IV tendon rupture
pt ed for RA
joint protection
I/II ice or III/IV heat
orthotics
- I/II compression gloves
- III/IV night orthoses and specific to deformity
manual therapy for RA
STM/MFR: spot treat contractures and tightness
ther ex for RA
pain free AROM
isometric strengthening
general conditioning
prolonged stretching (elbow)
supine, weight on wrist
for extension, extend to end ROM
for flexion flex to end ROM
elbow AROM
from neutral into supination and pronation
flexion and extension
biceps strengthening
using dumbell
palm up
concentric flexion and controlled down
can do eccentrics if needed
triceps strengthening
using dumbell
supine, arm straight up
concentrically extend
counterforce bracing
place it distal to point of pain
adds to the insertion of muscle
not going to be a solution - bandaid
does not help nerve
prolonged stretching (wrist)
wrist and finer flexors- pull all into extension
wrist flexors- make fist and pull into extension
wrist extensors- with straight fingers, pull wrist into flexion
wrist and finger extensors- pull all into flexion
wrist AAROM
flex/ex: roll hand over the ball
pro/sup: tilt ball like steering wheel
wrist AROM
ex/flex
pro/sup
rdev/udev
jux a cisor
get the washer from start to finish only using wrist movements.
external cuing makes motor learning skyrocket
wrist flexor strengthening
for med epi - 2 sets of 15
palm up
use dumbell
use theraband
twist a therabar - not as good
wrist extensor strengthening
for lateral epi
palm down - far enough off table - want full ROM
use dumbell
use theraband
twist a therabar - not as good
radial/ulnar deviation strengthening
using hammer/bat
- radial - in front of body
- ulnar - elbow at 90 flex
using band
- rad - band under foot
- ul - wrap band around both hands
pronation/supination strengthening
using hammer/bat for eccentric - help back to neutral
- supination - start at neutral and sup
- pro - start and neutral and pro
using band for concentric
- sup - start pro and sup all the way over, controlled back
- pro - start sup and pro all the way over, controlled back
OtC orthoses
wrist brace- good to take pressure off joint
anti vibration gloves - for nerves or RA
overview of protection principles
respect pain
balance rest and activity
exercise in pain free range
reduce effort
avoid positions of deformity
use larger joints
use adaptive equipment as needed
hand intrinsic stretching
press claw hand into table
can use other hand to add pressure on top
for stiffness post surgical
flexor retinaculum stretching
for carpal tunnel syndrome
press hand into wall
pull back on thenar emeinence
tenodesis movement “dart throwing”
active wrist motion causes passive finger motion
wrist extension and flexion
can hold something but dont have to
passive insuff
considered tendon gliding
if for mvmt control: do for 2 min
joint blocking
block just proximal to joint
MCP flexion - not much to block
PIP flexion
DIP flexion
DIP extension
for strength: 3x8 3x/week
for mvmt control: long duration
tendon glides
for mobility and ROM
motor reprogramming: 2-5 min
everything straight
intrinsic plus: lumbrical position
straight fist, max FDS: fist, but straight DIPs
full fist, max FDP: complete fist
hook fist, FDS vs FDP: only IPs flexed
finger extension
extend against resistance
hand master
rubberbands
theraputty
power web
finger flexion exercises
flex against resistance
isolated flexion in putty
power grip (fist) in putty
intrinsic flexion (MCP flexion) in putty
extrinsic flexion (IP flexion) in putty
power web
flexors are more efficient with putty
putty thumb exercises
pinch the long
pinch a ball
opposition
thumb punches (flexion)
abduction with rubber band
functional reach and grasp practice
for power:
- cylindrical - holding glass of water
- spherical - opening door know
- hook - holding bag, strongest grip
precision:
- pincer - fingers to thumb tip
- 3-jaw chunk
- lateral - key
in hand manipulation and translation
manip
- squirt bottle
- carabiner open/close
translation
- pen/key pickup
- single-coin placement
manual dexterity
beads in theraputty
bolt in washer or nut
distal upper extremity nerve glides
start with 1 x 10
fully passive
median: pull fingers 2-3 and wrist into extension
median thumb bias: roll thumb into supination
radial: pull fingers 2-3 and wrist in to flexion
ulnar: pull fingers 4-5 and wrist into extension
graded motor imagery
card
imagine
mirror therapy
phases of throwing
wind-up
stride
arm cocking
arm acceleration
arm deceleration
follow through
what muscles need to be strengthened in throwing
subscap for cocking and accel
t minor for decel
SA and lower trap
aspects of good form
synchronous trunk and hip translation
hand on top
max abd
closed front shoulder
foot leads to target
shoulder square to target
what are muscle relaxant medications?
neuromuscular blockers
- for PNS
- used in surgery
spasmolytics
- CNS
- ex. flexeril, baclofen
who benefits from muscle relaxant medications?
pts with muscle spasm due to overexertion
pts with spasticity
what are anti-inflammatory medications?
opioids
- highly controlled
- oxycodone, hydrocodone
NSAIDs
- Cox-1 / Cox-2 inhibitors
- aspirin, ibuprofen, aleve (1&2)
- celebrex, meloxicam (2)
– more effective on joint pain, less digestive issues
who benefits from anti-inflammatory medications?
pts experiencing pain or inflam
what are neuropathic medications?
antidepressants
- SSRI, SNRI for chronic pain
- cymbalta for neuropathic pain
anticonvulsants
- neurontin or lyrica for neuropathic pain
who benefits from neuropathic medications?
pts with neuropathic conditions
nerve based pain, hyperalgesia, allodynia
what is a corticosteroid injection?
injection of anesthetic and anti-inflam medication into inflamed tissue
who benefits from corticosteroid injection?
arthropathy - OA
tendinopathy - biceps/tricpes, lateral epi
tenovaginitis - DeQ, Trigger finger
what is platelet rich plasma?
injection of high concentration autologous platelets into injured tendons, ligs, or arthritic joints.
solution can be in/activated and/or be either leukocyte rich or poor.
who benefits from platelet rich plasma?
with mild to moderate CT injury
most lit support for lateral epicondyle
what does PRP do?
its used for tissue growth
what is the surgical intervention for dupytren’s contracture?
fascial contracture is managed by either surgical fasciectomy or enzymatic fasciotomy and manipulation
what is the carpal tunnel surgical intervention?
surgical sectioning of the flexor retinaculum by way of open release, mini-open release, or endoscopic release.
which CTS intervention is the most predictable but had the hardest recovery?
open release
who benefits from carpal tunnel surgical intervention?
pts with acute nerve compromise at the CT or recurrent issues with signs of median neuropathy
what is the surgical intervention for distal radius fracture?
anatomic reduction of fracture using casting, closed treatment, or ORIF
who benefits from surgical intervention for distal radius fracture?
pt with colles fx and other distal radius fx
how does surgical intervention for distal radius fracture work?
pull bones back together so they can heal
what is the surgical intervention for trigger finger?
dissection of the A1 pulley under local anesthetic
who benefits from surgical intervention for trigger finger?
pts with severe or recurrent trigger finger
what is the only pathology that involves ulnar drift?
RA
