Tendinopathies of UE

Question 1

Tendons

Answer 1

Connect Mm to bone

Question 2

Tendinopathies often fall in the category of

Answer 2

Cumulative Trauma (CTI) or Repetitive Strain Injuries (RSIs)
* Common work related injuries
* Can occur in anyone
* Can affect tendons and or Nn (nerve issues usually
due to the inflammation and swelling

Question 3

Other causes of Tendinopathy

Answer 3

Falling on an area
Trauma induced tendinopathy
Poor blood flow
Poor posture and mechanics
Poor proximal stability and core strength decreased ability to maintain a good safe posture leading to added stress on the tendons
* Tendonitis or nerve issue = always correct posture

Question 4

Tendon pain

Answer 4

“itis” (inflammation)

“osis” (scar tissues) - fibrosis of the tendon that has been injured more than once and laid down scar tissue (tendinosis)

“algia” (nerve irritation)

Could have a combination of all the above, which makes it hard to treat

Question 5

Tendonitis

Answer 5

Inflammation process. Inflammatory cells found in tissue.

Question 6

Tendinosis

Answer 6

Degenerative process with fibrosis, decreased circulation. Fibrosis found in the tissue.

Question 7

Tendonalgia

Answer 7

“Pain” neurogenic in nature. Free nerve ending are irritated and signaling “pain” to the brain. Neurotransmitters and inflammatory markers are present (immune system signals and sends those out)

*Doctors often call it tendonitis but does not mean you 
 take that at face value, so you must ask ?'s to figure out 
 if it is "itis"  "osis"  "algia".

Question 8

Tenosynovitis

Answer 8

The synovial sheath the tendon runs through is also inflamed

Question 9

Combination

Answer 9

Various processes occurring simultaneously

Question 10

Tendinopathy Secondary to an RSI

Answer 10

• Repetitive use especially against resistance
• Repetitive sheering of tissue across a bone
• Extreme postures for prolonged period of time
  Pulls on the origin and insertion sites
• Carrying resistance when Mm are stretched

Question 11

Lateral Epicondylitis (Tennis Elbow)

Answer 11

Very common

Very challenging diagnosis (is it inflammation = acute or scar tissue = chronic????

Originally is an “itis”

Starts as inflammation of the tendon fibers that attach the forearm extensor Mm to the lateral epicondyle

Routine use of the arm causing shearing of the ECRB over the radial head especially with the elbow extended or an injury to this area may stress or damage the muscle attachment

During healing the tendons often get stuck in fibroplasia (the process of forming fibrosis tissue)
The tissue has a failure to thrive.
Calcification, rupture and additional fibrosis follows.

Shearing over radial head and stress to muscle attachments

First stage wants to lay down collagen = fibrosis

Usually caught after the inflammatory stage

Difficult to alleviate symptoms if the condition is chronic

Treatment is different for acute vs chronic

Question 12

Over 23 ailments that can cause lateral elbow pain

Answer 12

Cervical Radiculopathy =
(C5/C6) narrowing of foramen (compression)

Proximal Neurovascular entrapment of lateral ante brachial cutaneous nerve

Arthritis

Tumors

Radial Tunnel/PIN entrapment = big one that mimics or coexists with tennis elbow (Posterior Interosseus Nerve entrapment)

Distal biceps insertion at radial tuberosity

Triceps insertion at olecranon

Shoulder tendonitis

Carpal Tunnel Syndrom

Trigger points

Loose Bodies (bone fragments (often see with falls, do X-ray

Question 13

Anatomy

Answer 13

Common Extensor Origin:
* ECRB = biggest, primary structure involved in LE and
has a poor blood supply at origin
* EDC = next biggest, the EDC of long finger combines with
the ECRB tendon to insert at the lat epicondyle
poor posture and body mechanics while typing
and playing piano. Excessive use of EDC instead
of floating digits can lead to LE
* ECRL
* ECU

• ECRB = origin: lat epicondyle of humerus
  ins: base of MC 3
  actions: ext and radial deviation of carpus
  nerve: deep radial N
  * active during sup and pro
• EDC = origin: lat epicondyle of humerus
  ins: extensor expansions of dig 2-4 and distal
  tendon of extensor digits minimize
  actions: extends carpus and dig 2-5
  nerve: deep radial N
• ECRL = origin: lat supracondylar ridge of humerus
  ins: base of MC 2
  actions: ext and radial deviation of carpus
  nerve: radial N
• ECU = origin: lat epicondyle of humerus and post
  border of ulna
  ins: base of MC 5
  actions: ext and ulnar deviation of carpus

When pt have been casted, after cast is removed they have a tendency to want to use the EDC to extend the wrist = put a pen or pencil in their hand and then have them extend the wrist this will force them to use their ECRB and ECRL

Question 14

Lateral Epicondylitis

Answer 14

NOT usually an inflammatory conditions
Tissue death due to:
* Microscopic tears of ECRB and EDC
* Calcifications = muscle started hardening and turning
into bone
* Excessive granulation = lots of scar tissue
* Alteration in neuropeptides = things that are not
supposed to be there
* Avascular areas = scar tissue
* Adhesions = things are stuck
* Mucoid Degeneration

Question 15

Immuno-reactive neurogenic component to lateral epicondylitis

Answer 15

Presence of Neuropeptides/Neurokinin 1-receptors, Substance P (SP) and calcitonin gene related peptide (CGRP)

Glutamate = good when it is supposed to be there but toxic if not supposed to be there. Toxic to nerve tissue and eats away at it, therefore free nerve endings increase sensitivity and pain.

Question 16

Evaluation Components

Answer 16

• History how long and how many times have they had LE
  (<12 weeks = acute) (>12 weeks = chronic)
• Cervical screening- Dermatomes and Myotomes
• Visual Analog scale (unidementional measurement of
  pain intensity
• Grip strength (elbow flex and ext if not in a lot of pain)
• Pinch strength
• Palpate for tenderness:
  radial head
  lateral epicondyle
  radial tunnel-crepitus, 2-5cm distal and ant to
  LE. Radial tunnel 4
  finger widths and dorsal
  over supinator
• Arcade of Frohse = where radial nerve bifurcates
  (dives deep) and can get
  trapped
• If posterior interoseus nerve gets pinned, it can look like
  LE
• Can have both radial tunnel and lateral epicondylitis
  (LE = tennis elbow and arcade of frohse = radial tunnel)
• If long finger extension test causes pain = ask where
  the pain is, LE = TE and arcade = RT
• Resisted wrist extension, supination (Cozen’s Test)
  pain = ask where and if pain at rest is greater than
  5 do not do resistance training
• ROM/Muscle tension with composite stretch
  progressively check positional progress and can use as a
  treatment tech, always stretch if non-painful
• Patient Rated Functional Assessment: PREE, DASH
• Muscle strength if not in a great deal of pain

Question 17

Grip Strength Tension Test

Indiana Hand Center

Answer 17

Should be seated
1) Elbow flexed
2) Elbow extended, wrist neutral and full pronation
Places tension on the origin (stretching and grip)
Positive = decrease in strength, probably TE
Negative = no decrease in strength, not TE
3) More challenging is extend arm horizontal to floor

Question 18

Treatment Interventions

Answer 18

• Always proximal to distal, correct posture (rhomboids,
  post delt) and strengthen coreForward shoulder and int rotation puts tension on
  lateral elbowExt rotation = puts force on medial elbow (Tommy
  Johns surgery)
• Determine whether condition is inflammatory or chronic

Question 19

Inflammatory Tendonitis

Answer 19

• Rest
• Ice massage or cold packs
• Cortisone injections
• Iontophoresis using Dexamethasone ( do not do
  if they have had a cortisone shot)
• Stretching exercises = as long as it is done progressively
  it should be pain free
  full stretch for ECRB = arm extended, hand in fist with
  ulnar deviation
• Wrist support = only decreases firing of extensors
  7%
• Tennis elbow strap = only works with power gripping
  wear 2 inches below LE, if worn wrong could compress
  radial nerve, good for placebo effect

Question 20

Chronic Tennis Elbow

Answer 20

• Most of what we see
• Scar tissue needs blood flow and remodeling (use heat)
• Exercise (graded eccentric exercises (help with
  concentric and let them do eccentric, want to remodel
  and elongate scar tissue, more reps less weight
• Best way to warm up tissue is active exercise, arm bike
  focused on extension
• Progressive stretching
• Joint mobilization (loosen up capsule)
• Modalities-Heat focus (hot packs)
• Strengthen core and correct posture

Question 21

Acute or Chronic Interventions

Answer 21

Long arm elbow splint for night wear, placing arm at 35 - 40 degrees of flexion to prevent extreme flexion which also places stress on the extensor origin

About 6 weeks if tolerated

Question 22

Physical Agents Modalities (PAMS)

Answer 22

• Ultrasound/Phonophoresis
  used to administer meds (dexamethasone)
  transcutaneously but now docs do cortisone
  injections (with cortisone may raise blood sugar
  if they have diabetes be aware)
• Cryotherapy
• Heat
• High volt Iastem
• TENS

Question 23

Exercise

Answer 23

Controlled and close to body, working toward farther away

Question 24

Instrument Assisted Soft Tissue Mobilization

Answer 24

Scar tissue massage through skin

Question 25

Kinesiotape

Answer 25

Opening over the arcade of frohse = decompress radial nerve, relaxing extensors

Question 26

Alternative Modalities

Answer 26

Acupuncture = Short term pain relief (24 hrs) Extracorporeal Shock Wave therapy: very expensive, cortisone found to be more effective Low Level Laser Therapy = no evidence except when used in combination with PT

Question 27

Cortisone injection

Answer 27

Occasionally work Dependent on timing of injection May have an effect on the sensory nerve response Cortisone injection can lead to cell death and atrophy and inhibits collagen synthesis

Question 28

Autologous Blood Injections/Protein Rich Plasma (PRP)

Answer 28

Induce healing by providing cellular mediators

Question 29

Botox Injections

Answer 29

Decreased muscle activity by blocking actylcholine gates

Question 30

Surgical Intervention

Answer 30

Open/Incision Arthroscopic Fasciotomy = fascia cut to relieve tension Debridement = clean up Percutaneous release = needle used to break up constricted tissue around tendon sheath Split procedure = lengthen ECRB 70-80% success rate Eventually resolves on its own in 2 yrs

Question 31

Exercise: | Selecting the most beneficial exercises based on tissue healing

Answer 31

Timing of exercise within the healing process needs to be adjusted for each patient Pain should be resolved or minimal when beginning resistance training Exercise should be performed without pain

Question 32

Progressive Stretching | Indiana Protocol stretches

Answer 32

An example of using the concept of non-composite (close to the body) and working toward composite movement (further away from the body) The next progression would include overpressure in non-composite and working toward composite with overpressure The patient is advanced when the stretch can be performed without pain or discomfort

Question 33

Progressive Stretching with Over Pressure | Mills Stretches

Answer 33

Be Careful!!! Aggressive stretching can cause damage to tendon All wounds result in scars and all scars contract Flexors and extensors should be stretched Start with elbow bent and passively use the other arm to apply over pressure

Question 34

Resistance Training

Answer 34

Stretch and controlled eccentric strengthening were found to have significant effects on decreasing pain and improving grip in the long-term Always start when pain level has decreased and non-composite first working toward composite

Question 35

Controlled Strengthening

Answer 35

Strengthening may begin once pain becomes minimal as long as it can be performed without increasing pain A general warm up on the UBE (forward motion) may be performed to increase blood flow. Exercised should be initiated in a non-composite (elbow flexed) position. Motions should be slow and controlled Could vary speed of motions between sets Eccentric exercises more effective (therotube = great for constant eccentric pull)

Question 36

Pronation/Supination

Answer 36

The ECRB is active during supination and pronation All forearm and wrist muscles should be strengthened as well as the rest of the kinetic chain including shoulder and elbow

Question 37

Wrist Flexion Biceps and Triceps Scapular Stabilizer Rotator Cuff and Scapular Stabilization

Answer 37

Perform all exercises slow and controlled May choose to start without resistance and advance Once patient can perform 3 sets of 10 the resistance can be increased Scapular Stabilizer = Prone extension Prone scaption Prone horizontal abduction Rotator Cuff and Scapular Stabilization = rhomboids and middle trap

Question 38

Speed, Accuracy, Neuromuscular Reducation

Answer 38

Advanced rehabilitation should focus on motor performance including speed of motion and reaction time Athletes Rhythmic Stabilization Specific Sports Training Work Hardening Ex: wad up newspaper into small ball and throw into trash

Question 39

Other beneficial exercises

Answer 39

Radial Nerve Glides ( not full extension) EDC exercises = rubber bands around fingers, putty (start close and work towards far away Clam shells (glut med) important to maintain neutral alignment of pelvis Neutral pelvis with isometric contractions of the transverse abdom Diaphragmatic breathing = keep tilt of pelvis neutral by tightening the transverse abdomen

Question 40

Activity Modification

Answer 40

Avoid repetitive wrist movements Avoid excessive finger extension (keyboarding) Avoid lifting (especially with arm in pronation) and pulling resistance-car door, refrigerator, brief case, coffee pot, skillet, jug of mild etc When using the effected extremity try to lift with the flexors with the forearm supinated and close to the body Maintain good posture = a forward internally rotated shoulder increases forces on the lateral epicondyle origin

Question 41

Sports Modification

Answer 41

Technique Interval Training Proper equipment = light racket made of graphite string tension 52-55lbs

Question 42

Medial Epicondylitis

Answer 42

Golfers Elbow Results from repetitive wrist and finger flexion or repetitive motion against resistance Involves the common origin of the wrist and finger flexors Ulnar nerve can get inflamed resulting in pain, tingling, and numbness in the ulnar nerve distribution of the hand Avoid lifting with forearm supinated and elbow extended

Question 43

Medial Epicondylitis Assessment

Answer 43

Palpation of the medial epicondyle Clear sensory and motor ulnar nerve at the cubital tunnel Do they have tingling?

Question 44

Trigger Finger - A1 Pulley Tenosynovitis

Answer 44

Tendon has to go through pulley system Can happen in multiple fingers Flexor Retinacular Pulley System: 5 annular pulleys 3 cruciate pulleys * A2 and A4 are necessary for finger mechanics. Prevent bowstringing ``` A1 - metacarpal head A2 - proximal phalanx A3 - PIP A4 - middle phalanx A5 - DIP ``` FDS and FDP run through the pulley system Pulley system keeps tendons up close to the phalanges and allows us to flex jt by jt by jt 3 cruciates usually at joints

Question 45

Dupuytren's

Answer 45

A fascial contracture = disease in the fascia (enzyme, hereditary). The fascia in the palm contracts, has pitting and thickening of fascia

Question 46

Trigger Finger

Answer 46

Swollen tendon creates a nodule that gets pulled under the bridge, can't get back out when trying to extend In early stage it can be manually released Common in the thumb

Question 47

Risk factors for trigger finger

Answer 47

``` RA OA DM Other inflammatory conditions Repetitive gripping Sustained pinching (thumb) ```

Question 48

Patient symptoms for Trigger finger

Answer 48

Tenderness at the level of the A1 pulley May c/o pain volubly over A1 pulley or with active flexion There might be a presence of a nodule or thickening Thickened flexor sheath can be palpated * Palpate for tenderness and thickness on palmar surface of A1 head (MC head) Don't confuse with Dupuytren's Disease Finger clicks when trying to straighten Finger gets stuck

Question 49

Green Classification of Staging for Trigger Finger

Answer 49

Grade 1 = Pain and tenderness at A1 pulley Grade 2 = Catching of digit Grade 3 = Locking of digit which is passively correctable Grade 4 = Fixed locked digit, joint contracture

Question 50

Trigger Finger Treatment

Answer 50

Conservative management through therapy Splinting: hand based flexion block fitted with MCP being the only jt immobilized in neutral extension (try to block MP flexion, allow PIP/DIP flexion, splint on one finger) include only involved digit or adjacent digit for comfort wear up to 6 weeks, usually 3-4 weeks Patient education: important with respect to modifying provocative activities, avoid or minimize activities that require repetitive gripping or demand a sustained pinch Digit is immobilized from making a full fist for up to 6 weeks (hook fist allowed in splint or intrinsic plus grasp is used). PROM can be performed to MP with IP extended at 3 weeks if MP flexion block is used At 4 weeks PROM to a full fist flexion, 5 times holding 10 seconds Progress re-evaluated after 6 weeks by assessing comfort during AROM If all that does not work: Medical Management: corticosteroid injection into tendon sheath Surgical Intervention: very easy snip the A1 pulley is released leaving the A2 pulley intact in patients w/ RA the A1 pulley is not released b/c this would enhance the biomechanical forces that are in part responsible for ulnar drift at the MP joint open procedure = 1cm horizontal incision Post surgical management: 2-3 days post op AROM 6x/day x 10min each isolated tendon glides, differential tendon glides, MP ext/flex with IP joints flexed - moving into extension as incision heals (2-3 wks) splinting is usually not necessary s/p release exception = limited MP or IP joint extension; wear at or if quite painful 10-14 days: scar management and desensitization techniques (silicone, heat, US, fluido, textures) 3-4 weeks: gently strengthening if wound has healed (putty, hand exerciser, HEP) * because they did not repair anything you don't have to wait 8 weeks, same with CTR

Question 51

Tigger Finger Exercises

Answer 51

Avoid full active flexion of the digit, but passively stretch to not get too tight Maintain PROM of each joint Perform individual joint blocking exercises (DIP, PIP, MCP) Perform finger extension exercises In severe cases = PIP blocking but it is better to block MCP b/c that is where A1 pulley is

Question 52

DeQuervain's Tenosynovitis

Answer 52

Inflammation or tendonosis of the sheath (retinaculum) of the tendons in the first extensor compartment Starts as an "itis" and turns into an "osis"

Question 53

S/S of DeQuervain's

Answer 53

Pain on the radial side of the thumb when pinching or grasping objects (radial styloid pain) Sometimes can see swelling Rule out CMC arthritis of the 1st Metacarpal joint by doing test (called differential diagnosis, always paint the picture for the doctor) Superficial branch of the Radial Nerve runs along the same path as tendons involved with this and it responds to tension and stress along with muscles when forces are applied

Question 54

The Extensor Compartments

Answer 54

6 Dorsal Extensor Compartments starting from radial side and working over to ulnar side 221211 = how many tendons are in each compartment longus, brevis, longus, brevis across First Dorsal Extensor Compartment: APL (abductor pollicis longus) EPB (extensor pollicis brevis) These pull the thumbs away from the palm Second Dorsal Extensor Compartment: ECRL (extensor carpi radialis longus) ECRB (extensor carpi radialis brevis) These extend and abduct carpus Third Dorsal Extensor Compartment: EPL (extensor pollicis longus) extends pollex and carpus Fourth Dorsal Extensor Compartment: EDC (extensor digitorum communis) EIP (extensor indicis propreous) extends carpus and digits 2-5 Fifth Dorsal Extensor Compartment: EDM (extensor digiti minimi) extends carpus and digit 5 Sixth Dorsal Extensor Compartment: ECU (extensor carpi ulnaris) extends and adducts carpus * If surgeon releases but does not release the sheath, it will not get better

Question 55

Intersection syndrome

Answer 55

ECRB and ECRL but as it crosses over APL and APB Pain is higher up

Question 56

DeQuervain's Tenosynovitis Diagnosis

Answer 56

Blackberry thumb Game keeper thumb = not DeQuervain's but ulnar collateral ligament * If you can visualize swelling, must measure edema and compare to the other side Positive Finkelstein's test (Eichhoff's test = active contraction with active stretch will cause tension, do not do this test) Pain along first dorsal compartment Decreased pinch and grip = lets us know how it is affecting function A nodule or thickening of the extensor retinaculum

Question 57

Eichhoff's test

Answer 57

This test aggravates the radial superficial nerve and can cause a false postitive Not specific or sensitive enough to test for DeQuervain's

Question 58

Finkelstein's test

Answer 58

Progressive tension testing = * ulnarlly deviate (forearm in neutral) no thumb * passively ulnar deviate (no thumb) * still ulnar deviation and then passively flex thumb positive if pain over the dorsal compartment is present when the wrist is ulnarly deviated while the thumb is held in flexion unlikely to have pain in the first 2 stages if chronic

Question 59

DeQuervain's Etiology

Answer 59

Frequently results from repetitive motion Could also result from blunt trauma to the styloid process Overuse and improper mechanics of gripping and wringing Pregnancy = Prolactin

Question 60

DeQuervain's S/S

Answer 60

Pain with grasp/release activities near base of thumb Edema near base of thumb Decreased range of motion: specifically in thumb Limited in flexion (stretch) and full extension (doing job)

Question 61

DeQervain's Tenosynovitis Treatment

Answer 61

Conservative management non-surgical (therapy and docs) could include medications All should get a thumb spica splint, most cross hand and immobilize ulnar deviation Must rest Splint: Thumb Spica Wrist 15 degree extension MP 10 degree flexion, thumb MCP midway between palmar and radial abduction 2/3 up forearm * splint doff qd (once a day) to perform isolated wrist/thumb AROM - progress to PROM * remove 4x/day for A/PROM to thumb and wrist separately * must be able to oppose to digits 2 and 3 Medical Management: NSAIDS Corticosteroid injections Surgical intervention Surgical intervention: decompression of first dorsal compt cut retinaculum 1cm incision vertical Post surgical therapy: initiate therapy within first 10 days (scar mobilization once sutures out) manual desensitization along super- ficial branch of radial nerve gently edema mgmt light compressive dressing gentle AROM / AAROM / PROM 4-6x daily x 10 mins 3-4 wks initiate wrist and thumb strengthening exercises as well as fx use of hand

Question 62

Intersection Syndrome

Answer 62

* Not as common as DeQuervain's but can be misdiagnosed = pain may be higher up and on dorsal side more than radial Tenosynovitis of second dorsal compartment crosses at the radial dorsal forearm (3 to 6cm proximal to the location of DeQuervain's or radial styloid) APL, EPB cross the ECRL and ECRB Repetitive motion or direct trauma Pain, crepitus (fascia has fluid bound up in it, soft tissue work is helpful), edema, point tenderness

Question 63

Intersection Treatment

Answer 63

Thumb spica splint with wrist in 15 to 20 degrees of extension Pt education: Avoid repetitive wrist flexion and extension with combined power grip Surgical: second dorsal compartment release

Question 64

Flexor Carpi Radialis and Flexor Carpi Ulnaris Tendonitis

Answer 64

* Any tendon can become fibroses or get "itis" * On computer typing all day and musicians float fingers while typing and don't type while resting on wrist pillows

Question 65

Extensor Carpi Ulnaris and Extensor Digitorum Communis

Answer 65

ECU = supination/pronation b/c in ECU sheath and if sheath not keeping it in place After casting = when cast removed our natural wiring EDC thinks it can move the wrist and if not corrected will get tendonitis * to correct put pen in hand and extend wrist to force them to use the ECRL and ECRB

Question 66

Impingement

Answer 66

Forward shoulder Scapular Dyskinesia Tight pectoralis minor Weak serrates anterior Sleeping posture Long head of the bicep gets inflamed from repetitive reaching or being "pinched" under acromion process Supraspinatus of the rotator cuff can also be impinged

Question 67

Proximal Bicep Tendonitis

Answer 67

Head of humerus Inflammation occurs where bicep tendon passes through the bicipital groove and over the head of the humerus, just like a rope through a pulley. Lots of overhead reaching or forward rounded upper back can be the cause

Question 68

Supraspinatus

Answer 68

Always strengthen rotator cuff Cross friction massage = always ext/int rotation to access supraspinatus

Question 69

Cross Friction Massage

Answer 69

Dr. James Cyriax Transverse friction massage (aka cross-friction and cross fiber massage) is a tech that promotes optimal collagen healing by increasing circulation and decreasing collagen cross-linking, thus decreasing the formation of adhesions and scar tissue Want to create a little inflammation to produce traumatic hyperemia and a histamine response to help flush the area of substance P

Question 70

IASTM (Instrument Assisted Soft Tissue Mobilization)

Answer 70

``` Graston ASTM Rockblades Baby spoons Jar lids Bones Rocks ```

Question 71

Impingement Treatment

Answer 71

Posture and Activity Modification * Must address Posture (static and dynamic) * Strengthen scapular stabilizers * Soft tissue work on the Pec Major, Minor or scalenes (tight) * Soft tissue work on the Upper trap and Levator Scapulae (tight) * Strengthen lower trap and rhomboid * Work on restoring the neuromuscular timing and control to correct the motor timing issue (Shirley Jarmen PT at Wash U, neuro-orthepedic approach)