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Musculoskeletal Physiotherapy 2 > Week 5 > Flashcards

Week 5 Flashcards

1
Q

Elbow joint complex

A

4 articulations
-involving 3 bones

proximally, 3 joints

  • humeroulnar
  • humeroradial
  • proximal radioulnar

*single synovial membrane and capsule

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2
Q

Elbow joint complex distally

A

1 joint

  • distal radioulnar
  • -ulnar notch of radius
  • -ulnar head

Allows full pronation and supination

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3
Q

Humeroulnar joint characteristics

A

Uniaxial joint

concave trochlear notch of ulnar and convex trochlea

Congruence and shape limits motion primarily in sagittal plane
- provides large degree of elbow joint structural stability

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4
Q

Radiohumeral joint characteristics

A 
Uniaxial hinge (modified)
Fovea of radius head and rounded capitulum

Limits sagittal plane stability BUT provides 50% resistance to valgus force

Any motion at elbow or forearm requires movement at this joint
-pain or limited motion can disrupt functional mobility of entire distal upper extremity

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5
Q

Radioulnar joint characteristics

A

uniaxial joint

proximal radio-ulnar

  • circumference of radial head
  • ulna radial notch & annular ligament

Both proximal and distal allow pronation and supination

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6
Q

Normal valgus angle between humerus & ulna

A

Normal = approx. 15 degrees
males - 5-10
females - 10-15

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7
Q

Function of the carrying angle

A

allows forearm to clear hip during arm swing of gait

slightly increases when carrying / lifting loads

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8
Q

Carrying angle abnormalities

A

Cubitus valgus - >15 degrees

Cubitus varus -

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9
Q

Elbow ligaments and capsule

A

articular capsule encloses HU, RH and proximal RU joints

Synovial joint

Reinforced by collateral ligaments

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10
Q

Medial (ulnar) collateral ligament

A

has 3 bundles

  • oblique anterior
    • stronger, most important functionally
  • oblique posterior
  • oblique transverse ligament

Resist valgus stress
- more commonly sprained

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11
Q

Lateral collateral ligaments

A

no discrete radial collateral ligament
radial collateral ligament
lateral ulnar collateral ligament

resist varum stress
-less commonly sprained

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12
Q

Annular ligament

A

‘pulled elbow’ syndrome
excessive pull on hand can result in radial head slipping through annular ligament

-young children susceptible

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13
Q

Elbow flexors

A

biceps brachii
brachialis
brachioradialis
pronator teres

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14
Q

Elbow extensors

A

triceps brachii

anconeus

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15
Q

Forearm pronators

A

pronator quadratus
pronator teres

secondary*
Flexor carpi radialis
palmaris longus
brachioradialis (supinated position

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16
Q

Forearm supinators

A

biceps brachii
supinator

*secondary*
radial wrist extensors 
extensor pollicis longus 
extensor indicis 
brachioradialis (pronated position
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17
Q

Innervation of Brachialis

A

musculocutaneous nerve (C5, C6)

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18
Q

Innervation of Biceps Brachii

A

Musculocutaneous nerve (C5, C6)

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19
Q

Innervation of Brachioradialis

A

Radial Nerve (C5, C6)

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20
Q

Innervation of Pronator teres

A

Median Nerve (C6, C7)

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21
Q

Innervation of Triceps Brachii

A

Radial nerve (C5,C6)

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22
Q

Innervation of anconeus

A

Radial nerve (C5, C6)

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23
Q

Innervation of pronator quadratus

A

median nerve (C6, C7)

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24
Q

Innervation of Pronator teres

A

Median nerve (C6, C7)

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25
Q

Innervation of supinator

A

Radial nerve (C5, C6)

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26
Q

What limits elbow flexion

A

(R-H, H-U) limited by muscle approx.; coronoid process engages fossa; ‘Tissue Approximation’

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27
Q

What limits elbow extension

A

(RH, HU) limited by olecranon process contacting fossa; ‘Bone to Bone’

28
Q

What limits pronation

A

(Prox RU, RH) limited by radius contacting ulna ‘elastic or tissue stretch’

29
Q

What limits supination

A

(Prox RU, RH) limited by soft tissues ; ‘elastic or tissue stretch ‘

30
Q

Resting/lose packed position of humero-ulnar

A

elbow flexed 70

forearm supinated 10

31
Q

Close-packed position of humero-ulnar

A

elbow fully extended

forearm fully supinated

32
Q

Radio humeral resting loose packed position

A

elbow fully extended

forearm fully supinated

33
Q

Radiohumeral close packed position

A

elbow flexed 90 degrees

forearm supinated 5 degrees

34
Q

Proximal radioulnar resting loose packed position

A

elbow flexed 70 degrees

forearm supinated 45 degrees

35
Q

Proximal radioulnar close packed position

A

forearm supinated 5 degrees

interosseous membrane fully lengthened

36
Q

inferior radioulnar open packed position

A

10 supination

37
Q

inferior radioulnar closed packed position

A

5 supination

38
Q

Capsular pattern - humero-ulna

A

more limited into flexion than extension

39
Q

capsular pattern radiohumeral

A

more limited flexion than extension

40
Q

Proximal radio-ulnar

A

equal supination/pronation limitation

41
Q

Examination of the elbow

A

baseline functional movement
-is there something that you can do to provoke the pain ? (e.g. squeeze a ball)

Active movements

  • flexion/extension
    • extension with/without wrist & finger flexion : why?
    • supination / pronation

Passive range of movement

  • as AROM + abduction and adduction
    • stress collateral ligaments
  • If PROM > AROM
  • -suggests non articular / contractile dysfunction
  • If PROM = AROM
  • -possible articular dysfunction

Repeated movement testing

42
Q

Examination of the elbow 2

A

resisted tests - not just pain provocation but also consider relevance of any identified weakness

  • -elbow flexion / extension
  • -Wrist/hand flexion/extension

Consider quick test :

  • Mobilisation with movement for lateral elbow pain
  • -lateral ulna glide

Neurological differential diagnosis

Potential for Cx or Tx spine involvement

43
Q

position of elbow comfort for those with joint inflammation, pain or injury

A

80 degrees flexion - volume of air to space in joint is lowest

-care maintaining this position for prolonged periods to avoid flexion contractures

44
Q

Lateral Epicondylalgia characteristics

A

localised pain over lateral elbow +- forearm

  • varying severity
  • may be repetitive activities or minor ADL’s (lifting cup)

Occupation / sport involves gripping

Sudden or gradual onset

increased pain by specific activities e.g. backhand stoke, tightly gripping object, writing, shaking hands

45
Q

Source of symptoms LE

A

Local

  • ECRB Literature points to ECRB Tendon
  • Radial nerve
  • Post interosseousentrapment (radial tunnel syndrome)
  • RH joint synovitis
  • RH bursitis

Referred or secondary hyperalgesia

  • Cervical spine (C6 facet joints)
  • Thoracic spine (autonomic contribution)
46
Q

PE of LE

A

pain reproduced by

  • resisted wrist extension or radial deviation
  • resisted finger extension
  • grip examiner’s hand or finger

-stretching forearm extensor muscles causes pain

  • tenderness lateral epicondule, extensor muscles, radiohumeral joint line
  • palpation*
47
Q

contributing factors to LE

A

stiff elbow joint (asses passive ext/abd)
restricted cervical or thoracic spine
neurodynamics (ULNTT 2 )
Restricted shoulder movement (rotation)
Unstable or stiff wrist
training : technique, intensity, volume, equipment
work duties, equipment

48
Q

Continuum of tendon pathology

A

pg 35

49
Q

Research on lateral epicondylalgia

A

increasinglt thought that LE Is not inflammatory in nature
-may be degenerative
neurogenic inflammation may play role

2nd hyperalgesia
-include spine in Rx

Evidence suggests the combination of

  • local tendon pathology
  • changes in pain system
  • motor system impairments
50
Q

LE research cont

A

deficits in

  • gripping capacity
  • -pain free deficit > maximal grip
  • Muscle strength
  • -wrist flexors and extensors
  • -wrist extensors more affected than finger extensors

Morphological changes

  • -ECRB
  • Motor control deficits
  • -ECRB, EDC, FDP
51
Q

LE physio management

A

source of symptoms
-SSTM, friction, massage, MWM, joint/neural mobs, ET
-Exercises/advice
Counterforce brace
-Taping to unload and support radial head
-self mobs and stretching

Contributing factors

  • spine
  • shoulders
  • wrist
  • training factors, work factors
52
Q

LE physio management

A

insufficient evidence to reject or support the efficacy of any one treatment
-corticosteroid injection effective short term relief but poor long term outcomes
-electrotherapy?
preliminary research supports some Rx’s; particularly manual therapy and exercise
-consider multimodal approach

53
Q

Medial elbow pain differential Dx

A 
medial epicondylalgia (golfer's elbow)
Chronic medial collateral ligament sprain (little league elbow(LLE)
Arthritis 
Joint laxity
Loose body
olecranon/coronoid impingement 
referred pain
nerve impingement
54
Q

Soft tissue lesions: medial epicondylalgia

A

similar to LE but less common
pain over medial elbow
work/sport involving strong gripping and adduction movement of elbow

origin of wrist flexors and forearm pronator primarily involved

refers from Cx spine
-C8, T1 facet joints

55
Q

ME physiotherapy management

A

as with LE, but the opposite direction

source of symtoms 
-SSTM, friction, massage, joint/neural mobs, MWM, ET
exercises/advice 
counterforce brace
stretching 
contributing factors
-spine 
shoulder
wrist
training factors, work factors
56
Q

Soft tissue lesions

A

bicipital tendinosis/it is

-proximal radioulnar joint
pain cubital fossa
pain with resisted elbow flexion or forearm supination
insertion biceps tendon (bicipital tuberosity) tender

57
Q

Triceps tendinosis

A 
caused by sudden extension
e.g. weight lift, javelin
posterior elbow pain
pain with resisted elbow extension
insertion triceps tendon (olecranon) tender
58
Q

Distal biceps rupture

A

insidious but usually traumatic onset
-lifting
Primarily c/o weakness and altered appearance
active elbow flexion will still be possible though
-why
surgical intervention likely to be indicated

59
Q

Joint disorders

A

compressed elbow
-FOOSH
damage to articular cartilage RH joint
commonly associated with Colles fracture

60
Q

loose bodies

A

result of previous trauma
osteoarthritic cartilaginous or bony foreign body
osteochondritis dissecans of capitulum
Synovial osteochondromatosis (SOC)
–benign changes or proliferation in synovial/joint lining
–tissue changes to form bone forming cartilage
–only one joint affected

61
Q

Ulna nerve entrapment (C8-T1)

A

commonly in cubital tunnel after prolonged elbow flexion

  • tinel’s sign : ulnar nerve behind medial epicondyle
  • rarely - between 2 heads of flexor carpi ulnaris
  • pain or paraesthesia in sensory distribution
62
Q

Median nerve entrapment (C6-T1)

A

Above elbow
-under vestigial remnant of ligament of struthers (humerus shaft - medial epicondyle

below elbow
-as passes through the two heads of origin of pronator teres

Sensory symptoms similar to carpal tunnel syndrome

63
Q

Radial nerve entrapment (C5-T1)

A

divides at elbow into superficial sensory and deep motor branches

entrapment of superficial radial branch
-pain or altered sensation over radial (dorsal) aspect wrist or thumb

Entrapment of posterior interosseous deep branch
-difficult to differentiate between extensor tendinopathy
-more common in repetitive pronation and supination
-TOP of supinator muscle
-PALPATION
Pain on resisted supination at 90 degrees flexion

64
Q

Nerve entrapment treatment

A

address cause e.g. sstm; stretch tight muscles ; decrease swelling with ice, ET, rest, foam pads etc

neural mobilisation

medical

  • NSAIDs, cortisone injection
  • surgery (e.g. nerve transposition)
65
Q

What you need to know about elbows

A

anatomy - joints, muscles, ligaments, nerve and all palpable structures

examination of elbow

common clinical presentations
-and some potential treatments

Musculoskeletal Physiotherapy 2 (10 decks)

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