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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
Innervation of supinator
Radial nerve (C5, C6)
26
What limits elbow flexion
(R-H, H-U) limited by muscle approx.; coronoid process engages fossa; 'Tissue Approximation'
27
What limits elbow extension
(RH, HU) limited by olecranon process contacting fossa; 'Bone to Bone'
28
What limits pronation
(Prox RU, RH) limited by radius contacting ulna 'elastic or tissue stretch'
29
What limits supination
(Prox RU, RH) limited by soft tissues ; 'elastic or tissue stretch '
30
Resting/lose packed position of humero-ulnar
elbow flexed 70 | forearm supinated 10
31
Close-packed position of humero-ulnar
elbow fully extended | forearm fully supinated
32
Radio humeral resting loose packed position
elbow fully extended | forearm fully supinated
33
Radiohumeral close packed position
elbow flexed 90 degrees | forearm supinated 5 degrees
34
Proximal radioulnar resting loose packed position
elbow flexed 70 degrees | forearm supinated 45 degrees
35
Proximal radioulnar close packed position
forearm supinated 5 degrees | interosseous membrane fully lengthened
36
inferior radioulnar open packed position
10 supination
37
inferior radioulnar closed packed position
5 supination
38
Capsular pattern - humero-ulna
more limited into flexion than extension
39
capsular pattern radiohumeral
more limited flexion than extension
40
Proximal radio-ulnar
equal supination/pronation limitation
41
Examination of the elbow
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
Examination of the elbow 2
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
position of elbow comfort for those with joint inflammation, pain or injury
80 degrees flexion - volume of air to space in joint is lowest -care maintaining this position for prolonged periods to avoid flexion contractures
44
Lateral Epicondylalgia characteristics
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
Source of symptoms LE
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
PE of LE
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
contributing factors to LE
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
Continuum of tendon pathology
pg 35
49
Research on lateral epicondylalgia
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
LE research cont
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
LE physio management
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
LE physio management
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
Medial elbow pain differential Dx
``` 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
Soft tissue lesions: medial epicondylalgia
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
ME physiotherapy management
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
Soft tissue lesions
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
Triceps tendinosis
``` caused by sudden extension e.g. weight lift, javelin posterior elbow pain pain with resisted elbow extension insertion triceps tendon (olecranon) tender ```
58
Distal biceps rupture
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
Joint disorders
compressed elbow -FOOSH damage to articular cartilage RH joint commonly associated with Colles fracture
60
loose bodies
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
Ulna nerve entrapment (C8-T1)
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
Median nerve entrapment (C6-T1)
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
Radial nerve entrapment (C5-T1)
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
Nerve entrapment treatment
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
What you need to know about elbows
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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