Wk 7 Flashcards
4 requirements to maximise healing
- minimise pain, swelling, inflammation, haemorrhage, to offer the best possible conditions for healing
- protection of DAMAGED tissue
- controlled mobilisation during the collagen
maturation and remodelling initiation phase. - progressive loading of the tissue
what is radial head fracture Mx guided by?
surgeon
Type I radial head # Mx
- Short-term immobilisation (sling/brace) for 2-7 days then early ROM (especially
extension) - Some evidence that doing ROM too early (i.e. day 1 or 2) can increase pain and
delaying ROM (>7 days) can lead to stiffness
Type II-IV radial head # Mx
- typically require ORIF
- Type III might need arthroplasty (i.e. partial elbow replacement) if > 3 fragments
complications of elbow dislocations
- long term loss of extension
- heterotropic ossification
- chronic posterolateral instability
elbow dislocation Mx
early active management
EBP elbow disloc Mx
started active ROM after 2 days
(within pain) but no passive ROM for first 3 weeks (sling
for first 2-3 days as needed).
Complex dislocation Mx
e.g. after terrible triad
ORIF typically required for majority cases
what do you do post ORIF for terrible triad?
- follow surgeon’s orders
- commence hand and wrist ROM immediately
what is kept on after ORIF for terrible triad?
brace for 24/24 except during ROM exercises (regular short sessions through day) which start day 7-10
what position helps stabilise elbow by activating triceps
Gentle elbow AROM can be done with lying supine with shoulder supported at 90 degrees flexion - active assist flexion and extension to -30 degrees
COMPLEX DISLOCATION MX
how many weeks is the protext repair phase?
0-2
COMPLEX DISLOCATION MX
instructions for protect repair phase
- Keep brace on except when doing exercises
- Commence hand/wrist ROM immediately
- Gentle elbow AROM can usually start after ~7-
10 days (check with surgeon!) - Avoid extremes of flexion & extn
- Static isometrics (biceps, triceps, brachialis) in
brace`
COMPLEX DISLOCATION MX
Increase ROM and strength phase week
2-12
COMPLEX DISLOCATION MX
instructions for increase ROM and strength phase
- Brace usually removed by week 3
- Continue elbow AROM
- Commence gentle PROM (no aggressive
stretching or pushing PROM due to HO risk) - Commence graduated strengthening from
~week 6 around elbow and shoulder
COMPLEX DISLOCATION MX
Strength and conditioning phase week
12 +
COMPLEX DISLOCATION MX
Strength and conditioning phase instructions
- Incorporate more functional activities/demands
think about kinetic chain - Typically avoid high impact activities/sports
until 6 months post-op
signs & symptoms of medial epicondyle avulsion #’s
- sudden ‘pop’ during a throw followed by pain
- point tenderness is elicited over the medial epicondyle
- although a fracture is usually an acute traumatic event, MEA # is frequently preceded by a history of medial elbow pain
- often associated with an elbow dislocation
MEDIAL EPICONDYLE AVULSION MX
<5mm displacement
above-elbow backslab @ 90* elbow flexion for 3 weeks
- backslab & sling should be worn under clothing
MEDIAL EPICONDYLE AVULSION MX
5-15mm displacement
Mx = dependent on number of factors, including; age, sporting activities
MEDIAL EPICONDYLE AVULSION MX
>15mm displacement with elbow disloc
- reudction +/- ORIF
- closed reduction for dislocation performed –> order repeat X-rays to check that the medial epicondyle fracture is not trapped in the jt (any doubt, urgent ORIF)
MOI MCL tear/ medial instability
repeated strain on MCL via throwing
MCL tear/ medial instability presentation
- laxity on valgus stress test (/ pain with moving stress test)
- pain over medial elbow during flexion, throwing
- possible swelling (absent often in chronic)
- loss of ROM ext
- unable to throw at full speed
- Ulnar nerve sensitivity
- positive radiographic exam
when is conservative Mx of MCl tear needed?
for partial tears and even with full tears
what is used to protext the elbow from valgus stress in MCL injry
rest and splint bracing / taping
what do you avoid with conservative Mx with MCL tear?
passive ROM ext
what should you restrore with MCL tear?
elbow/ wrist flexor/ extensor synergies important
what do you avoid with MCL/ medial instability
actitvies that promote valgus stress
exercise guidelines for MCL tear/ medial instability
- Pain free ROM - while avoiding valgus stress
- Proprioception
- Strength (wrist flexors, elbow flexors/ extensors) – initially in brace
- Sport specific activities
- Isometric –> isotonic –> proprioceptive –>plyometric/functional
what happens if conservative Mx fails for complete tears?
then surgery is required (UCL reconstruction), also know as Tommy John surgery
long-term problems of acute traumatic elbow injuries
- Loss of ROM (especially extn) – linked to duration of immobilisation
- Loss of strength (elbow/wrist/shoulder)
- Recurrent instability
- Heterotopic ossification
- Neurovascular compromise
- Chronic pain syndromes
ulnar nerve injury typical MOI
traction with throwing activities
causes of ulnar nerve injury
- Anatomical/congenital
variations - Perineural adhesion
- Joint disease/osteophytes
- Prolonged bed rest
- Leaning on elbow
(repetitive minor trauma)
signs & symptoms of ulnar nerve injury
- Common in 30-60 yr olds
- Posteromedial elbow pain
- P & N / numbness / weakness
- Pain on palpation of nerve
- History – traction versus compression (secondary
to valgus instability) - Radiographs – osteophytes and DJD
- May report snapping – hereditary subluxation
over the medial epicondyle (stretch aetiology
rather than compression)
ulnar nerve injury Rx
- Avoid sustained elbow flexion
- e.g. when sitting, sleeping – splinting may help
- Avoid repetitive elbow flexion and pronation
- Avoid vibratory tools
- Vitamin B6 (evidence??)
- Improve flexibility of forearm/wrist flexors and
pronators - Surgical intervention if conservative management
fails
what is lateral elbow tendinopathy?
pain over the lateral humeral epicondyle/ radiate distally into forearm due to a degeneration/ trauma to the common extensor tendon over time.
risk factors of LET
- handling tools heavier than 1
kg - handling loads heavier than 20 kg at least 10 times per day
- and repetitive movements for more than 2 hours per day
CLINICAL PRESENTATION OF LET
History
may be associated with repetitive use
CLINICAL PRESENTATION OF LET
Area of Pain
- lateral epicondyle +/- into forearm
- not radiating above elbow
- not neural symptoms (DDx with RTS)
CLINICAL PRESENTATION OF LET
Painful activities
- POP over lateral epicondyle
- pain on resisted iso wrist extension or 2nd/3rd finger extension
- pain on gripping
CLINICAL PRESENTATION OF LET
Behaviour of symptoms
- functional movement = sore –> grip, twist, lift
- LE specific patient functional questionnaires (PRTEE)
3 components of the integrated model of multifactorial pathology for LET:
- tendon pathology
- motor control impairments
- sensory system impairments
when is medication and/or interventionist medical Rx recommended?
with those with poor prognosis / failure to progress after 12 weeks of conservative Mx
which tendon is most affected in LET?
ECRB
pathophysiology of the tendon pathology changes in LET?
increased solularity, increased ground substance –> Neurovascular ingrowths that can = more pain
how do you Mx the tendon pathology impairment of LET
EPA, MWM, Polidocanol, steroid, exercise
how is the sensory system affected in LET?
central changes have occurred –> can tolerate less pain e.g. less ice time
Mx of sensory impairments for LET
Blood, Prolotherapy, Polidocanol, Exercise
motor control impairments in LET
- grip in a more flexed position
- extend through MCPs
- poorer rxn time on each side
- weaker generally
how to Mx motor control impairments of LET
EXERCISE
what does the EBP recommend as a Rx pathway for LET?
- Advice and Education (First level) vs wait and see
- Exercise (+/- MWM)- graded and progressive for 8 weeks
- Manual Therapy- MWM’s and C/Spine mobilisations
components of A&E for LET
- Tendinopathy explanation
- Load management
- Palm up lifting
- WHS review- tools/ work station/ equipment/rest breaks
- Self-management
- Lifestyle modifications- sleep, nutrition, exercise, smoking
- Counsel regarding injections
components of exercise for LET
- Isometrics (pain) – not terribly effective in isolation
- Concentric
- Eccentric (better than concentric for pain relief in early stages)
- General upper limb strengthening (RC, deltoids, biceps, triceps…)
- Functional strength
- CV fitness
components of manual therapy for LET?
- MWMs (pain Mx)
- cervical spine mobs
- NDT mobs
what A&E is most important for LET?
- what tennis elbow is
- activity modification
CST injection for tennis elbow
- short term benefits (4-6 wks)
- > > likelihood of recurrence vs placebo/ no injection
specific elbow considerations
1. grip posture retraining
- palm down/ thumb up (avoid MCP extn)
- extended wrist posture = very importnat
when are isos good for LET?
if too painful to do isotonic
exercise
aim of isos
pain relief
when the aim = to increase strength and function, what happens to isos?
not in isolation
dosage of isotonics for LET?
typically 3 sets of 10-15 reps, rest of ~1min between sets, 5-7 sessions per week.
dosage of isos for LET
3-5 sets x up to 45-60secs daily.
what do you do, for LET, if most painful gripping/ extending wrist when elbow in extension + pronation ?
try strengthening in elbow flexion and in a neutral pron/sup position (or even supinated)
If it is too painful to move through full range at the wrist for LET…
start with isometrics or perform in a limited ROM
If they can do some repetitions of isotonic exercise (LET)…
start there (not always start with Isos)
other Rx options for LET
- Manual therapy – particularly MWMs
- Taping
- Bracing
what is an MWM effective for doing in LET?
increasing pain-free grip strength (acutely)evide
evidence for elbow brace
= mixed; may be effective short term for pain
RTS MOI
repeated use of extensor/ supinator muscle mass
RTS definition
compression of deep branch of radial nerve (posterior interosseous nerve- PIN as it passes through the supinator
when is the PIN particularly vulnerable?
with humeral #’s and post-surgery
RTS SIGNS & SYMPTOMS
where is the pain?
relatively deep in upper forearm (distal to elbow)
RTS SIGNS & SYMPTOMS
When is the pain agg?
gripping & twisting tasks
RTS SIGNS & SYMPTOMS
what is TOP and where?
radial nerve - between triceps and biceps laterally, over supinator, in snuff box
RTS SIGNS & SYMPTOMS
What can RTS lead fo?
weakness of thumb abduction /
extension, extensor digitorum & ECU and sensation
changes around dorsum of hand (btw thumb and
index finger)
what is the dominant feature of RTS?
pain»_space; strength loss / sensation change
RTS Rx
Proposed Physio Mx =
- Early management is crucial to try and prevent damage to the
nerve through either ongoing trauma or secondary inflammation and swelling. - Flexibility and postural exercises–> trunk, cervical and thoracic spine to reduce any role posture may have on the nerve tissue.
- Cervical/ thoracic mobilisations and NDT techniques (radial
nerve ULNT2B) sliders to assist with the mobility of the nerve.
characteristics of osteochondritis dissecans
Poorly localised lateral elbow pain, with crepitus,
catching and locking
are swelling and flexion contractures present with OD?
sometimes
OD creates…
laxity of MCL
where is OD TOP?
capitellum through elbow flex/ext
what is the Rx goal for OD?
prevent symptoms, not cure it
Rx for a non-displaced lesion
- Sports physician/Orthopaedic RV required
- Rest, gentle ROM ex initially (prevent loss of extension ROM)
- Gradual strengthening around shoulder, elbow, wrist and kinetic chain to prepare for loads associated with throwing
- No throwing until symptoms gone and full ROM restored
Rx for a displaced OD lesion
- Sports physician/Orthopaedic RV required
- Rest
- Arthroscopic debridement, removal of loose bodies
- Post-op physiotherapy Mx will focus on restoring ROM then strength
- Poor prognosis – older patient, larger lesion, lesion on a weight-bearing area
medial epicondylalgia presentation
More typical tendinopathy presentation– reactive
(inflammatory) through to degenerative. Presentation may be
acute, sub acute or chronic
what does golfers elbow respond well to
conservative Mx
area of pain for golfers elbow
over the medial epicondyle, forearm flexors, pronator teres
golfers elbow aggs
- Resisted wrist flexion and ulnar deviation
- Resisted pronation
- Passive elbow and wrist extension in supination
- History of increased load or change of
technique/ equipment
Golfer’s elbow Rx
- Isometrics - to target pain if necessary (30-45second holds x 5)
- Isotonics- long slow load/ concentric/ eccentric strengthening and progressive load
- Eccentric programs (3 sets 15 reps twice daily)
- Counterforce brace
- Address technique/equipment/biomechanical faults
- Kinetic chain- address shoulder, trunk, lower limbscreening and global strengthening and flexibility
- Functional rehabilitation- links to shoulder approaches
- Surgical intervention if conservative treatment fails
(unusual)
what is posterior impingement caused by (3)?
- repetitive hyperextension / valgus stress overload syndrome - adolescent throwers
- valgus instability
- OA in the older patient of the radiohumeral jt
what can Repetitive hyperextension/ valgus stress overload syndromeadolescent throwers (chronic issue) cause
bony spurs at olecranon tip on fossa -> flexion
deformity (ie. elbow can’t fully extend)
what does valgus instability, posterior impingement, cause
Olecranon not fitting into fossa -> postero-medial pain
how can OA in the older patient cause posterior impingement
generalised osteophyte formation- flexion deformity and
pain on extension
posterior impingement of the elbow Rx
- Rest from aggravating factors- may use ROM limiting
brace if compliance poor - Restriction of extension movements and throwing
- Return of pain free ROM
- Increase strength and stability at joint- supinators/
pronators, flexor/ extensor strength - Correction of throwing technique
where can the median nerve get entrapped?
- above elbow at
ligament of Struthers - or below elbow between pronator teres and at carpal
tunnel
symptoms of median nerve entrapment
sensation changes and/or
pain at palmar aspect of hand and fingers
+/- weakness in wrist flexors
where does the radial nerve divide and into what branches?
at elbow into
superficial sensory and
deep motor branches
what does entrapment of the superficial branch of the radial nerve cause?
pain/ altered sensation over
radial aspect of wrist or
thumb
what can radial nerve entrapment impact?
wrist ext
where can the ulna nerve be entrapped?
at Arcade of Struthers (above elbow)
- at medial epicondyle
- cubital tunnel
*Sometimes between two heads of flexor carpi ulnaris
symptoms of ulna nerve entrapment
Pain or paraesthesia in sensory distribution
+ve… for ulnar nerve entrapment
tinels sign
nerve entrapment Mx
address causes
- posture
- anatomical/ biomechanical reasons
- muscle imbalances e.g. stretch tight muscles, improve core strength etc.
- NDs +/- mobilisation: sliders and tensioners
Medical
- cortisone injection
- surgery
- NSAIDS
