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113 Cards in this Set
- Front
- Back
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Ligaments of the Elbow
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Ulnar collateral ligament: 1° stabilizer from posterior distal aspect o medial epicondyle to base of coronoid process. majority of resistance to valgus stress at 90* Injured in throwing sports
Annular Ligament: around head of radius, retains contact w/ radial notch of ulna Radial collateral ligament: connected with annular ligament |
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Stability & Motion at the elbow Joints
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Stable Medial &Lateral due to collateral ligaments
Less stable anterior-posterior humero-ulnar joint: Flexion/Extension, Abdxn/Addxn gluiding proximal radioulnar joint: pivot action for pronation and supination humero-radial joint: assists pivot & glide |
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INterosseus membrane
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Fiber run from distal medial ulna to proximal lateral radius
stabilizes for mvmt shares compressive forces from shoulder and wrist between bones. |
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rotational motion of the elbow
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Test w/ elbow in 90*
Ends of radius move in opposite directions Pronation: head glides posterior, distal radius goes anterior Supination: head anterior, distal radius goes posterior we live in a pronated world |
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Joints of the Wrist
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radiocarpal:distal radius to scaphoid & lunate
distal radioulnar ulnar and radial collateral ligaments TFCC:triangular fibrocartilage complex ligaments and a meniscus between the radius ulna and triquetrium fibrocartilagous joint |
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Carrying Angle
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5* in males
12* in females ↑ if overweight, SD addxn/abdxn of wrist and elbow are reciprocal so that you can move food to you rmotuh ABdxn at elbow → ADdxn at wrist ADdxn at elbow → ABdxn at wrist possible to tx carrying angle w/ ME at wrist |
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Dermatomes of the Arm
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C5- lateral arm, axillary nerve
C6- lateral forearm, musculocutaneous nerve C8- medial forearm, antebrachial cutaneous nerve T1- medial arm, brachial cutaneous nerve. |
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Ulnar Nerve Entrapment
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Handlebar use: loss of sensation, cannot flex 4 &5th digits → claw hand
Cubital Tunnel Syndrome: Entrapemnt of the Ulnar Nerve at the elbow; flexor carpi radialis > FC ulnaris → wrist is drawn to radial abdxn |
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Compartment Syndrome
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Pressure
Pain out of proprotion & w/ passive movement Paralysis Paresthesia Pulselessness Pallor |
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Muscle imbalance in arm
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Tonic: flexion & pronation
Phasic: extension & supination |
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Tennis elbow
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lateral epicondylitis/tendinosis from overuse: rotation of arm & extension of wrist, turning a screwdriver
lifting w/ palm facing down increases pain: have pt try to lift a chair holding it from back pain reduced by: pt in Losee posotion: elbow flexed to 90* placed acorss the abdomen faced up + pressure 1" bewlo lateral epicondyle Tx: 90+% respond to conservative tx: rest, forearm strap during activities, heat/ice/US/electrical stim, 2 wks NSAIDs, 1 wk oral corticosteroids Injection of steroids into maximum area of tenderness max 3x once pain ↓ stretching, & strengthening non responders: fasciotomy |
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Carpal tunnel syndrome
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Pressure on median nerve, [many causes: esp repetitive mvmts, may be proximal median entrapment...tho tx the pt not the sx: neuropathy 2° hypothyroidism]
Initially: transient pain/parasthesia of median nerve distribution, relieved by shaking; worse at night & with provocative mvmts ± tinels/phalens ischemia 2° to blocked outflow & eventually inflow → Progressive: constant P/P, weakness of thumb, atrophy of thenar eminence Tx: OMTE, PRICE, Splint → sugical injx of retinaculum, decompress'n OMT: ↓ SNS via thoracic & rib SD, ↑ brachial plexus fnx via cervical/TO SD, remove myofascia restriction in UE, direct techniques ↑ space in carpal tunnel |
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Tinel sign
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tapping median nerve produces pain/paresthesia of carpal tunnel
± present in early stages |
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Phalen's test
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reverse prayer position dorsum to dorsum reproduces pain/parestheis of carpal tunnel ≥ 1 min
± present in early stages |
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Weakness of thumb atrophy of thenar eminence
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hallmark of progressive carpal tunnel syndrome
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Bilateral CTS
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Hypothyroidism
Diabetes Pregnancy Leukemia Paraproteinemia Gout Collagen Vascular Disease |
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musculotendinous jnx of forearm
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vulnerable to injury
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Retricted Pronation Tx
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ME: Doc stabalizes elbow w/ lateral hand, medial hand pronates forearm
HVLA: Doc in front, grasps proximal forarm w/ index finger of lateral hand over dorsal radial head, engage barrier of extension & supination + addxn; thrust in lateral/anterior direction |
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Retricted Supination Tx
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ME: Doc stabalizes elbow w/ lateral hand, medial hand supinates forearm
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Wrist Joint Play
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Doc's got index finger through web of thumb, hand otherwise rapped around dorsum of wrist doc's palm to pts dorsum; Other hand grasps ulna from ant & post
Distal radio-ulnar: move ulna back and forth Ulna-meniscal triquetaral Jont: with one thumb on posterior of ulna & index finger on volar aspect of pisiform bone, squeese two together repeat squeeze-release through doc's right hand |
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Repeat Steroid Injections
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Based on pt response to 1st
<1/3 improvement, 2nd wont help 1/3-2/3 improvement, 2nd indicated 2/3-full impvoement, 2nd wont help |
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Palpaiting the lateral elbow joint capsule
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only palpable if abnormal
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Origins of Extensors/Flexors of the Fingers &Hands
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Most extensors: Lateral epicondyule
Extensor indicis: dorsal aspect of midshaft ulna + IO membrane Extensor Pollicis Longus: middle posterior ulna + IO membrane |
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The anatomical stuff box
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.
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Tennis elbow injection
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adverse outcomes: loss of skin color at injx site, fat atrophy, infx, bleeding, tendone rupture, steroid flare; have a signed consent prior to injx
1. gloves + sterile technique 2:arm at side elbow flexed 3: palpate &mark tender area: ECRB Etensor carpi radialis brevis just distal to lateral epicondyle 4: clense with iodine, then wipe iodine away with EtOH to prevent skin irritation 5: 25 guage 1/5 in needle, bounce off bone & inject 1 ccof solution (lidocaine & steroid). Continue to bounce & inject all 5 cc 6 dress w/ sterile adhesive banade aftercare:pain may increase for 2 days, often improves with ice. narcotic analgesics may be necessary |
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Which is more common:
anterior or posterior radial head dysfnx |
posterior (pronation)
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Reverse Phalen's
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Praying Hands
specific not sensitive, useful for determining degree of CTS |
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Carpal tunnel compression test
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Most sensitive test for CTS
Doc supports wrist w/ one hand uses other hand to compress over distal flexion crease for 1+ minute + if ssx CTS |
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most sensitive test for CTS
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Carpal Tunnel Compression Test
Doc supports wrist w/ one hand uses other hand to compress over distal flexion crease for 1+ minute + if ssx CTS |
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Allen's Test
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Determining Patence of the Radial and Ulnar arteries at the wrist
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HVLA for wrist dysnfx
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Grasp pts hand on side of dysnfx, localizes dorsal radiocarpal joint with thumbs. [anterior dysfnx, wrist in extension]
Doc exerts whip like thrust while exerting downward force through the carpal bone contraindicated if pt has significant pain with normal ROM |
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Flexor retinaculum stretch
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AT Still's Wrist Technique
Doc interlaces fingers of both hands and encircles the pts wrist doc's thenar eminence contact wrist over flexor retinaculum compression provided by physician as pt opens & closes hand 5+ times |
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AT Still's Wrist Technique
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Flexor retinaculum stretch
Doc interlaces fingers of both hands and encircles the pts wrist doc's thenar empinence contact wrist over flexor retinaculum compression provided by physician as pt opens & closes hand 5+ times |
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Oppen's Roll
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Sucher Technique
pts hand palm up, doc's thumbs over hypothenar and thenar eminences. simulatensously abudct extend & laterally rotate the tumb while adducting, edxtending and internally rotating the 5th digit. may be accqntuated by lacint 5th digis in pts 1st & 4th web sapaces |
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Sucher Technique
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Oppen's Roll
pts hand palm up, doc's thumbs over hypothenar and thenar eminences. simulatensously abudct extend & laterally rotate the tumb while adducting, edxtending and internally rotating the 5th digit. may be accqntuated by lacint 5th digis in pts 1st & 4th web sapaces |
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Self Stretches for Carpal Tunnel Syndrome
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Extension Dorsiflieixion Stretch: Place hand flat up against wall with fingers pointed up, forearm pronated, elbow fully extended. Lean into wall, hold for 5 seconds, relax
Repeat w/ forearm supinated Plamar Flexion stretch: same except back of hand against wall apparently nothing about switching this one to have forearm pronated |
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TOS
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pain, numbness or weakness in arm 2° to compresssion of brachial plexus at cervicobrachial jnx
Typically in ulnar distribution 2° to repetitive use, peak onset 30's, overwhelmingly females younger onset probably congential bilateral ≈ probably not TOS Sites of entrapment:anterior scalene, costoclavicular region, pect minor |
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Thoracity Outlet vs Inlet
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Inlet is boney strx: T1 1st rib, Manubrium
Outlet is everything that goes through inlet |
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Mechanism of Anterior Scaline Dysnfx
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Hyperextension Injury of Neck
Poor posture w/ head forward fatigue of respiratory assist exhaled 1 and 2nd rib |
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Brachial plexus /costoclavicular region mexhanism of dysfnx
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inhaled 1 or 2nd ribs
inferior clavicular head dysfnx abnormal clavicle pain normally along ulnar distribution |
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pect minor mechanims of dysnfx
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Hyperextension in jury of shoulder
overuse/fatigue of muscle exhaled rib abnormal position of corocoid process |
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Factors which predispose to TOS
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Cervoc;a robs. ;pmg tramsverse [rpcess pf C&
abnormal/SD of 1st rib Scalenes postural changes trauma degenration CT disease Tumor Distal areas of SD |
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Adson's Test
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arm extended posteriorly with head turned away form affected sde
+ w/ reproduction fo neurologic symptom indicates nerve root impingement proximal to brachial plexus → hypertonic anterior/middle scalenes |
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Pain referral of scalenes
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anteiror and middle attack to TP of C4-5 to the first rib
tenderpoint is in body of muscle tx:flexion forward SB/rotate towards |
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Military posture Test
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aka Costoclavicular MeCostoclavicular Maneuver
Head is extneded with shoulderr retracted positive if diminished radial pulse or reprodxn of neruologic sx indicates nerve root impingment distal to brachial plexus: indicates inhaled 1st rib or inferior clavicle |
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hyperextension test
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arm is extended behind and raise up to 90*
positive if dimihsed pulse or reprodxn of neurologic sx indicates hypertonic pect minor and attachment to humorus |
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Pain referral of pect minor
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attaches form ribs 3-5 to coracoid process
tp is 3 cm inferior to coracoid process 1-2 cm medial or in muscle belly tx arm addx diagonally across chet in plane of muscle |
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Axial compression test
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Pt seated, doc pushes straight down on head
positive induces pain or numbness at distribution of spinal pathology degenerative disc, spinal setnosis et al. |
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Tx TOS
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OMT
postrual education wegiht redxn PT avoid aggravating factors surgical if comlications |
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Sensory, Tendon, Motor testing of UE
Which is most sensitive |
DTR's: C5: Bicpes, C6: briochioradialis, C7: Triceps
Sensory: C5 lateral arm C6 voalr index finger, C7 volar middle finger, C8 volar 5th giner, T1 volar medial forarm Motor: C5 Biceps, C6 Wrist extension, C7: triceps, C8: finger flexn, T1: Inerossei: finger abdxn addnx |
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Costoclavicular Maneuver
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"Military Posture Test"
Head is extneded with shoulderr retracted positive if diminished radial pulse or reprodxn of neruologic sx indicates nerve root impingment distal to brachial plexus: indicates inhaled 1st rib or inferior clavicle |
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Jackson's Test
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Slightly side ben c-spine to affected side then apply axial compression
repeat with head to other side + if sx elicited on affected side |
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spurling maneoer
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provocative test to exacerbate encroachment of cervical nerve root at neural foramen
extnesion and rotation of neck towards teh involved side + axial load older pt:foraminal stensosis younger pt: intervertebral disk prolase |
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Coutnerstain for posterior rib tenderpoint
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which would be found in an exhaled rib dysnfx
doc's knee up on dsyfnx side, sidebend pt towards dysfnx, head sidebent towards, rotated away + flex/ext for fine tuning |
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ME for Exhaled Rib Dysnfx
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Anterior and middle scalene go to rib 1
posterior scalene to rib 2 woe is me, doc pushing anterior and down on posterior aspect of rib w/ pt inhaled and raises head toward ceiling to tx 1st rib pt head in neutral rib 2 head rotated away |
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Coutnerstain for anterior rib
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TP for first rib is ON THE EDGE OF THE STERNUM just below sternoclavicular joint
TP for 2nd rib is midclavicular line at 2nd rib interspace Doc's knee opposite dysfnx, pts head flexed rotated and sidebent toward tenderpoint more flexion for 2nd than first |
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ME for inhaled rib dysnfx
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flex sidebend toward involved rib, caudal pressure on rib anteriorly
w/ exhaled pt, return to neutral first rib in supraclavicular fossa 2nd rib just below the clavicle |
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Superior Clavical Head ME
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Pt supine, arm hanging down
doc stabalizes pt and extends & internally rotates arm works on pect major |
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ME for anterior Clavicular Head
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Pt supine, grabs doc's shoulder
One hand on proximal clavcicular head one hand hodlign scapular doc flexes clavical toward the maneubrium until mvmt palpated at sternoclavicular joint by straightening back and pulling scapula anteriorly pt pulls down |
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Chin Pivot HVLA
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Flexed dysfnx
stand on sdysfnx side side bend neck opposide dysfnx rotated head twoard dysfnx cross hands, one on pts head other hypothenar eminance over dysfnx tp take up slack, thrust in lateral, downward caudad direction |
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Hypertonic Structures of the Shoulder
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Shoulder Capsule (ant & Post)
Upper Traps Levator scap SCM Scalenes Lats Pects (Maj & Min) |
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Inhibited Shoulder Muscles
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Middle &Lower Traps
Serrratus Anterior Deep Cervical Flexors (Longus Colli, Longus Capitus) Rhomboids Abdominals |
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Dstinguishing Key Cervical Restrictors
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Restriction Sidebending & Rotating to Opposite Sides:
Upper Traps, SCM, Scalenes Restriction Sidebending and Rotating to Same Side: Levator Scaps |
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Latissimus Dorsi
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gets hypertonic
inervated by cervical nerves Great Integrator: connects Ilia, sacrum, lumbar & Thoracic spine, lower 4 ribs and anterior humorus |
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FRS in teh lower T spine
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esp T11 L and T12 R or Bilaterally flexed
frequent from slumped posture Inhibits lower traps |
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Levator Scap
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Only cervical muscle which sidebends and rotates to same side
C1-C4 to scapula associated with C2 dysnfx |
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muscle associated with C2 dysfnx
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levator scap C1-4 to Scapula
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T4 ERS L
T5 ERS R T6 ERS L |
Alternating stacked ERSs in mid Thoracic region
Inhibitor of Serratus Muscles marked flattening of mid scapular area |
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Tonic/Phasic Deep spinal muscles
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Rotatores get tight:tootsie roll bump
semispinalis, levator costales intertransversaria and multifidi get weak |
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Where can you palpate the iliopsoas
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directly below the inguinal ligament
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Intercostals & Respiration
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Accessory muscles:
external inhale internal exhale |
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Tight anterior thoracis
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will restrict large circle UE rotation
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Tonic and Phasic Muscles of the shoulder
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Tonic:
Pects, Terres Major, Subscapularis, Teres Shoulder Capsule, (A & P) Note: pects get tight form weak traps & serrtus Phasic: Deltoids, non-subscapularis rotator cuff |
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Tonic and phasic arm muscles
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Tight Flexors
Weak Extendors forarm extesnors (weak) more vulnerable to overuse and injury → lateral epicondylitis |
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Treating tonic/phasic muscles
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Proprioceptive retraining
stretching hyptonic strengthning inhibited |
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Cervical Flexion Test
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Pt supine instruct to tuck chin and look at feet
tests for ewak longus colli tight SCM/Scalenes |
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Bilateral shoulder abduction maneover
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Tests for winging scapular/assymetrix
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Unilateral shoulder abduction maneover
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Ideal:
supraspinatus → Deltoid → Infraspinatus → Mid/Lower Traps → Contralateral QL Inhibited by tight Levator Scap Dysfnx: Traps Fire late, Ipsilateral QLinstead of contralateral |
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Scapular stablizeation Test
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wall pushup, pt asked to touch nose to wall and hold
for winging inhibited: serratus anteiror, lower traps, rhomboids |
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Scapular Derpession Test
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Pt prone, arm out in front, instruct pt to pull shoulder blade down and back
monitor lower trap testss for inhibited lower trap → htnic levator scap and uppper trap |
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Bilateral shoulder flexion test
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pt supine with knees bent
doc lifts arms above head and down observe for assymetryc: htnic Lat on side of restrction |
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Bilateral Shoulder Flexion Test
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Loss of symmetry: tight lat
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Anterior shoulder position test
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pt supine assess shoulder symmetry
dysfnx if shoulder anterior: tight posterior shoulder capsule, tight pect minor htnic shoulder capsule [levator scap, upper trap] inhibited mid/low trap, sererratus anterior, rhomboids pect minor substitudes → shoulde rimpingement syndrome esp on supraspinatus tendon |
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Proper direct stretching technique
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4-7x/weak
low number of long stretched: 30-90 s 1-3 reps 90 seconds also fnx as SCS start low, go slow stretch htnic mscles first then antagonists to promote balance |
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Levator scap self stretch
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Flex
sidebend away rotate away hold table and lean away |
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Upper trapezeius, SCM stetch
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Flex, SB away, rotate back to tuck chin
self stretch: add hold table and lean away |
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Scalene muscles manual stretch
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football hold: head off table in axilla
hold down rib 1 & 2 translate head posteriorly ME: pt lifts head towards celiing SB towards rotate away Self stretch: grasp trap to stabalize rib 1 & 2 sedebend away, rotate towards, tuck chin stretch; reposition rotation to get other fibers |
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pect major & minor stretch
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manual: also stretches anterior capsule w/ promixal hand; normal ROM to ceiling
Self: against wall feet parallel to wall, stance perpendicular ot wall. Frontarm stablizes, move hand up and down wall to stretch upper middle and lower fibers; lead stretch ith shoulder not hip, stretch on exhale |
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psoterior shoulder capsule stretch
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lateral recumband dysnfx side down
elbow at 90*, drop arm till tight and hold with other hand roll on and roll off tight shoulder ME bring palm of hand up towards ceiling. |
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Lat stretch
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Manual: Pt supine, knees bent; lift arms above head in flexion, ME bring them down via extension
self stretch: prayer position elbows together hold 12 o'clock with pelvis, sit back on heels drop chest to floor elongate trunk do at start and end of routine |
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Principels for strengthening/retiraining phasic muscles
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multiple short repititions 2-3x/week
3-5 seconds, 3-5 reps start low, go slow |
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Retraining deep neck flexors
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Pt seated, nod head forward and tuck chin without firing SCM
Monitor SCMs with thumb and fignertips to ensure they do not fire 5s 5x |
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Lower trap retraining
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pt prone,
beginner: pivot on elbow and lift hand/forarm from table advanced beginnner + lift arm off table 5s 5x |
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serratus anterior retraining
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pt stands with hands on wall at shoulder height arms extneded, spin in netural (tuck butt under)
touch nose to wall and Roll shoudler pblaedes in and down Hold for 5 seconds drop head, extend arms and push upper thoracic spine back "rholl shoulder blades out and up" hold for 5 seconds 5s 5x don't push off with pects |
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Retraining rhomboids
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pt seated feet on floor
graps fingers and together, arms parallel to floow attemp to pull eblows backwards toard wall 5s 5x flip hands and repeat |
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Lower Trapezius Retraining
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Pt seated feet on floor
grasp fingers with arm over head not contacting head pull elbows to floor 5s 5x flip hand position and repeat |
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Shoulder circles Self Treatment
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lateral recumbant arms extended and hands together infront of body
slowly reach overhead keeping hand on floor if hand comes off floor, stop and reach with fingers, arm and shoulde rthen release and keep going extend arm behind body as far as possible then return to start one cycle of clockwise coutnerclockwise makes one full rep perform 3 reps/side goal: maintain hand on floor all the way around and back |
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Self mobilization for Thoracic FRS
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start on all 4's with flat back, slowly curl back upward esp mid T's
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Self mobilization for Cervical dysnfx
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grasp back of neck just below restricted vertebra w/ ipsilateral hand
extend, rotate & sidebend into barrier Look down and away from barrier 3-5s take up slack and repeat 3-5x for extended dysfnx same but use contralateral hand, flex, look up and away from barrier |
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S/CS
Radial Head |
Lateral Epicondyle
Hold in full extension and then fully supinate & abduct |
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S/CS
Pronator |
medial Epicondyle
Fully flex then pronate & abduct and hold |
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S/CS
Triceps |
pain in biceps
hyperextension of elbow+ fine tune AB/ADdxn |
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S/CS
Flexions |
pain on coronoind of ulna: arm resists full extension
pull forearm out to side with palm facing forward then marked flexion |
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S/CS
PWR |
Palmar Wrist Retinaculum Tender Point
Tnderpoint along palmar surface of carpals Presure applied posteriorly Doc faces dorsum of pts wrist, palmar flexes wrist over tp. Fine tune. |
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S/CS
PIN |
Palmar Interosseus Joints
within the palm of hand on medial and lateral sides of shafts of metacarpals pressure applied posteriomedially or posterolaterally Tx: markedly flex fingers over tp w/ lateral flexion toward tenderpoint tune tune w/ rotation |
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S/CS
CM1 |
First carpometacarpal
thenar eminence on palmar surface of first metacarpal pressure pplied posterolaterally physiciian flexes or opposes thumb over tp and fine tunes w/ AD/AB & rotation |
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S/CS
TP: Lateral Epicondyle |
Radial Head
Hold in full extension and then fully supinate & abduct |
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S/CS
TP: medial Epicondyle |
Pronator
Fully flex then pronate & abduct and hold |
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S/CS
TP: pain in biceps |
Extnesion Triceps
hyperextension of elbow+ fine tune AB/ADdxn |
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S/CS
TP: pain on coronoind of ulna: arm resists full extension |
Flexions (Biceps/Coronoid)
pull forearm out to side with palm facing forward then marked flexion |
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S/CS
TP: palmar surface of carpals |
PWR: Palmar Wrist Retinaculum Tender Point
Presure applied posteriorly Doc faces dorsum of pts wrist, palmar flexes wrist over tp. Fine tune. |
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S/CS
TP: within the palm of hand on medial and lateral sides of shafts of metacarpals |
PIN: Palmar Interosseus Joints
Tx: markedly flex fingers over tp w/ lateral flexion toward tenderpoint tune tune w/ rotation |
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S/CS
TP: thenar eminence on palmar surface of first metacarpal |
CM1: First carpometacarpal
pressure pplied posterolaterally physiciian flexes or opposes thumb over tp and fine tunes w/ AD/AB & rotation |
