Musculo Test 2

Trigger Finger what kind of system? how many annular and cruciate pulleys? which pulleys are needed for finger mechanics?

A1 pulley tenosynovitis Pulley system 5 annular pulleys and 3 cruciate that hold tendons close to bone A2 and A4 are needed for finger mechanics

Tendinopathies often fall in the Category of? Where/how do they happen? Who do they happen to? What do they affect in the body?

Also known as CTI (cumulative trauma) or RSIs (repetitive strain) work, trauma, blood flow, posture/mechanics (poor proximal stability leads to poor distal manipulation) Can occur in anyone Can affect tendons and or nerves

Induce healing by providing cellular mediators

Autologous Blood Injections/Protein Rich Plasma (PRP) for LEC

Activity Modification for LEC

Avoid repetitive wrist movements Avoid excessive finger extension (keyboarding) Avoid lifting and pulling resistance-car door, refrigerator door, brief case, coffee pot, skillet, jug of milk, juice etc. When using the effected extremity try to lift with the flexors with the forearm supinated and close to the body . Maintain good posture.

Heat Massage and Soft Tissue Mobilization Stretch (Non-Composite to Composite) Joint Mobilization if appropriate Instrument Assisted Soft Tissue Mobilization Ultrasound (Continuous) Eccentric exercise (Non-composite to composite with low load) Splint or orthotic if work or night posture is causing re-injury

Chronic Tendonosis

Transverse friction massage (also known as cross-friction and cross-fiber massage) is a technique that promotes optimal collagen healing by increasing circulation and decreasing collagen cross-linking, thus decreasing the formation of adhesions and scar tissue. Produce traumatic hyperemia and a histamine response to help flush the area of substance P

Cross Friction Massage:Dr. James Cyriax

Sports Modification

Technique Interval training Proper equipment-light racket(12-12.5 oz.) made of graphite, string tension 52-55 lbs on 16 gauge nylon, size of racket grip etc

According to CHT's most effective treatment for LEC?

joint mob most effective treatment, modalaties are hit and miss

Non-compliance Accidental injury or fall Place and hold exercises Blocking exercises Poor repair Poor nutrition Other diagnoses affecting healing (infection, DM, smoker)

Causes of Rupture

Can pulleys be cut?

Yes unless they are A2 and A4, which need to be ventilated then NOT completely cut

Complications of flexor tendon repairs: the most common complication? what does it cause? when is tendon rupture most common? what should you do? how to avoid flexor contractures of PIP?

adhesion, stiff joints between 7-10 days, refer to surgeon ASAP dorsal blocking splints with velcro for IPs in extension at night & may need volar gutter component

flexor tendon injury complications

adhesions tendon rupture Injury to neurovascular structures Hypersensitivity Complex regional pain syndrome Bowstringing of the tendon Infection tendon gapping

LEC caught in what stage? What happens if LEC is chronic? Is treatment the same for LEC chronic and LEC acute? Is LEC fully understood?

after the inflammatory stage can't alleviate symptoms no no

Extensor tendon zones?

all odd number occur over a joint 8 finger zones 5 thumb zones slide 16

Controlled strengthening: when should you start protocol

begin once pain becomes minimal and as long as it can be performed without increasing pain. warm up on UBE(forward motion like a hand bike) elbow flexed slow and controlled motions eccentric are most effective exercises

Long arm elbow splint for night wear placing the arm at 35 to 40 degrees of flexion to prevent extreme flexion which also places stress on the extensor origin what kind of intervention acute or chronic?

both tennis elbow

What happens if the pulley system of the fingers isn't working and what are the effects?

bowstringing, especially if A2 and A4 are out and that causes problems with AROM especially with making a fist

Three main therapy approaches

controlled mobilization (MOST COMMON) early active mobilization (new) immobilization

When does repair site have 100% strength - 50% - 33% + 20%

end of week 0 end of week 1 end of week 3 end of week 6 strength from suture, then suture degrades and strength from collagen being laid down

What follows a core suture?

epitendinous suture to complete the tendon repair

intrinsic plus done by who? monkey claw = intrinsic minus done by who?

extensor hood mechanism EDC

dorsal blocking splint for? volar base splint for?

flexor tendon injuries extensor tendon injuries

Exercise for LEC: when does timing need to be adjusted when should you begin resistance training should exercises be done with pain

for each patient within the healing process when pain is resolved or minimal no

Controlled mobilization: 1st week splint must allow what? Dressing? ___________________________ Controlled mobilization: First 4 weeks flexion? extension? Goal? When are sutures removed? Scar massage? ___________________________ Controlled mobilization: After 4 weeks splint? ROM? ___________________________ Controlled mobilization: After 6 weeks splint? gripping? lifting? push/pull? ___________________________ Controlled mobilization: After 8 weeks strengthening? PROM? 10 weeks? 12 weeks?

full IP extension Bulky surgical dressing is removed carefully adhering to protective motion precautions ______________________________ educate patient on PASSIVE PIP and DIP movement with dorsal blocking splint on gently one digit at a time active extension with splint Goals is for PROM to proximal palmar crease in 2-3 weeks after 2 weeks can be initiated but finger must be kept in protective position ___________________________ take off splint & Continue to use a static dorsal-blocking splint between exercises and at night for 1 more week. gentle composite ROM wrist ROM and tendon gliding continue PROM ___________________________ Discontinue Splint No gripping anything heavier than a toothbrush don't lift heavy objects don't push/pull anything __________________________________ light strengthening exercises such as squeezing a sponge or nerf ball can be intiated PROM in extension can be performed if there is a deficit After 10 weeks, moderate strengthening exercises are begun. After 12 weeks, the patient resumes normal activities.

what suppresses adhesions?

good surgical technique early tendon mobilization motion between tendon and sheath

Evaluation Components

history (Determine whether condition is inflammatory or chronic) Cervical Screening-Dermatomes and Myotomes Visual Analog scale- pain Grip strength with elbow flexion and extension (if not in a great deal of pain) Pinch strength Palpate -radial head -lateral epicondyle -radial tunnel (crepitis) Long finger extension test Resisted wrist extension, supination (Cozen's Test). ROM/Muscle tension with composite stretch Patient Rated Functional Assessment: PREE, DASH

Rotator Cuff and Scapular Stabilization Strengthening

horizontal abduction/adduction with weight on pulley

Botox Injections for LEC: inject where site determined by what does it do

in to the extensors local tenderness and pain provocation on long finger and wrist extensor test. Decrease muscle activity (ECRB contraction) by blocking acetylcholine gates (ACH causes muscle contraction & botox blocks that)

What we deal with when treating tendons? "itis" "osis" "algia"

inflammation scar tissues nerve irritation (combo of all the above)

Xray (tendon rupture, bony avulsion fracture), surgery needed younger kids keep immobilized Rosalyn Evans or Indiana Flexor tendon protocol for adults. Surgical repair should be strong...4 to 6 strand core stitch.

jersey finger

can't grab objects ring finger involved Painful, swollen finger, especially of the volar DIPJ Inability to bend/flex the tip (distal phalanx)

jersey finger, zone 1 slide 23

Most common injury to the extensor tendon Lesions may be open or closed and may have an associated fracture Also known as baseball finger can't actively extend finger BUT doctor can passively extend it

mallet finger

Extensor tendon injury zone 1 and 2 Extensor tendon injury zone 3 and 4 extensor tendon injury zone 4 extensor tendon injury zone 5, 6, 7, 8

mallet finger- lesion of terminal extensor tendon (zone 1 or 2, if lateral bands are involved) Boutonniere Deformity- rupture of central slip or triangular ligament (flexion of pipJ & extension of dipJ) adhesions, short arc motion protocol 5- sagittal band rupture

Advanced rehabilitation focuses on what?

motor performance speed of motion reaction time specific sports training work hardening

Alternative modalities for LEC: Acupuncture Extracorporal Shock Wave therapy Low Level Laser Therapy

pain relief for less 24 hours short term not effective, expensive, cortisone works better No evidence except when used in combination with physical therapy

EDC: innervation action origin & insertion

posterior interosseous nerve (branch of deep radial nerve) -extends MPs of digits 2-5 -with the lumbricals extends IP joints -weakly extend wrist lateral epicondyle & BASE OF MIDDLE PHALANX in EXTENSOR ZONE 3- CENTRAL SLIP

What are the 3 roles of an epitendonous suture?

prevent adhesions prevent triggering repair sheath

Surgical tendon repairs: Within the first two weeks of tendon laceration. When is the optimal time for flexor tendon repair? The longer the severed tendons have to develop adhesions and scar tissue, the less the possibility of restoring full function. true or false

primary repair first 2 weeks for sure, but best if in 24 hours true

Scapular stabilizer strengthening?

prone extension prone scaption prone horizontal abduction

LEC treat what first?

proximal to distal, Correct posture and strengthen core

Blood supply for the hand What test confirms blood supply integrity of the hand

radial and ulnar artery come together to form the superficial palmar arch (superficial to flexor tendons) and the deep palmar arch (deep to flexor tendons) allen's test for radial and ulnar artery slide 4

What emulates tennis elbow?

radial nerve injury

Junturae Tendinum

rule that if injury occurs to the long, ring, or small finger you should splint all three because of the junctura many authors thing you should immobilize all 4 fingers

flexor tendon top 2 problems?

scarring and rupture

lacerations that were not repaired soon enough? what kind of prognosis for above? what type of surgery is needed?

secondary repair worse, because of tendon scarring and contraction tendon graft OR 2 stage repair with huntington rods 1) put rods in place 2) put tendon grafts

Tendon glides

straight hook duck straight fist full fist hanging limp wrist wrist extension slide 58

Multiple Surgical Interventions: Open Arthroscopic Fasciotomy Debridement Percutaneous release Success rate? How long to eventually resolve on its own?

surgical interventons after conservative interventions variable success: 70 - 80% 2 years

Separation of the two ends that creates a space and causes the tendon to have a gap from end to end (surgical technique and over aggressive stretching). Makes the tendon longer therefore it can not pull as effectively

tendon gapping

smaller weights more reps are good for

tendons

The strength of the flexor tendon repair is proportional to? More scarring may be evident with what? How many sutures do well and allow for early active motion inside protective dorsal shell splint.?

the number of core suture strands crossing the repair site more core strands but new techniques are causing a change in this. Six to eight strand core sutures

Other LEC tools for exercise

theraband theratube/ flexbar

Stretch what is ? and strengthen what is ? A significant increase in ECRB length occurs when in what position?

tight & weak ulnar deviation without forearm rotation

z plasty can be done for incisions all over the hand to avoid scarring over creases that limit motion true or false

true

Joint mob for LEC: more effective than what? what is it good for? what is instrument assisted soft tissue mob? what other tool helps?

ultrasound and standard therapy Mobilization and Mobilization with Movement techniques were both effective in reducing pain graften kinesiotape

Acute top treatments for LEC? Chronic top treatments for LEC?

ultrasound, ice and iontophoresis education (rest), heat*, strength

Origin: Lateral epicondyle Insertion: Dorsal surface, base of the long metacarpal Has a poor blood supply at the origin

ECRB

primary structure involved in LEC?

ECRB

Muscles whose origin is on lateral epicondyle? They have a common what?

ECRB ED ECRL ECU Common extensor ORIGIN that they all sprout from

ulnar sided wrist pain and snapping sound with supination

ECU subluxation and tendonopathy because it snaps over the styloid

Extensors in the digits

EDC EI EDM EPL EPB

Campers Chiasm What happens if it is damaged?

where FDS and FDP cross on the volar surface both tendons need repair and gliding so that they don't scar down

WALANT Doctor?

wide awake lidocaine anesthesia no tourniquet Dr. Don Lalonde: New Brunswick Canada Epinephrine- for stopping of flow of blood Patient is awake: Can check the repair and educate patient during procedure

Flexor tendon injuries come from?

work carving pumpkins broken glass cooking

Aggressive stretching can lead to what? Flexors and extensors need stretching or just one?

wounds and scar tissue that cause contractions both

Can you have both radial tunnel and lateral epicondylitis?

yes

Extends from the midportion of the middle phalanx (FDS Insertion) to the distal palmar crease Adhesions reduce excursion and results in a stiff finger used to be called no mans land has THE WORST prognosis because it would scar down or rupture

zone 2

The most common area for flexor tendon laceration Dependng on how deep the cut is, it can affect both the flexor digitorum profundus and the flexor digitorum superficialis Gliding of this tendons distal, proximal and against each other is imperative to hand function

zone 2

Laceration at the level of the MCPs Can be treated in a variety of ways -immobilization -Early controlled mobilization with dynamic splinting -Relative Motion Splinting

zone 5 laceration

Impingement

Forward Shoulder Scapular Dyskinesia Tight pectoralis minor Weak serratus anterior Sleeping posture Supraspinatus of the rotator cuff Long head of the bicep gets inflamed from repetitive reaching or being "pinched".

What do you do for flexor tendon ruptures?

HAVE TO GET SURGERY

Most important prognostic indicators reported by hand therapists for resolution of symptoms? prognostic indicators for return to work?

Patient's occupation Duration of symptoms Previous history of LE Compliance with home programs Ability to modify job activities Patient's occupation

What backs up pain rating, because if you're limited with pain you're limited with motion?

ROM

RSI

Repetitive 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 muscles are stretched. (wrist extended & elbow extended, pulling luggage can cause tennis elbow)

Rheumatoid Arthritis Diabetes Osteoarthritis Other inflammatory conditions Repetitive gripping Sustained pinching (thumb)

Risk factors of Trigger finger

Dr. Robert Nirschl's Stages of Lateral Epicondylitis

Stage I: Peritendinous Inflammation ("I've had it for 2 weeks, and never had it before" it's acute and can be healed with ice and light stuff) Stage II: Angioblastic Degeneration-Angioblastic Fibroplasia—pain not do to inflammation/Sensory Nerve (more nerve damage) Stage III: Further degeneration/Rupture Stage IV: Fibrosis and Calcification

Six most commonly used modalities and treatments (for both acute and chronic LE):

Stretching Home exercise program Education regarding risk factors Education regarding rest and activity modification Education regarding ergonomic modification Education regarding pain management

Inflammatory process. Inflammatory cells found in tissue Degenerative process with fibrosis, decreased circulation. Fibrosis found in the tissue. "Pain" neurogenic in nature. Free nerve endings are irritated and signaling "pain" to the brain. Neurotransmitters, (when there is actually no pain) The synovial sheath the tendon runs through is also inflamed. Various processes occurring simultaneously

Tendinitis Tendinosis Tendonalgia Tenosynovitis Combination

Extends from the muscle belly to attach a muscle to a bone

Tendon

Prevent tendon rupture Patient Education Promote tendon healing Encourage tendon gliding Prevent flexion contractures Restore PROM and AROM Maintain ROM of uninvolved joints Return to previous level of function

Therapy goals

What type of therapy should you use post flexor tendon injury?

There are plenty Depends on 1) surgical technique 2) surgeons preference 3) therapist preference/experience

what promotes adhesions?

Trauma to the tendon and sheath- tendon/sheath get hurt Tendon ischemia- lack of blood to tendon Digital immobilization- fingers stuck Prolonged edema- prolonged swelling

Prevent tendon rupture Protect the tendon Promote tendon healing Encourage tendon gliding Prevent flexion contractures Control edema Restore PROM and AROM Maintain ROM of uninvolved joints Return to previous level of function

Treatment Goals

Avoid full active flexion of the digit Maintain PROM of each joint Perform individual joint blocking exercises Perform finger extension exercises

Trigger Finger Exercises

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 IPs extended at *3 weeks* if MP flexion block is used. At *4 weeks PROM to a full fist flexion* 5 times holding 10 sec Progress re-evaluated after 6 weeks by assessing comfort during AROM.

Trigger Finger Treatment

Complications

*Infection* happens in 5% of cases, can be resolved by antibiotics but if severe can cause failure of the repair *tendon rupture* in 5-10% of cases, contributed by infection, technical failure or patient non-compliance. *tendon adhesion* -Some loss of tendon glide & weak grip common. -Loss of flexion and extension can result from adhesions -Further surgery is required for more severe cases to free the tendon (tenolysis). *Joint stiffness*: -Joints in the region can become stiff even if not directly injured as a result of factors such as edema, infection and immobility. -The loss of movement is minor in the majority of patients. -Further surgery is required for more severe cases.

What are the list of NEVERS?

- NEVER bend fingers by themselves, use uninjured hand - NEVER make a fist - NEVER pick up anything - NEVER straighten fingers using uninjured hand

extensor hood mechanism

- extensor expansion mechanism - extensor aponeurosis made up of tendinous fibers from -palmar interossi 3 -dorsal interrosei 4 -lumbricals -EDC proximal to insertion - lateral bands - central slip slide 10, 11

Relative Motion Protocol

1-3 Weeks: 2 splints -wrist splint at approx. 20-25° extension (may not be necessary) Orthotic with injured digit in approximately 15° more extension than adjacent digits at the MP joint, with the splint beneath the proximal phalanx of the injured digit and on top (dorsum) of the proximal phalanx of the adjacent digits with intact long extensors 3-6 Weeks: wrist portion of the splint discontinued, but finger pan continued and full Activity encouraged the entire time 6 Weeks: Splint discontinued slide 50

Tendon repair is at its weakest day? Immobilized tendon is how much weaker at day 5-10 then at day 1? Estimated core suture tensile strength decreases by how much by the end of week one? Ends of a repaired tendon take about how many days to stick together?

10-12 (Schmidt, 1998). Immobilized tendon is 50% weaker day 5-10 than at day one of repair (Strickland, 1993). 50% by the end of week one (Evans, 1993). 21 days to stick together

Exercise for LEC: level of support what is it good for what type is best

1b and 2b increasing grip with decreased pain eccentric training is best

Early Motion Method:

24 hours - 3 days: Dynamic splint; Wrist at 30 degrees static extension, MCPs in full dynamic extension. Volar component to permit 30 degrees of active MCP flexion At night, wear immobilization splint. 3 weeks: Remove volar splint components, but continue with dorsal dynamic splint. Gradual Isolated MCP and IP motion within splint. 4 - 5 weeks: Composite finger flexion with wrist in extension 6 - 12 weeks: Same as immobilization method

How many thumb pulleys? Which pulley is most important?

3: A1 at MP joint oblique over proximal phalynx AII at IP joint oblique pulley is most important

Early Active Mobilization: Dr Strickland Indiana Hand Center used with how many strand repairs? Indiana uses place and hold

4 strand or better

Immobilization technique: how long do you stay immobilized? Used with who? Incidence of tendon rupture?

4 weeks Young patients (children younger than 10 years), Cognitive deficits (unable to follow the protocol). Incompliant patients (unwilling to follow the protocol). Greater incidence of tendon rupture because tendon gains tensile strength when repair site has gentle tension Has not resulted in consistently good results

The dorsal extensor compartments

6 compartments: 1: APL & EPB 2: ECRL & ECRB 3: EPL 4: EDC & EI 5: EDM 6: ECU

Peak tensile strength when?

60 days/8 weeks post injury

What position increases force on the LE?

A forward internally rotated shoulder increases forces on the LE origin

What muscle is active during supination and pronation? What should be strengthened on affected arm?

ECRB all forearm and wrist muscles, shoulder, elbow

Cervical Radiculopathy (C5/C6) Proximal Neurovascular entrapment of lateral antebrachial cutaneous nerve. Arthritis Tumors Radial tunnel/PIN entrapment Distal biceps insertion at radial tuberosity Triceps insertion at olecranon Shoulder tendonitis Carpal Tunnel Syndrome Trigger points Loose Bodies (bone fragments) typing with wrists extended

Causes of LEC

Pain on the radial side of the thumb when pinching or grasping objects. Rule out CMC arthritis of the 1st Metacarpal joint

DeQuervain's Tenosynovitis

Positive Finkelstein's test (grasp thumb and ulnarly deviate passively or actively causes pain along 1st dorsal compartment) Pain along first dorsal compartment Decreased pinch and grip A nodule or thickening of the extensor retinaculum.

DeQuervain's Tenosynovitis

Inflammation or tendonosis of the sheath of the tendons in the first extensor compartment. sheath of APL & EPB

DeQuervain's Tenosynovitis (Identified by Dr. Fritz DeQuervain in 1895 (Swiss Surgeon)

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 (a lot of women get carpal tunnel and dequervains during pregnancy) (prolactin can lead to tendonitis symptoms and resolves after you stop breast feeding)

DeQuervain's Tenosynovitis Etiology

Splint: Thumb Spica. Wrist 15º extension, thumb MP 10º flexion; thumb MCP midway between palmar and radial abduction splint doff qd to perform isolated wrist/thumb AROM - progress to PROM Must be able to oppose to digits 2 and 3

DeQuervain's Tenosynovitis Splinting Treatment

Decompression of first dorsal compartment Post-surgical therapy Initiate therapy within the first 10 days post op gentle edema mgmt. and light compressive dressing gentle AROM/AAROM/PROM initiated 4-6x daily x10 minutes once sutures removed, scar mobilization initiated manual desensitization (along superficial branch of radial nerve) 3-4 weeks: initiate wrist and thumb strengthening exercises as well as functional use of hand

DeQuervain's Tenosynovitis Surgical intervention

Cryotherapy verses heat Exercise Remove 4x/day for A/PROM to thumb and wrist separately Patient education on activity modification NSAIDS Corticosteroid injections Surgical intervention

DeQuervain's Tenosynovitis Treatment

Pain with grasp/release activities near base of thumb Edema near base of thumb Decreased range of motion: specifically in thumb

DeQuervain's Tenosynovitis symptoms

avoid extend and ulnarly deviate (motion this muscle does) avoid wrist flexion and radial deviation avoid repetitive flexion of the wrist (avoid contracting affected muscles) don't overstretch repetitively, just gently and passivley

Extensor carpi ulnaris Flexor carpi radialis

Acute- RICE, Ice massage, cold packs, ultrasound, iontophoresis, cross friction massage, ASTYM Must correct the biomechanics that caused the problem. Sleeping Posture, Activity Modification

Flexor Carpi Radialis and Extensor Carpi Ulnaris Tendonitis

other tendons that get inflamed

Flexor Carpi Radialis and Extensor Carpi Ulnaris Tendonitis Extensor Carpi Ulnaris and Extensor Digitorum Communis

Tensosynovitis of second dorsal compartment where the first dorsal compartment crosses it in the radial dorsal APL, EPB cross the ECRL and ECRB Repetitive motion or direct trauma Pain, creptis,edema, point tenderness squeaky wrist more proximal than DQ

Intersection Syndrome

Thumb spica splint with wrist in 15 to 20 degrees of extension. Patient Education: Avoid repetitive wrist flexion and extension with combined power grip. Surgical: Second dorsal compartment release

Intersection Syndrome

Medial Epicondylitis Assessment

Palpation of the medial epicondyle Clear ulnar nerve at the cubital tunnel

Ligaments in the dorsal finger?

The triangular ligament- on top The transverse retinacular ligament- on the side Superior oblique retinacular ligament (SORL) also known as ligament of Landsmere Sagittal Bands

Heat or ice Ultrasound (pulsed 3.3 MHz) Iontophoresis

Trigger finger modality

Relative Motion Splinting

Used in patients with two or more intact long extensor finger tendons. This takes advantage of the single motor unit anatomical arrangement you need at least 2 EDCs in tact for relative motion splinting can go back to everyday function/work The lacerated tendon or tendons are palces in approximately 15 degrees more extension than adjacent intact digits, the tension at the suture line is sufficiently reduced to allow the injured digit an otherwise full range of active motion, with full active flexion and extension of the IP joints and the MP joints. The wrist is protected in approximately 20-25 degrees of extension for three weeks with a separate splint to avoid passive tension on the repaired extensors during composite wrist flexion, and the digits are protected by the relative motion splint for six weeks. The patient is allowed full active use of his or her hand with the splint in position. During this management, many laborers have been able to return to their full time work, and others to their full time play.

Work Station Design Sleeping Postures Not taking breaks Poor body mechanics Muscle imbalance Co-morbidities Medications

What is Causing the Problem of impingement?

Duran: 1st week Dressing?

Wound is redressed with either xerform or adaptic and 1 inch guaze wrap. Some folks use coban or digi-sleeve but it is not usually necessary

Extends from the fingertip to the midportion of the middle phalanx. FDP is involved thus can't bend the tip of the finger. An injury in this area is known as jersey finger. 2nd worst prognosis happens during tackling in football

Zone 1 slide 20

Extends from the distal palmar crease to the distal portion of the transverse carpal ligament Not as much scarring in this area Don't need a lot of intervention

Zone 3

Overlies the transverse carpal ligament

Zone 4

Extends from the wrist crease to the level of the musculotendinous junction of the flexor tendons spaghetti wrist

Zone 5

Tendon gliding?

active contraction of the injured muscle using tenodesis

what fully extends pipJ with tension? what only extends the dipJ with tension?

lateral bands terminal insertion/tendon

If a pulley is repaired then what do you do during therapy?

protect it

Proximal bicep tendonitis

slide 25 DQ

all exercises should be when do you move to a higher resistance in exercise can you start without any resistance

slow and controlled once patient can do 3 sets of 10 yes

the EDC of the long finger combines with? What can you do instead of excessively using the EDC?

the ECRB tendon to insert at the lateral epicondyle float the digits

Where does pain occur at the humeral head for a tendon?

when the bicep tendon goes through the bicipital grove and over the humeral head like a rope pulley and it gets sheared

mallet finger treatment 0-6 6-8 8 12

- NOT STAX SPLINT - DIP in hyperextension in splint 0-6: splint in hyperextension 6-8: remove splint only for exercises -active DIP flexion to 20/30 degrees 8 weeks: wear splint only at night, light grip and strength 12: unrestricted use (30 degrees of flexion at PIP and 10 degrees hyper-extension at DIP if lateral band is torn)

Tendon blood supply Which type of blood supply is not a direct route?

- intrinsic vascular supply - extrinsic diffusion from synovial fluid as it gets pumped in to the tendon fibers through flexion and extension of the fingers - intrinsic vascular supply is not a direct route to flexor digitorum superficialis & profundus. it stops first at THE VINCULI

Immobilization Method

0- 4 weeks: Immobilization in a volar forearm based splint for 4 weeks; Wrist at 30 degrees extension, MCP joints neutral, IP joints in full extension. 4 weeks Composite MCP/IP flexion while wrist in full extension. Individual finger extension. Continue splinting between exercises and at night. 6 - 10 weeks: Splinting can be discontinued if no extensor lag is present. Initiate composite finger/wrist flexion Gentle gripping and light prehension activities Isolated EDC exercises Extending the MCP joint while the IP joints are taped into flexion. Resistive extension exercises are included as tolerated 10 - 12 weeks: Progress activity 12 weeks: Resume normal activities

boutonniere treatment

0-4-6 weeks: splint pip joint in 0 degrees extension DIP active flexion so that SORL doesn't get tight 6-8: remove splint only for exercises - gentle active ROM for PIP flexion and extension 10-12: gentle strengthening for full fist Continue to wear the splint between exercises and at night for up to 4 months

Duran protocol: Day 1? Day 3?

1) dorsal blocking splint with everything in flexion except IP's which are neutral with velcros 2) day 3 starts protected PROM in flexion

Tissue needs blood flow and remodeling *Exercise (graded eccentric exercises)* (lift wrist in extension THEN with weight, slowly lower it in to flexion- noncomposite because elbow is at 90 and exercise is not involved across more than one joint, IF elbow was extended and shoulder extended THEN its composite) *Progressive stretching* Joint mobilization *Modalities-Heat focus (Hot packs, U.S conts.)* Strengthen core and correct posture

Chronic Tennis Elbow

Graston ASTM Rockblades Baby spoons Jar lids Bones Rocks

IASTM Instrument Assisted Soft Tissue Mobilization Graston

Must address Posture (static and dynamic) Strengthen the scapular stabilizers Soft tissue work on the Pec Major, Minor and scalenes Soft Tissue work on the Upper trap and Levator Scapulae Strengthen lower trap and rhomboid Work on restoring the neuromuscular timing and control to correct the motor timing issue Adapt (built up handles) Alter (living with caregiver) Create

Impingement treatment

Progressive stretching for LEC: uses what protocol whats the process what is the end result positions slide 50

Indiana non composite --> composite --> non composite with overlay --> composite with overlay you want to perform stretches without pain or discomfort

Rest Ice massage or cold packs Cortisone injections (not everyone can have it, like those with diabetes) Iontophoresis using Dexamethasone- to go patches *Stretching exercises* Wrist support- OR it's a placebo affect to remind patient to be careful Tennis elbow strap- Only works with power gripping to reduce forces at ECRB Splinting doesn't help much

Inflammatory: Tendonitis

Tennis elbow Inflammation of the tendons that attach the forearm extensors to the lateral epicondyle Repetitive use causing shearing of ECRB over radial head especially with elbow extension Injury to lateral epicondyle could strain muscle attachment Fibroplasia of tendons happens during healing process and tendons get stuck can lead to calcification and rupture

Lateral epicondylitis

Chronic verses acute Heat verses cold Modalities: Ultrasound, iontophoresis Ulnar nerve glides Elbow strap (pad over flexors on medial side) Massage Manual Therapy Soft tissue mobilization (tools or manual) Kinesio-tape Progressive Stretches Patient Education- Activity Modification and Pathology Strengthen core and correct posture Graded strengthening

MEC Treatment

Golfers elbow 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

Medial Epicondylitis

Other Beneficial Exercises for LEC

Radial Nerve Glides EDC exercises- rubber bands, putty etc. Clam shells (glut med) Neutral pelvis with isometric contractions of the transverse abdom.

Conservative management through therapy Splinting Hand-based *flexion block* fitted with MCP being the only jt immobilized in neutral extension Include only involved digit or adjacent digit for comfort Wear up to 6 weeks, usually 3-4 weeks Pt Education Important with respect to modifying provocative activities, avoid or minimize activities that require repetitive gripping or demand a sustained pinch Corticosteroid injection into tendon sheath Fluidotherapy

Trigger Finger Treatments

Tenderness at the level of the A1 pulley volarly There might be a presence of a nodule or thickening. Don't confuse with Dupuytren's Disease Finger clicks when trying to straighten Finger gets stuck pain with active flexion

Trigger finger symptoms

If you've had the condition for 3 months OR you've had it before then it is chronic or acute?

chronic

Where does vinclui branch off? vinculum brevis and vinculum longus each go to where? where is the vascular supply mainly for tendons, palmar or dorsal surface?

common palmar digital artery go to each fds and fdp tendon dorsal side of the tendons

Blood supply for fingers

common palmar digital artery & proper palmar digital artery neurovascualar bundles contain digital artery, vein, and nerve 2 bundles: 1 radial & 1 ulnar

flexor tendon repairs need what kind of splint/protocol? what position should the hand and fingers be in?

dorsal shell blocking splint duran protocol rosalyn evans splint design neutral or slight flexion slide 46

the flexor tendon sheath is what kind of tunnel and how is it sealed what 2 things does the synovial fluid provide tendon with?

double walled fibrosseous tunnel that is sealed at both ends 1) nutrition 2) low friction glide

Triangular ligament purpose? Transverse retinacular ligament? SORL purpose? Sagittal bands purpose? what can attack all these structures and cause hand deformity?

keeps terminal components of lateral bands from slipping down (boutounneire deformity) keeps lateral bands from going up or dorsally (swan neck) gets tight with immobilization. It is located at the distal end of the middle phalanx and extends across the DIP and inserts on the distal phalax. If tight it will limit DIP flexion. Sagittal bands are at the MCP level and keep the EDC on a track over the dorsal MP joint. When a sagittal band is loose or ruptured the tendon can sublux. RA attacks the soft tissues and can affect all of these structures which results in hand deformity

extensor hood mechanism: what connects the middle phalanx and the distal phalanx? When the extensor muscle contracts it shortens and pulls on these attachments to straighten the finger. true or false

lateral bands true

Best type of surgical repair

lots of different surgery's 1) reliable 2) doesn't impair healing 3) strong based on surgeons preference, experience, skill level

Is place and hold a good protocol?

no because tendon jumps and pulls hard

Resistance Training: protocol best way goal grip exercises in what position for elbow?

no research for specific protocol stretch and controlled eccentric strengthening (theraputty) increase grip and decrease pain slight flexion

LEC is an inflammatory problem or not? what is it?

not, osis or algia issue Microscopic tears of ECRB and EDC Calcifications Excessive granulation Alteration in neuropeptides (glutamate eats away at nerves when it leaks to other tissues) Avascular areas Adhesions Mucoid Degeneration- slimy gross grayish stuff

CORTISONE INJECTION for LEC: does it work what does it depend on what can it affect can lead to

occasionaly timing of injection sensory nerve response cell death, atrophy, inhibits the production of collagen

Non-bulky? Pro? Con? ------------- Bulky? Pro? Con?

old school 2 strand repair Passes under pulleys secondary to less bulk Gaps and is weak --------------- 6 strand core: Dr. Strickland New techniques to vent pulleys have solved this problem Doesn't pass easily under pulleys normally

Grips strength postions LEC? Pinch strength positions LEC?

once in regular, pronate straight down, straight up at 90 (Indiana Hand Center) pinch strength do 3 times of: lateral key, 3 jaw, pad-pad ad average it

PAMS for LEC: Ultrasound/Phonophoresis Iontophoresis When is Iontophoresis just as effective as phonophoresis?

only one found effective with or without meds, BUT only for short term (ultrasound over placebo) level 2b support for 6 visits in 10 days (no difference between steroid and placebo) when using naproxen

Counter-Force Strap/Tennis Elbow Strap: when does it work when is it appropriate to use other 2 purposes

only works for power gripping to reduce ECRB stress splinting appropriate only in final stages of rehab with return to heavier activity. tactile cue for behavior modification or has a TENS effect