UE Test 3: Tendinopathies
What happens at the second therapy session? (1 day - 1 wk)
(1 day/ 1 wk later) - review HEP, reassess - adjust orthosis - reinforce previous education for strenuous activities (4-6 wks post)
What are the HEP instructions for eccentric strenghtening?
- 1 to 2 times a day - 10 repetitions - slowly increase to 30 reps (endurance exercise) - use 1 ib weight then increase to 2 when it becomes easy
How long should stretching of extensor muscles be?
- 20 to 30 seconds - every 2 hours - 2-5 reps - pain free range
What muscles are involved in dequervain's tenosynovitis?
- APL - EPB
What are some phase 1 exercises for tennis elbow?
- AROM in pain free ranges - pain-free PROM - gentle isometric exercises - proximal stretching and postural strengthening - massage (cross friction over tendons)
What types of functional assessments would be used?
- DASH/QuickDASH - modified COPM - patient interview - occupational profile
What is duputren's related too?
- DM - alscoholism - hand trauma - HIV - meds that treat epilepsy
What PAM can be used for pain management for lateral epicondylitis?
- MHP/ice - teach how to make a rice sock - ultrasound - e-stim
What should education include?
- activity modification - body mechanics - taking breaks (allow recovery for tissues)
What is dupuytren's disease?
- benign connective tissue disorder affecting palmar fascia in hand - progressive thickening can lead to flexion contracture of the MCP and PIP joints - presence of nodules or cords in the palm
What happens no improvement occurs in trigger finger after non-operative treatment?
- corticosteroid inject - surgery
What assessments would you use for lateral epicondylitis?
- cozen's test - miller's test - grip strength test - pinch - posture - functional assessment
What symptoms for FCU?
- does not have a sheath - pain with resisted wrist flexion w/ UD & ABD of SF
What are OT post-op management goals for trigger finger release?
- edema control - scar management - ROM - few OT sessions, if any
What are phase 1 interventions?
- education - orthosis/counterforce brace - pain management - regain tendon length
How should a client be positioned when lifting with tennis elbow?
- elbows in at side (non extended) - wrists neutral - palm up for lifting, carrying, holding
What type of orthosis would you use for dupytronen's disease?
- hold digit in extension - can be volar or dorsal (always. hand-based) - consider wound dressings - may be worn full-time (1-2 wks) post op - then worn at night only for up to 3 months
What exercises would you do for DeQuervain's?
- isometric exercise of APL and EPB - short arc AROM of these structures - isolated wrist flexion and extension - isolation thumb IP flexion
What happens third (2-3 wks) after surgery/manipulation?
- monitor ROM - re-evaluate orthosis - introduce composite taping or dynamic orthosis/flexion glove if needed - review timelines - watch for flares (refer back to MD if they happen)
What orthosis interventions would be used for DeQuervain's?
- orthosis - education and training on activity modification - progressive stretching and strengthening
What other evaluations would you do for DeQuervain's?
- pain history and scales - A/PROM - MMT (include proximal - RC/Scap) - grip/pinch - posture assessment - functional assessment - occupational profile
What are medical interventions for dupuytren's disease?
- percutaneous needle aponeurotomy - fasciotomy (operative treatment - release) - fasciectomy (operative - removal) *most common - collagenase enzymatic fasciotomy/injection
What happens 4-6 wks after contracture release?
- perform final reassessment - finalize HEP and orthosis needs - discharge with HEP
How should a counterforce brace/strap be positioned?
- place over proximal end of forearm extensor muscle bellies to decrease tension on common tendon insertion
Where else can Dupuytren's disease occur?
- plantar surface of feet (ledderhouse disease) - penis (peyronie disease)
What muscles are typically involved in medial epicondylitis (golfer's elbow)?
- pronator teres - FCR
What is the treatment for ECU?
- rest - orthotic intervention - activity modification - occasionally injection/surgery
What are tests for intersection syndrome?
- same as DeQuervain's but more proximal - pain/swelling 4cm proximal wrist - pain w/ resisted wrist extension
What is the clinical picture for golfer's elbow?
- tenderness at medial epicondyle - pain w/ forceful pronation - pain with resisted flexion - pain with resisted elbow extension with supination and wrist extension
What is the clinical picture of lateral epicondilytis?
- tenderness/pain at lateral epicondyle - pain w/ gripping, resisted wrist extension, supination, digital extension and radial deviation - tightness of extrinsic extensors (dorsal forearm) - nighttime aching and forearm stiffness
What are some Dupuytren's disease post-op exercises?
- tendon glides - blocking - active ROM - passive ROM - wrist tenodesis - ADL retraining
What is phase 1 of interventions for lateral epicondylitis?
- the patient is in pain at rest and pain increases with movement (does not mean inflammatory phase)
What happens in step 1 of therapy after contracture release? (1-2 days)
- therapy visit 1-2 days after nonsurgical manipulation, 1 wk after surgical - Assessment of wound, edema, ROM, pain, sensation, & function - education (wound care, edema) - light ROM = digit EXTENSION and intrinsic stretching - resume light ADLs (with affected hand)
What are some functional activity -based ideas someone with tennis elbow needs to keep in mind?
- using soft force for pinch/grip - paddled and/or enlarged handles for tools, pens, objects - two handed (if possible) techniques with arms close to body versus outward reach
When would medical interventions need to take place with dupuytren's disease?
- when MP contracts to 30 degrees+ - PIP 15 degrees - loss of function capacity of hand
What structures are involved in intersection syndrome?
- where APL and EPB intersect with ECRB and ECRL - involves 1st and 2nd dorsal wrist compartments
What happens in step 4 following contracture release? (3-4 wks)
3-4 wks after manipulation/surgery = full ROM should be achieved by 4 wks for manipulation - initiate graded progressive strengthening exercises
What is trigger finger associated with?
DM, RA, gout, CTS, & dupuytren's contracture
What is the most common type of tendinopathy of the wrist?
DeQuervain's
What muscle is most involved with lateral epicondylitis?
ECRB (extensor carpi radialis brevis)
What is the second most common type of tendinopathy of the wrist?
ECU tendinopathy
Do cords/nodules appear slowly or rapidly in dupuytren's disease?
both
Why should concentric strengthening be avoided?
can be painful and contradicts instructions to avoid palm down lifting
What is medial epicondylitis?
degeneration of flexors attaching to medial epicondyle
What causes tendon length insufficiency?
degeneration of the tendon that results in scarring
What is the clinical picture for trigger finger?
digit "snaps" or catches during AROM (can occur in any digit) *catches in the A1 pulley*
What is another name for trigger finger?
digital stenosing tenosynovitis
What extension of flexion during grip more painful for someone with lateral epicondylitis?
extension
Degeneration of what happens at lateral epicondyle insertion?
extensor tendons
What would make achieving ROM after contracture release take longer?
fasciectomy
What happens in a severe case of trigger finger?
finger locks into a flexed position and client can't open without "prying" it open
What is a good assesment for DeQuervain's?
finkelstein's test
What causes DeQuervain's tenosynovitis?
forceful, repetitive, grasp with wrist ulnar deviation, receptive thumb abduction, and/or repetitive thumb MCP flexion
How can you lengthen a tendon?
forearm stretching of extensor muscles
What is considered the most important assessment?
functional assessment
When would you introduce composite taping or dynamic orthosis/flexion glove?
if trouble regaining flexion after Dupuytren's disease
What is trigger finger?
inability of finger to perform smooth digital flexion or extension due to inflammatory pathology on tendon or tendon sheath
What is dequervain's tensosynovitis?
inflammation of tendinosis of 1st dorsal compartment of dorsal wrist
What is eccentric strengthening?
loads the tendon in a lengthening position and can be done so without causing pain
Who is most likely to get dupuytren's disease?
men of northern European descent
How should the wrist be positioned in an orthosis with golfer's elbow?
neutral or slight flexion to take tension off of flexors
What splint would be used for FCR?
neutral wrist splinting (volar wrist cock-up) - rest from aggravating activities and activity modification
What type of orthosis should be used for trigger finger?
orthosis with MCP in extension and PIPs free x 3 weeks
What type of orthosis would you use for DeQuervain's?
orthosis-forearm-based thumb spica with IP free to prevent painful motions
What causes ECU tendinopathy?
overuse injury - common in wrist intensive sports (tennis, rowing, golf, baseball)
What is phase 2 of interventions for lateral epicondylitis?
pain is mild and light functional activities are no longer painful
What are symptoms for FCR?
pain with resisted wrist flexion combined with RD
When should an orthosis be used for tennis elbow?
phase 1 (its temporary)
What does trigger finger casue?
receptive gripping
What is degeneration of extensor tendons caused by?
repetitive stress
How would you test for ECU?
resisted wrist extension with UD
What is the purpose of using an orthosis for tennis elbow?
rest structures to diminish pain
What does phase 2 of interventions for lateral epicondylitis focus on?
restoring, flexibility, strength, and endurance
What should you do prior to strengthening exercises?
stretch
How would you perform a stretch for golfer's elbow?
supination with elbow extended and wrist passively moved in extension to lengthen flexor pronator tendon group
What orthotic should be used for intersection synndrome?
thumb spica orthosis/brace
What can you use tenodesis for?
to isolate wrist extensors vs. digit extensors
What does phase 1 of interventions for lateral epicondylitis focus on?
to reduce pain and tendon lengthening
Where do nodules or cords typically show up for dupuytren's disease?
ulnar side
What are symptoms of ECU?
ulnar sided wrist pain (6th dorsal compartment)
What should you do to avoid concentric strengtheinign?
use other hand to lift affect hand in extension and then focus on lowering slowly
What is concentric strengthening?
when the muscle shortens and the origin and insertion of the muscle move towards each other
Who is most likely to get trigger finger?
women
Who is more likely to get DeQuervain's?
women are 4 times more likely (ages 35-55)
How should the wrist be positioned in an orthosis with tennis elbow?
wrist extension