Pt Mgmt- Unit 10: elbow

categories of elbow pain and movement dysfunction

1. local neuro/musculoskeletal -anterior elbow: anterior capsule strain, biceps tear/tendonitis, dislocation, pronator syndrome -posterior elbow: olecranon bursitis, triceps tendonitis, posterior impingement, trochlear chondromalacia -medial elbow: medial epicondylitis, UCL injury, ulnar neuritis, flexor/pronator strain, fracture, little league elbow -lateral elbow: fracture, LCL injury, lateral epicondylitis, osteochondral degeneration, radial tunnel syndrome, posterior interosseous nerve syndrome 2. remote/referred neuro/musculoskeletal 3. systemic sources -gout -infective arthritis -polyarthritis - vascular disorders

What are the three main ligaments of the elbow complex? How do ligaments at the elbow complex become injured?

1. ulnar collateral ligament 2. lateral collateral ligament 3. annular ligament -trauma -repeated microfailure (muscle weakness, poor muscle endurance, inefficient movement pattern) -leads to ligament tear/rupture

Gout vs OA

(can look similar) gout: -systemic signs such as fever, chills, warmth at joints/nodules OA: -no systemic signs such as fever and chills, joint pain but redness and warmth not present

lateral epicondylalgia common characteristics

-Age 35-54 -dominant arm - repetitive work/sports/performing arts with gripping or wrist extension -recurrent episodes common -tendinosis of ECRB>ECRL muscle -easy to recognize clinically -underlying pathology is complex

myotomal pattern of weakness

-C5 - rhomboids, supraspinatus -C5,C6 - teres major -C6 - supinator -C6, C7 - coracobrachialis, ECRL, ECRB, FCR, pronator teres, APL -C6, C7, C8 - latissimus dorsi, ECU, EDC, EDM, EPL -C7, C8 - triceps -C7, C8, T1 - FDS -C8, T1 - FCU/FDP, ADP/APB, add pollicis, lumbricals, pronator quadratus, opponens pollicis, opponens DM

self reported outcomes for the elbow

-DASH : disabilities of the arm, shoulder, and hand - quick DASH - ESAS: elbow self-assessment score -PREE: patient rated-elbow evaluation

what are local common sources of pain in the elbow?

-anterior elbow: anterior capsule strain, biceps tear/tendonitis, dislocation, pronator syndrome -posterior elbow: olecranon bursitis, triceps tendonitis, posterior impingement, trochlear chondromalacia -medial elbow: medial epicondylitis, UCL injury, ulnar neuritis, flexor/pronator strain, fracture, little league elbow -lateral elbow: fracture, LCL injury, lateral epicondylitis, osteochondral degeneration, radial tunnel syndrome, posterior interosseous nerve syndrome

subjective interview: specific questions for the elbow

-chief complaint? -how old is the patient? -MOI vs insidious - hand dominance? -history of elbow pain following overuse or repetitive use? -are symptoms related to occupation? -history of locking or catching?

when we think the muscle is a source of pain, what do we do?

-complete a cluster of tests to confirm if the muscle in question is a source of pain 1. stretch the muscle 2. contract the muscle 3. palpate the muscle/tendon

red flags of the elbow

-elbow and arm pain with exertion (cardiac) -other constitutional symptoms that may indicate a systemic cause of symptoms (EX: night pain, night sweats, etc)

how would you assess the integrity of the annular ligament?

-encircles radial head and helps keep the radial attached to the ulna -dislocation in children (common) -look for lump from displaced radial head

inspection of the hand and wrist

-expose full UE: possibility of referral from other sources -posture -attitude of the hand -nails (are they blue/is there a cardiac issue?), skin (shiny, red?), wound/scar

what is tinels sign?

-lightly tap of percuss over median nerve at the level of the carpal tunnel -positive test: sensation of tingling of "pins and needles" distal to the point of percussion. it must reproduce their symptoms to be positive

neuro screen

-need to rule out referral of pain/parasthesias from cervical spine or other regions proximal to the wrist and hand -parasthesias in a peripheral nerve of dermatomal distribution -- which nerve/what level

what is the modified allen test?

-occlude the radial and ulnar arteries at the wrist -exsanguinate the hand by elevation and have patient regularly flex and extend fingers -alternately release the arteries to avaluate sidtsl filling - color should return in 3-5 seconds

what is little league elbow?

-overuse throwing condition in children -excessive valgus stress on tendons/ligaments on medial side of elbow (UCL) - repeated pulling can tear tendon/ligaments away from the bone -called medial epicondylar apophysitis -disrupt growth plate or take a bony fragment with it -disrupt normal bone growth; leads to deformity if ignored

what does the elbow complex do?

-positions the hand in space - transmits power from the shoulder to the hand -ligaments and articulations make it a stable and strong joint -vulnerable to overuse from repetitive activities because it allows little in the way of compensatory adjustments

outline of the subjective and objective info (UE)

-salient features of history - pertinent exam findings - patient goals -your prognosis (time course) -treatment plan -reassessment or change of plan

olecranon bursitis

-superficial tissue -between skin and olecranon process - prolonged weight bearing or direct trauma causes swelling -normally you cant palpate bursa unless swollen

how much elbow flexion is required to perform ADLs?

30-130 elbow flexion

how would you assess the integrity of the lateral collateral ligament?

applu varus stress - in 5-30 degrees of flexion - assess amount of mobility -assess symptom response -compared to uninvolved side

how would you assess the integrity of the ulnar collateral ligaments?

apply valgus stress -in 20-30 degrees flexion -assess amount of mobility -assess symptom response -compared to uninvolved side milking maneuver aims to localize posterior band of UCL -elbow flexed 90 degrees - stabilize humerus -pull supinated forearm laterally on stabilized humerus

from the subjective interview, ________________ sources of elbow pain and movement dysfunction. into what?

categorize -local neuro/musculoskeletal -remote/referred neuro/musculoskeletal -systemic sources

epicondylitis vs epicondylagia

Epicondylitis, or the itis component of that, makes you think that there is an inflammatory component. -Old view -lateral elbow pain -microscopic tears at common extensor tendon -associated with overuse - attempt to heal; healing surface pulled apart with continued use results in inflammation -treatments aimed at reducing inflammation Epicondylalgia is a more general term for lateral or medial elbow pain, pain at the epicondyle -New view -affected tendon lacks inflammatory cells -large number of fibroblasts, disorganiced immature collagen cells, vascular hyperplasia -suggests degenerative process -pain sources: vascular, nerve, neurochemical -also called tendinosis or tendinopathy -similar findings in achilles, patellar, shoulder tendons

Explain why performing wrist extension and radial deviation with the elbow bent biases extensor carpi radialis brevis.

Extensor carpi radialis longus crosses the elbow joint above extensor carpi radialis brevis. Wrist extension and radial deviation with the elbow bent biases extensor carpi radialis brevis over extensor carpi radialis longus. This is a result of an altered length-tension relationship of the muscle based on elbow position.

Name the vascular test that follows the steps below: Compress the radial and ulnar arteries at the wrist. Exsanguinate the hand by elevation, and have the patient regularly flex and extend. Alternately release the arteries to evaluate distal filling. Color should return in 3-5 seconds. Capillary refill test Modified Allen test

Modified Allen test

elbow joint assessment

PROM -amount of motion available -end-feel joint accessory motion -normal, hypo-, hyper-

If a patient presents with hypomobility of posterior to anterior (PA) glide of the distal radial-ulnar joint, which osteokinematic motion is likely limited? Supination Pronation

Pronation

if your patient sustained an injury to a nerve, what signs or symptoms might they have?

patient might complain of: -weakness -changes in sensation numbness/tingling pattern of motor/sensory loss -peripheral nerve -cervical nerve root -central (ex: stroke) major peripheral nerves -musculocutaneous -median -radial -ulnar can be a source of pain nerves need to slide between tissues they interface with

If a patient presents with hypomobility of the dorsal to palmar glide of the carpals on the radius, which osteokinematic wrist motion is likely limited? a. Wrist extension b. Wrist flexion

a. Wrist extension

If a patient presents with hypomobility of anterior to posterior (AP) glide of the proximal radial-ulnar joint, which osteokinematic motion is likely limited? a. pronation b. supination

a. pronation

demographics for the subjective exam for the hand and wrist include? what else do you need to ask the patient?

age hand dominance what is the patients occupation? hobbies and recreational activities

what is lateral epicondylitis (tennis elbow) and how do we rule it in or rule it out?

an irritation of the tendons, tendon complexes, as it attaches to the lateral epicondyle perform a cluster of tests -Mills test (passive wrist flexion) -resisted wrist extension (ECRB and ECRL) -cozens sign -palpate extensor origin

what is medial epicondylitis (golfers elbow)? how do we rule it in or out?

an irritation of the tendons, tendon complexes, as it attaches to the medial epicondyle. we perform a cluster of tests - passive wrist extension -resisted wrist flexion -resisted wrist pronation -palpate flexor origin

to access the arthrokinematics associated with supination, which direction would you glide the radius?

anterior -this is because the associated movement with the radius in supination is posterior and its shape is convex... therefore we would test the opposite direction

If a patient presents with hypomobility of the palmar to dorsal glide of the middle phalanx on the proximal phalanx, which osteokinematic finger motion is likely limited? a. Flexion b. Extension

b. Extension

Which phalanx is resistance applied to during finger abduction and adduction manual muscle testing? a. Middle phalanx b. Proximal phalanx c. Distal phalanx

b. Proximal phalanx

if a patient has pain in her anterior elbow on the medial side.... what are possible sources of pain?

bone joint capsule muscle ligament nerve bursa

A 35-year-old male is referred to physical therapy with elbow pain. He reports golfing 18 holes reproduces his medial elbow symptoms. Which cluster of tests would be most appropriate to diagnosis the affected tissue? a. Passive wrist flexion, resisted wrist extension, resisted supination, and palpation at extensor origin. b. Active wrist extension, resisted wrist flexion, resisted pronation, and palpation at flexor origin. c. Passive wrist extension, resisted wrist flexion, resisted pronation, and palpation at flexor origin. d. Passive wrist flexion, resisted wrist extension, resisted supination, and palpation at flexor origin.

c. Passive wrist extension, resisted wrist flexion, resisted pronation, and palpation at flexor origin.

what does the proximal radioulnar joint do?

convex radial head concave ulnar notch stabilize ulna and move radius motion resisted= supination/pronation resting postion 70 flexion, 35 supination anterior glide of the radius - supination posterior glide of the radius - pronation

Which of the following is NOT a likely source of medial elbow pain? a. Ulnar nerve b. Ulnar collateral ligament c. Flexor carpi ulnaris tendon d. Annular ligament

d. Annular ligament

what is the purpose of the 2 point discrimination test?

to assess the patients ability to perform tasks requiring precision grip

A 25-year-old construction worker is referred to physical therapy with reports of tightening with a screwdriver. You decide to perform a manual muscle test of his supinator muscle. What is a common compensation that you could observe while testing? a. Humeral abduction and internal rotation b. Humeral extension and internal rotation c. Humeral flexion and external rotation d. Humeral adduction and external rotation

d. Humeral adduction and external rotation

A 24-year-old baseball player is referred to physical therapy with reports of medial elbow pain when throwing the baseball. Which special test would be the most effective in identifying the pathological structure? a. Passive wrist flexion b. Varus stress c. Mill's test d. Milking maneuver

d. Milking maneuver

systemic illnesses related to the hand and wrists

diabetes -controlled -effect on wound/incision healing collagen vascular disease

T/F lateral epicondyle pain is typically an inflammatory pain

false

what are some systemic problems that cause elbow pain?

gout infective arthritis polyarthritis vascular disorders

history of specific injury? MOI? Past med hist?

history: -date of injury -location -other associated injury at time of injury MOI: -forces involved -falls with a fracture may include an undetected triangular fibrocartilage complex or ligamentous injury -lacerations Past medical history: -surgeries -previous treatments for this injury -previous UE injuries, neck injuries, etc

Red flags at the hand and wrists

medical diagnosis that can cause wrist, hand, and finger pain -RA -infection: most common site = wrist at flexor pollicis longus -tumors: usually benign -vascular occlusion

distal radioulnar joint

motion resisted = pronation/supination stabilize ulna resting position = 10 supination anterior glide of the radius = pronation posterior glide of the radius = supination

what happens to the tendons when a laceration occurs with an open hand versus a closed hand

open: laceration of skin and tendon occur on the same level closed: when your hand is closed, your tendons glide proximally, therefore if there is a laceration when yous hand is closed, the skin laceration will be proximal to the tendon laceration

what does the humeroradial joint do?

resists flex/ext and pronation/supination stabilize humerus resting postion = full extension, full supination (tested in resting postition of HU joint) distract radius

what does the humeroulnar joint do?

resists flexion/extension stabilize humerus resisting position = 70 flexion, 10 supination distract ulna

what is the capillary refill test?

squeeze tip of finger tip will turn white, let go and see how long it takes for the blood to refill and resume normal color -should be <2 seconds

what is the phalens test?

tests for compression of the median nerve in the carpal tunnel place backs of hands together in front of you -hold the position for one minute -positive=reproduction of patients symptoms -mean +LR = 2.68 -mean -LR = 0.54 modification: add pinch component (increases carpal tunnel pressures) reverse phalens test (looks like youre praying)

what is the semmes-weinstein monofilaments used for?

used to establist the threshold of light touch