Quiz 8 KNES 315
finger sprains and dislocations management
*because of the probability of entrapping the volar plate in an IP joint, which can lead to permanent dysfunction of the finger, no attempt should be made to reduce a finger dislocation by an untrained individual; * immediate treatment for all dislocations involves immobilization in a finger splint, application of cold, and referral to a physician 224
glenohumeral dislocations
*the GH joint is the most frequently dislocated major joint in the body;* 90% of shoulder dislocations are anterior; posteiror dislocations rank second in occurrence; inferior dislocations are rare and often accompanied by neurovascular injury and fracutre; dislocations can be acute or chronic 199
impingement syndrome
___________________ involves an abutment of the supraspinatus tendon and subacromial bursa under the coracoacromial ligament and acromion process; the glenoid labrum and long head of the biceps brachii may also be injured 207
injuries that should be referred
___________________ to a physician include: obvious deformity suggesting a suspected fracture, separation, or dislocation significant loss of motion or weakness in the myoyomes joint instability abnormal sensations in either the segmental dermatomes or peripheral cutaneous patterns absent or weak pulse distal to the injury any significant, unexplained pain 207
anterior GH dislocations
____________________ are more common than posterior dislocations; the injured arm is held in slight abduction and external rotation 207
bennett's fracture
a ___________________ is an articualr fracture of the proximal end of the first metacarpal and is usually associated with a dislocation; it is typically caused by axial compression, as occurs when a punch is thrown with a closed fist or the individual falls on a closed fist; the pull of the abductor pollicis longus tendon at the base of the of the metacarpal displaces the shaft proximally; however, a small medial fragment is held in place by the deep volar ligament, leading to a fracture- dislocation 232 bf
moderate AC sprain
a ___________________ is characterized by an elevated distal clavicle, indicating that the coracoclavicular ligament and the AC ligaments have been torn; the individual typically has a depressed or drooping shoulder 207
dislocations signs and symptoms
a snapping or cracking sensation is experienced on impact; it is followed by severe pain, rapid swelling, total loss of function, and an obvious deformity; the arm is frequently held in flexion, with the forearm appearing shortened; the olecreanon and radial head are palpable posteriorly, and a slight indentation in the triceps is visible just proximal to the olecranon 222
schaphoid fractures management
a suspected fracture should be immobilized and the individual should be referred to a physician immediately; application of cold can help to reduce swelling and inflammation 231 sf
finger sprains and dislocations signs and symptoms
a swollen, painful finger caused by a ball striking the extended finger is the most frequent inital report; *an obvious deformity may not be present unless there is a fracture; * *the most common dislocation in the body occurs at the PIP joint;* pain is present at the joint line and increases when the mechanism of injury is produced; because digital nerves and vessels run along the sides of the fingers and thumb, dislocation here can be potentially serious 224
acute and chronic bursitis elbow management
acute management involves ice, rest, and a compressive wrap applied for the first 24 hours; if there is significant distension, the individual should be referred to a physician as the condition may necessitate aspiration to releive the swelling; chronic bursitis is managed with application of cold to the area, nonsteroidal anti-inflammatory medications, and the use of elbow cushions to protect the area from further insult 221
contusions to elbow, hand, and wrist management
although many contusions are minor, it is always important to be alert for an underlying fracture; initial treatment involves ice, compression, elevation, and rest; symptoms usually disappear in 2 to 3 days; if not, the individual should be referred to a physician for follow-up-care 221
bursae of the elbow
although there are several small bursae about the elbow, the most clinically relevant is the subcutaneous olecranon bursa located between the olecranon and skin surface; the lubricating function of the bursa activates smooth gliding of the skin over the olecranon process during elbow flexion and extension 213
boutonniere deformity management
any injury that limits PIP extension to 30 degrees or less and produces dorsal tenderness over the base of the middle phalanx should be treated as an acute tendon rupture and immediately referred to a physician 226 bd
overuse conditions of elbow
as the ball is released, the elbow is almost fully extended and is positioned slightly anterior to the trunk; when release takes place, the elbow is flexed approximately 20 to 30 degrees; as these forces decrease, however, the extreme pronation of the forearm places the lateral ligaments under tension during deceleration, eccentric contractions of the long head of the biceps brachii, supinator, and extensor muscles decelarate the forearm in pronation; additional stress occurs on structures around the olecranon as pronation and extension jam the olecranon into the olecranon fossa; impingement can occur during this jamming 226 oe
wrist sprain
axial loading on the proximal palm during a fall on an outstretched hand is the leading cause of wrist sprains; this injury is often neglected, leading to chronic wrist pain 223
glenohumeral joint sprain
damage to the ____________________ can occur when the arm is forcefully abducted (e.g. when making an arm takle in football), but more commonly is caused by excessive shoulder external rotation and extension (i.e., arm in the overhead position); when the arm rotates externally, the anterior capsule and GH ligaments are stretched or torn, causing the humeral head to slip out of the glenoid fossa in an anterior-inferior direction; a direct blow or forceful movement that pushes the humerus posteriorly can also result in damage to the joint capsule 198
contusions to elbow, hand, and wrist
direct blows to arm and forearm are frequently associated with contact and collision sports; ____________ result from a compressive force sustained from a direct blow; such injuries vary in severity in accordance with the area and depth over which blood vessels are ruptured 219
finger sprains and dislocations
excessive varus/valgus stress and hyperextension can damage the collateral ligaments of the fingers; although many individuals will consider the injury to be a simple "jammed finger" this injury often involves an avulsion fracture from a tendon rupture, which requires immediate surgery to repair the damage; hyperextension of the proximal phalanx can stretch or rupture the volar plate on the palmar side of the joint; as such, it is critical to refer this individual to a physician to rule out a more extensive injury 224
physician for care
if a decision is made to refer an individual to a _______________, the limb should be appropriately immobilized to protect the area and, if tolerable, cold should be applied to reduce swelling and hemorrhage 235
coach assessment
if no problems are noted during neck movement, the coach could continue with assessing the ROM of the shoulder finally, while it is not per se a part of a shoulder assessment, there may be times when an individual reports pain to the shoulder in the absence of any trauma involving the shoulder; the coach should keep in mind that *the shoulder is a common site for referred pain from orthopedic or visceral origins; as such, the possibility of an internal injury (i.e. involving the thorax or abdomen) should be considered particularly when the individual presents a vague history of injury to the shoulder girdle* 207
thoracic outlet compression syndrome managmeent
immediate referral to a physician is necessary for more extensive assessment to rule out serious vascular involvement 203 to
wrist sprain management
immediate treatment involves immobilization, application of cold, elevation, and immediate referral to a physician to rule out a fracture or carpal dislocation 223
rotator cuff and impingement injuries management
in assessing this condition, it should become apparent to the coach during the history component that injury is overuse in nature, and, as such,* the coach should refrain from continuing assessment; rather, the coach should refer the individual to a physician for accurate diagnosis and treatment options*; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potenital spasm 201 rc
hand
in the ______________, several joints are required to provide the extensive motion capabilities needed for sports participation; included are the carpometacarpal (CM), intermetacarpal (IM), metacarpapophalangeal (MCP), and interphalangeal (IP) joints; the fingers are numbered digits one through five, with the first digit being the thumb 212
gamekeeper's thumb management
initial treatment includes application of cold, compression, elevation, and referral to a physician for further care 224
acromioclavicular joint sprains type III second degree
injured structures: rupture of AC ligament and coracoclavicular ligament 197
elbow strains signs and symptoms
injury to the elbow flexors (brachialis, biceps brachii, and brachioradialis) will result in point tenderness on the anterior distal arm; pain increases with resisted elbow flexion; if the strain is to the triceps, resisted elbow extension produces discomfort; strains to the common wrist flexor group result in pain on resisted wrist flexion, whereas strains to the wrist extensors produce pain with wrist extension 225
physical conditioning
lack of flexibility can predispose an individual to joint sprains and muscular strains; warm-up exercises should focus on general joint flexibility, and may be performed alone or with a partner using proprioceptive neuromuscular facilitation (PNF) stretching techniques; individuals using the throwing motion in their sport should increase ROM in external rotation, as this has been shown to increase the velocity of the throwing arm and decrease shearing forces on the GH joint 194
sprains to the shoulder complex
liagemntous injuries to the SC joint, AC joint, and GH joint can result from compression, tension, and shearing forces occurring in a single episode, or from repetitive overload; a common method of injury is a fall or direct hit on the lateral aspect of the acromion; the force is first transmitted to the site of impact, then to the AC joint and the clavicle, and finally to the SC joint; failure can occur at any one of these sites; acute sprains are common in hockey, rugby, football, soccer, equestrain sports, and the martial arts 196
wrist injuries
most _______________ are caused by axial loading on the proximal palm during a fall on an outstretched hand 235
elbow strains
muscular strains occur as a result of excessive overload against resistance or overstretching the tendon beyond its normal range; in mild or moderate strains, pain and restricted motion may not be a major factor; in many injuries, muscular strains occur simultaneously with a joint sprain; the joint sprain takes precedence in priority of care, especially with an associated dislocation; as a result, tendon damage may go unrecognized and untreated 225
proper technique
nearly all overuse injuries are directly related to repetitive throwing-type motions that produce microtraumatic tensile forces on the surrounding soft tissue structures; *children who use a sidearm throwing motion are three times more likely to develop problems than those who use a more traditional overhead technique; * movement analysis can detect improper technique in the acceleration and follow-through phase that contribute to these excessive tensile forces an important skill technique that can prevent injury of the wrist and hand is proper instruction on the shoulder-roll method of falling; in this technique, the force of impact is dispersed over a wider area, lessening the risk for injury from direct axial loading on the extended wrist 219
history and observation
subsequent to the _______________________ components of an assessment, the coach should have established a strong suspicion of the structures that may be damaged; as such, during the physical examination component, only those tests that are absolutely necessary, if any, should be performed 207
boxer's fracture signs and symptoms
sudden pain, inability to grip objects, rapid swelling, and possible deformity are present; palpation reveals tenderness and pain over the fracture site, and possible crepitus and body deviation; delayed ecchymosis is common; pain increases with axial compression of the involved metacarpal and percussion 233 vox
clavicular fractures signs and symptoms
swelling, ecchymosis, and a deformity may be visible and palpable at the fracture site; greenstick fractures, typically seen in adolescents also produce a noticeable deformity; pain occurs with any shoulder motion, and may radiate into the trapezius area; in older adults, fractures of the distal clavicle may involve tears of the coracococlavicular ligament, resulting in an increaesd deformity; complications, although rare, may arise if bony fragments penetrate local arteries or nerves 204 cf
tendinitis and stenosing tenosynovitis signs and symptoms
tendinitis in the WRIST flexors or extensors leads to stiffness and an aching pain that is aggravated by activity; it may appear several hours after participation in physical activity; pain is usually localized over the involved tendons and is aggravated with passive stretching and resisted motion of the affected tendons 227 tst
boutonniere deformity signs and symptoms
the *deformity is not usually present immediately, but develops over 2 to 3 weeks* as the lateral slips move in a palmar direction and cause hyperextension at the MCP joint, flexion at the PIP joint, and hyperextension at the DIP joint; because the head of the proximal phalanx protrudes through the split in the extensor hood, this condition is sometimes referred to as a *buttonhole rupture*; the PIP joint is swollen and lacks full extension 226 bd
interphalangeal joint motion
the IP joints permit flexion and extension, and in some individuals, slight hyperextension; these are classic hinge joints 218
sternoclavicular joint sprain (anterior)
the SC joint is the main axis of rotation for movements of the clavicle and scapula; the majority of injuries result form compression related to a direct blow, as when a supine individual is landed on by another participant, or more commonly by indirect forces transmitted form a blow to the shoulder or a fall in an outstretched arm; the disruption typically drives the proximal clavicle superior, medial, and anteiror, disrupting the costoclavicular and SC ligaments and leading to anterior displacement 196
elbow
the ______________- encompasses three articulations- the humeroulnar, humeroradial, and proximal radioulnar joints 235
wrist
the _________________ and hand are composed of numerous small bones and articulations; these function effectively to enable the dexerous movements performed by the hands during both daily lviing and sport activities; the _____________ consists of a series of radiocarpal and intercarpal articulations; most wrist motion, however, occurs at the radiocarpal joint, a condyloid joint where the radius articulates with he scaphoid, lunate, and triquetrium; the joint allows sagittal plane motion (flexion, extension, and hyperextension) and frontal plane motion (radial deviation and ulnar deviation), as well as circumduction 212
shoulder complex
the __________________ does not function in an isolated fashion; rather, a series of joints work together in a coordinated manner to allow complicated patterns of motion; subsequently, injury to one structure can affect other structures 207
surgical neck
the ___________________ is the most common site for proximal humeral fractures in adults; however, adolescents have a high degree of proximal humeral epiphyseal fractures due to repetitive medial rotation and adduction traction forces placed on the shoulder during pitching motions 207
acromioclavicular joint sprains
the ____________________ is weak and easily injured by direct blow, fall on the point of the shoulder (called a shoulder pointer), or force transmitted up the long axis of the humerus during a fall with the humerus in an adducted position; in these cases, the acromion is driven away from the clavicle or vice versa; although often referred to as a separated shoulder, ruptures of the AC and/or costoclavicular ligaments can result in an AC dislocation; therefore, they are more correctly referred to as sprains 197
acute and chronic bursitis elbow signs and symptoms
the acutely inflammed bursa presents with an immediate tender, swollen area of redness in the posterior elbow; the swelling is relatively painless; if the bursa ruptures, a discrete, sharply demarcated goose egg is visible directly over the olecranon process; motion is limited at the extreme of flexion as tension increases over the bursa 221
septic bursitis elbow signs and symptoms
the area is hot to the touch and inflamed; the individual shows traditional signs of infection, including malaise (feeling lousy), fever, pain, restricted motion, tenderness, and swelling at the elbow 221
shoulder
the arm articulates with the trunk at the ________________, or pectoral girdle, composed of the scapula and clavicle; the __________________ region has five separate articulations: the sternoclavicular joint, AC joint, coracoclavicualr joint, glenohumaral joint, and scapulothoracic joint; the articulation referred to specifically as the shoulder joint is the glenohumeral joint; the remaining articulations are collectively referred to as the shoulder girdle; the SC and AC joints enhance emotion of the clavicle and scapula, enabling the GH joint to provide a greater range of motion (ROM) 189
sternoclavicular joint sprain (anterior) management
the immediate management includes the application of cold to the area; the individual should also be placed in a sling; this injury requires physician referral; if a grade II or grade III injury is suspected, the individual should be referred to an emergency medical facility 197
gamekeeper's thumb signs and symptoms
the palmar aspect of the joint is painful, swollen, and may have visible bruising; instability is detected by replicating the mechanism of injury or by stressing the thumb in flexion
overuse conditions of elbow
the throwing mechanism can lead to significant overuse injuries at the elbow; during the initial acceleration phase, the body is brought rapidly forward, but the elbow and hand lag behind the upper arm; this action results in a tremendous tensile valgus stress placed on the medial aspect of the elbow, particularly the ulnar collateral ligmaent and adjacent tissues; as acceleration continues, the elbow extensors and wrist flexors contract to add velocity to the throw; this whipping action produces significant valgus stress on the medial elbow and concomitant lateral compressive stress in the radiocapitellar joint 226 oe
elbow dislocations management
this injury should be considered a medical emergency; as such, activation of the emergency action plan is warranted, including summoning of EMS; because of the risk of neurovascular injury, the coach should not make any attempt to change the position of the arm; if tolerable, application of cold to the area will help to manage swelling and inflammation while EMS is en route; reduction of a dislocated elbow is usually performed under general or regional anesthesia 223
metacarpal fractures
uncomplicated fractures of the ________________ result in severe pain, swelling, and deformity; unique fractures at the base of the first metacarpal may involve a simple intra-articular fracture (E.g. BENNETT's fracture); a unique fracture involving the neck of the fourth or fifth metacarpal is called a BOXER's fracture; it occurs when an individual punches an object with a closed fifst, leaing to rotation of the head of the metacarpal over the neck; axial compression on the hand can lead to a fracture-dislocation of the proximal end of the metacarpal; it often goes undetected because edema obscures the extent of injury; fractures of the shaft of the metacarpal are more easily recognizable 232 mf
epiphyseal and avulsion fractuces
avulsion fractures to the coracoid process can be seen in a young individual when forceful, repetitive throwing places too much stress on the growth plate; fractures of the greater and lesser tubercule are often associated with anterior and posterior GH dislocations, respectively; when the tubercle cannot be maintained in a stable position, open reduction and internal fixation is often required 204eaf
acute posterior glenohumeral dislocations
________________ occur from a fall or a blow to the anterior surface of the shoulder which drives the head of the humerus posteriorly 199
pronation and supination
________________- of the forearm occur when the radius rotates around the ulna; there are three radioulnar articulations: the proximal, middle, and distal radioulnar joints; the primary pronator muscle is the pronator quadratus, which attaches to the distal ulna and radius; the pronator teres, which crosses the proximal radioulnar joint, assists with pronation; as the name suggests, the supinator is the muscle primarily responsible for supination; during resistance or elbow flexion, the biceps also participates in supination 217
acromioclavicular joint sprains managmeent
________________: the immediate management includes the application of cold to the area; the individual should also be placed in a sling; this injury requires physician referral; *if a type II or higher is suspected, the individual should be referred to an emergency medical facility 198*
ulnar dislocations
most _____________________ occur in individuals younger than 20 years, with a peak incidence in early adolescence; the mechanism is usually hyperextension, or a sudden, violent unidirectional valgus force that drives the ulna posterior or posterolateral 235
biceps tendon rupture management
the immediate management includes placing the individual in a sling and applying cold to the area; this action should be followed by immediate referral to a physician or emergency medical care facility 202 btr
clavicular fractures management
the immediate management includes placing the individual in a sling and swathe; this action should be followed by immediate referral to a physician or emergency care facility 204 cf
on-site assessment of an acute elbow, wrist, or hand injury: HOP
HISTORY -Chief complaint What's wrong -Mechanism of injury what happened? what were you doing? was there a direct blow? did you fall? How (outstretched arm; flexed arm; outstretched hand)? are you able to demonstrate how it happened? -Acute or chronic injury (onset) Do you remember when it started hurting? how long has this been bothering you? -Pain where is the pain? can you point to a location where it hurts the most? -Type Can you describe the pain (e.g. sharp, shooting, dull, achy, diffuse)? -Intensity what is the level of pain on a scale of 1 to 10? -Sounds/feelings did you hear anything when the injury happened (e.g. pop, snap, crack)? did you feel any unusual sensations (e.g. tearing, tingling, numbing, crackling) when the injury happened? -Previous history Hae you ever injured your shoulder before? If so, what happened? what was the injury? were you treated for it? -Other important/helpful information Have you made any changes in performance technique (E.g. throwing style, swimming strokes)? Are you able to perform activity specific skills (e.g. throw, swimming strokes) Have you changed your weight training work-outs (e.g. increased weight or number of repetitions; added new exercises)? Are you able to perform normal motions/ADLs? Is there anything else you would like to tell me about your condition? OBSERVATION -General presentation guarding moving easily; hesitant to move -Specific to elbow The manner in which the individual is holding their arm Resting position-swelling in the joint may prevent full elbow extension or flexion soft tissue symmetry (i.e. muscle atrophy, hypertrophy) -Specific to forearm, wrist, and hand posture shape and contour of the bony and soft tissue structures MCP joints and between (peaks and valleys- normal or filled with swelling) Angular deformities of the fingers (that may indicate previous fracture or dislocation) Injury site appearance-deformity; swelling; discoloration PALPATION the coach should only perform palpation if there is a clear understanding of what is being palpated and why? A productive assessment appropriate to the standard of care of a coach does not necessitate palpation TESTING -Active range of motion-bilateral comparison Elbow flexion and extension forearm supination and pronation wrist flexion and extension ulnar deviation and radial deviation finger flexion and extension at MCP, PIP, and DIP joints abduction and adduction at MCP joints thumb (first CMC joint) flexion and extension thumb abduction and adduction opposition PASSIVE Range of motion should not be performed by the coach RESISTIVE Range of motion the coach should only perform resistive range of motion for the muscles that govern the shoulder if instruction and approval for doing so has been obtained in advance from an appropriate healthcare practitioner active range of motion is normal and pain-free as a way to assess strength ACTIVITY/ SPORT-SPECIFIC FUNCTIONAL TESTING performance of active movements typical of the movements executed by the individual during sport or activity participation (including weight training) should assess strength, agility, flexibility, joint stability, endurance, coordination, balance, and activity specific skill performance 234
on-site shoulder assessment
HISTORY -chief complaint what's wrong? -mechanism of injury what happened? what were you doing? was there a direct blow? did you fall? how (outstretched arm; flexed arm; outstretched hand)? Are you able to demonstrate how it happened? -Acute or chronic injury (onset) do you remember when it started hurting how long has this been botheirng you? -Pain location where is the pain? can you point to a location where it hurts the most? type- can you describe the pain (e.g. sharp, shooting, dull, achy, diffuse)? intensity- what is the level of pain on a scale from 1 to 10? -Sounds/feelings did you hear anything when the injury happened (e.g. pop, snap, crack)? did you feel any unusual sensations (e.g. tearing, tingling, numbing, cracking) when the injury happened? -previous history have you ever injured your shoulder before? if so, what happened? what was the injury? were you treated for it? -OTHER important/helpful information *have you made any changes in performance technique* (e.g. throwing style, swimming strokes)? are you able to perform activity-specific skills (e.g. throw, swimming strokes)? have you changed your weight training workouts (E.g. increased weight or number of repetitions; added new exercises)? are you able to perform normal motions/ ADLs? is there anything else you would like to tell me about your condition? OBSERVATION -general presentation guarding moving easily; hesitatnt to move - specific to shoulder the manner in which the individual is holding their arm resting position- swelling in the joint may prevent full shoulder adduction soft tissue symmetry (i.e. muscle atrophy, hypertrophy) shape and contour of the bony and soft tissue structures (scapula and muscle atrophy) injury site appearance- deformity, swelling, discoloration PALPATION the coach should only perform palpation if there is a clear understanding of that is being palpated and why? A productive assessment appropriate to the standard of care of a coach does not nessessitate palpation TESTING *Active Range of Motion (AROM)*- bilateral comparison shoulder abduction with the hand supinated shoulder adduction to the side of the body humeral internal and external rotation shoulder flexion and extension *Passive Range of Motion (PROM*) should not be performed by the coach *Resistive Range of motion* the coach should only perform resistive range of motion for the muscles that govern the shoulder if instruction and approval for doing so has been obtained in advance from an appropriate healthcare practitioner AROM is normal and pain free is a way to assess strength ACTIVITY / SPORT SPECIFIC FUNCTIONAL TESTING performance of active movements typical of the movements executed by the individual during sport or activity participation (including weight training) should assess strength, agility, flexibility, joint stability, endurance, coordination, balance, and activity specific skill performance 206
medial epicondylitis
__________________ produces severe pain on resisted wrist flexion and pronation, and with a valgus stress 235
jersey finger signs and symptoms
__________________: if avulsed, the tendon can be palpated at the proximal aspect of the involved finger; the individual is unable to flex the DIP joint against resistance 225 jf
muscular strains
_______________________ occur from excessive overload against resistance or from stretching the tendon beyond its normal range; ruptures of a muscle tendon may cause the tendon to retract, necessitating surgical reattachment of the tendon in its proper position 235
acute and chronic bursitis elbow
a fall on a flexed elbow can lead to an acutely inflammed bursa; constantly leaning on one's elbow, repetitive pressure, and friction can lead to a chronic inflammed bursa 221
septic bursitis elbow management
an individual with an infected bursa should be referred to a physician; the physician usually aspirates the bursa and takes a culture of the fluid to determine the presence of septic bursitis 221
protective equipment
contact and collision sports, such as football, lacrosse, and ice hockey, require shoulder pads to protect exposed bony protuberances from impact; although shoulder pads do prevent some soft tissue injuries in this region, they do not protect the GH joint from excessive motion 195
phalangeal fractures
fractures of the phalanges are very common in sport participation; these fractures can be difficult to manage; they may be cuased by having the fingers stepped on or impinged between two hard objects such as a football helmet and the ground or by hyperextension that may lead to a fracture-dislocation 233 pf
septic bursitis elbow
occasionally, the bursa can become infected, regardless of acute trauma to the area; this may result from skin breakdown and a poor blood supply to the area 221
carpometacarpal joint motion
the CM joint of the thumb allows a large range of movement, comparable to that of a ball-and-socket joint; however, the fifth CM joint permits significantly less range of motion and only a very small amount of motion is allowed at the second through fourth CM joints, because of the presence of restrictive ligaments 218
metacarpophalangeal joint motion
the _____________ of the fingers allow flexion, extension, abduction, adduction, and circumduction; among the fingers, adduction is defined as movement away from the middle finger and adduction is movement toward the middle finger; the _____________ of the thumb functions more as a hinge joint, with the primary movements being flexion and extension 218
most common dislocation
the _________________ in the body occurs at the PIP joint; because digital nerves and vessels run along the lateral sides of the fingers and thumb, dislocations can be serious if reduced by an untrained individual 235
elbow dislocations
*in adolescents, the most common traumatic injury to the elbow is subluxation or dislocation of the proximal radial head, often associated with an immature annular ligament; * referred to as nursemaid's elbow or pulled-elbow syndrome, the condition results from longitudinal traction of an extended and pronated upper extremity, such as when a young child is swung by the arms; a small tear in the annular ligament allows the radial head to migrate out from under the annular ligament; *if an individual is unable to pronate and supinate the forearm without pain, immediate referral to a physician is warranted* 222
coach assessment
*in completing the observation component of the on-site assessment of an acute injury, both arms should be visibly clear, so that a bilateral comparison can be performed;* it will be important for the coach to recognize possible fractures and dislocations before moving the elbow, wrist, or hand; if a fracture or dislocation is suspected, the coach should not perform any of the testing components of the assessment; if the individual is in significant pain and/or is unable or unwilling to move the body part, the coach should complete the assessment with the body part in a comfortable position and avoid passively moving the involved or surrounding areas 233
tendinitis and stenosing tenosynovitis management
WRIST: the coach should refer this individual to a physician for accurate diagnosis and treatment options; the coach should not permit the individual to continue activity, as doing so could potenitally exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potential spasm 227 tst
CTS
______________ is the most common compression syndrome of the wrist and hand; it is characterized by pain and numbness that wakes the individual in the middle of the night, and is often relieved by shaking the hands 235
sternoclavicular joint sprain (posterior) management
___________________: posterior displacment can become life-threatening; the emergency plan should be activated including summoning of EMS 197
thoracic outlet compression syndrome
_______________________ may involve compression of the lower trunk of the brachial plexus or the subclavian artery and vein; if a nerve is compressed, an aching pain or numbness may extend across the shoulder to the ulnar aspect of the hand; if arterial or venous vessels are compressed, coolness, numbness in the entire arm, and fatigue occur after exerteional, overhead activity 207
epiphyseal and avulsion fractuces
________________________ centers around the shoulder region remain unfused for a longer span of time than is typically seen at other epiphyseal sites; *for example, the medial clavicular growth plate does not close until approximately age 25 years, and is often misdiagnosed as a SC subluxation/ dislocation;* the proximal humeral epiphysis does not close until 18 to 21 years of age; an epiphyseal fracture at this site, called little league shoulder, is often caused by repetitive medial rotation and adduction traction forces placed on the shoulder during pitching; catchers may also sustain this fracture because they throw the ball as hard and often as pitchers, but with less of a windup; the injury usually occurs during the deceleration and follow-through phases of throwing or pitching 204 eaf
prevention of shoulder conditions
acute and chronic injuries to the shoulder complex are common in sports participation; many contact and collision sports do require some protective equipment, but in most cases, *flexibility, physical conditioning, and proper technique* are the primary factors that can reduce the risk of injury to this vulnerable area 194
protective equipment
although ice hockey and men's lacrosse do have specific pads to protect the upper arm, elbow, and forearm, most sports do not require any protection for the elbow region; goalies, baseball and softball catchers, and field players in many sports, such as hockey and lacrosse, are required to wear wrist and hand protection; the padded gloves prevent direct compression from a stick, puck, or ball; several other gloves have extra padding on high-impact areas, aid in gripping, and protect the hand from abrasions 219
clavicular fractures
because of the S-shaped configuration of the clavicle, it is highly susceptible to compressive forces caused by a blow or fall on the point of the shoulder, a direct blow to the bone by an opponent or object, or falling on an outsttretched arm; activities that have a high incidence of clavicular injury include ice hockey, football, martial arts, lacrosse, gymnastics, weight lifting, wrestling, racquetball, squash, and bicycling; nearly 80% of traumatic fractures occur in the middle one third of the clavicle; the sternocleidomastoid muscle pulls the proximal bone fragment upward, allowing the distal shoulder to collapse downward and medially from the force of gravity and the pull of the pectoalis major muscle 204 cf
proper skill technique
coordinated muscle contractions are necessary for the smooth execution of the throwing motion; any disruption in the sequencing of integrated movements can lead to additional stress on the GH joint and surrounding soft tissue structures; high-speed photography often used to record the mechanics of the throwing motion, can lead to early detection of improper technique; in addition to proper throwing technique, participants in contact and collision sports should be taught the shoulder roll method of falling, rather than falling on an outstretched arm; this technique reduces direct compression of the articular joints and disperses the force over a wider area 196
boxer's fracture
fractures involving the distal metaphysis or neck of the fourth or fifth metacarpals are commonly seen in young males involved in punching activities, as such the name boxer's fracture (although the fracture rarely occurs in boxers); the fracture typically has an apex dorsal angulation and is inherently unstable secondary to the deforming muscle forces and the frequent volar communication 233 box
glenohumeral joint sprain signs and symptoms
in a FIRST DEGREE injury, the anterior shoulder is particularly painful to palpation and movement, especially when the mechanism of injury is reproduced; active ROM may be slightly limited, but pain does not occur on adduction or internal rotation, such as occurs with a muscular strain; a SECOND DEGREE sprain produces some joint laxity; in addition, pain, swelling, and bruising are usually significant, and ROM particularly abduction is limited a THIRD DEGREE injury is considered a dislocation and is discussed in the next section dislocation 198
distal radial and ulnar fractures signs and symptoms
in adolescents, fractures of the growth plate may present with the distal fragment being dorsally displaced; other signs and symptoms associated with traumatic fractures include intense pain, swelling, deformity, and a false joint; swelling and hemorrhage may lead to circulatory impairment, or the median nerve may be damaged as it passes through the forearm 230 druf
wrist and finger strains
in the hand, muscle trains involving the finger flexors or extensors tend to be more serious than the elbow; these injuries may involve avulsing the tendon from the bone 225
metacarpal fractures signs and symptoms
increased pain and a palpable deformity are present in the palm of the hand directly over the involved metacarpal; gentle percussion and compression along the long axis of the bone increase pain at the fracture site 232 mf
phalangeal fractures signs and symptoms
increased pain is present with circulative compression around the involved phalanx; gentle percussion and compression along the long axis of the bone increase pain at the fracture site; particular attention should be given to a possible fracture of the middle and proximal phalanges; these fractures tend to have marked deformity because of the strong pull of the flexor and extensor tendons; the four fingers move as a unit; failure to maintain the longitudinal and rotational alignments of the fingers can lead to long-term disability in grasping or manipuling small objects in the palm of the hand; this deformity often results in a finger overlapping another when a fist is made 233 pf
acromioclavicular joint sprains type IV to VI third degree
injured structures: rupture of AC ligament and coracoclavicular ligament, and tearing of deltoid and trapezius fascia 197
acromioclavicular joint sprains type I first degree
injured structures: stretch or partial damage of the AC ligament and capsule
nerves and blood vessels of the shoulder
innervation of the upper extremity arises from the brachial plexus, a combination of nerves branching primarily from the lower four cervical (C5 to C8) and the first thoracic (T1) spinal nerves; the branches from these nerves extend from the neck anteriorly and laterally, passing between the clavicle and first rib; injuries to the clavicle in this region can damage the brachial plexus; the subclavian artery passes beneath the clavicle to become the axillary artery, providing the major blood supply to the shoulder; branches of the axillary artery include the thoracoacromial trunk, lateral thoracic artery, and thoracodorsal artery, as well as the anterior and posterior humeral circumflex arteries that supply the head of the humerus 191
acromioclavicular joint sprains classification
like other joint injuries, AC sprains may be classified as first-degree (i.e. mild), second degree (i.e. moderate), or third degree (i.e. severe); however, because of the complexity of the joint, AC sprains are often classified as types I to VI based on the extent of ligamentous damage, degree of instability, and direction in which the clavicle displaces relative to the acromion and coracoid processes 197
acute anterior glenohumeral dislocations
many acute dislocations have an associated fracture or nerve damage; therefore, this injury is considered serious, and necessitates immediate transportation to the nearest facility for reduction 199
signs and symptoms necessitating immediate referral
possible epiphyseal or apophyseal fractures tingling or numbness in the forearm or hand obvious deformity suggesting a dislocation or fracture excessive joint swelling significantly limited range of motion weakness in a myotome gross joint instability absent or weak pulse all adolescent wrist sprains because of possible epiphyseal or apophyseal injuries any unexplained pain 235
biceps tendon rupture
prolonged tendintiis can make the tendon vulnerable to forceful rupture during repetitive overhead motions, commonly seen in swimmers, or in forceful flexion activities against excessive resistance, as seen in weight lifters or gymnasts; the rupture occurs as a result of the avascular portion of the proximal long head of the biceps tendon constantly passing over the head of the humers during arm motion; this condition is often seen in degenerative tendons in older individuals and in individuals who have had corticosteroid injections in the tendon 202 btr
chronic dislocations
recurrent dislocations, or "trick shoulders," tend to be anterior dislocations that are intracapsular; the mechanism of injury is the same as acute dislocations; however, as the number of occurrences increases, the forces needed to produce the injury decrease, as do the associated muscle spasm, pain, and swelling; the individual is aware of the shoulder displacing because the arm gives the sensation of going dead, referred to as the *dead arm syndrome;* *activities in which recurrent posterior subluxations are common include the follow-through of a throwing motion or a racquet swing, the ascent phase of a push up or a bench press, the recoil following a block in football, and certain swimming strokes 199*
contusions to elbow, hand, and wrist signs and symptoms
tackler's exostosis, also known as blocker's spur, commonly seen in football linemen, *is not a true myositis ossificans, because the ectopic formation is not infiltrated into the muscle, but rather is an irritative exostosis arising from the bone;* a painful bony mass, usually in the form of a spur with a sharp edge, can be palpated on the anterolateral aspect of the humerus 219
arms
the ______________ perform lifting and carrying tasks, cushion the body during collisions, and lessen body momentum during falls; acute injuries to the elbow, wrist, and hand often result from the natural tendency to sustain the forces of a fall on the hyperextended wrist, which can sprain or dislocate the wrist or elbow; performance in many sports is also contingent on the ability of the arms to effectively swing a racquet or club, or to position the hands for throwing and catching a ball; this can lead to overuse injuries, such as medial or lateral epicondylitis; in addition sports such as wrestling, football, hockey, and skiing place undue stress on the thumb and fingers, leading to finger sprains and strains 211
shoulder
the ________________ is the most freely movable joint in the body, with the motion capability in all three planes; sagittal plane movements at the shoulder include flexion (e.g. elevation of the arm in an anterior direction), extension (i.e. return of the arm from a position of flexion to the side of the body), and hyperextension (i.e. elevation of the arm in a posterior direction) frontal plane movements include abduction (i.e. elevation of the arm in a lateral direction) and adduction (i.e. return of the arm from a position of abduction to the side of the body; transverse plane movements include horizontal adduction (i.e. horizontally extended arm is moved medially) and horizontal abduction (i.e. horizontally extended arm is moved laterally); the humerus can also rotate medially (i.e. anterior face of humerus is moved medially) and laterally (i.e. anteiror face of humerus is moved laterally; elevation of the humerus in all planes is accompanied by about 55 degrees of external rotation 193
scapular fractures management
the arm should be immobilized immediately in a sling and swathe; application of ice should be used to minimize the hematoma formation; the individual should be immediately referred to a physician or emergency medical care facility 204sf
extension and hyperextension of wrist and hand
the extensor carpi radialis longus, extensor carpi radialis brevis, and extensor carpi ulnaris produce extension and hyperextension at the wrist; the other posterior wrist muscles may also assist with extension and movements, particularly when the fingers are in flexion; included are the extensor pollciis longus, extensor indicis, extensor digiti minimi, and extensor digitorum 218
glenohumeral joint sprain management
the immediate management includes the application of cold to the area; the individual should also be placed in a sling; this injury requires physician referral to ensure accurate assessment and appropriate treatment 198
flexion of wrist and hand
the major flexor muscles of the wrist are the *flexor carpi radialis and flexor carpi ulnaris*; the palmaris longus, which is often absent in one or both forearms, contributes to flexion; the flexor digitorum superficialis and flexor digitorum profundus assist with flexion at the wrist when the fingers are completely extended, but when the fingers are in flexion, these muscles cannot develop sufficient tension to assist 218
nerves and blood vessels to elbow, wrist, and hand
the major nerves of the elbow region (median, ulnar, and radial) descent from the brachial plexus and extend into the forearm and hand; the major arteries of the elbow and forearm region are the brachial, ulnar, and radial arteries; the brachial artery supplies blood to the elbow joint and the flexor muscles of the arm and can be easily palpated in the anterior elbow; distal to the elbow, the brachial artery splits into the ulnar and radial arteries the radial artery supplies the muscles on the radial side of the forearm, as well as the thumb and index finger; the ulnar artery divides into anterior and posterior interosseous arteries to supply the deep flexor muscles and extensor muscles of the forearm, respectievly; in the palm, the radial and ulnar arteries merge to form the superficial and deep palmar arches; digital arteries branch from the palmar arches to supply the fingers, and branches from the carpal arch run distally along the metacarpal bones the radial artery is superficial on the anterior aspect of the wrist; the pulse is readily palpable at this site; pulses can be taken for both arteries on the anterior aspect of the wrist 213
shoulder injuries
the management for a majority of _________________ involves immobilizing the arm in a sling, swathe, or another commercial product that adequately pads and supports the limb, applying cold to reduce swelling, and referring the individual to a physician or emergency care facility; there are conditions which could require summoning of EMS (g.g. posterior SC sprain) 207
bennett's fracture management
the management is same as for a metacarpal fracture 232 fractures should be immobilized in the position of function, with the palm face down and fingers slightly flexed; cold should be applied to reduce hemorrhage and swelling; an elastic compression bandage should not be applied to a swollen hand, because it may lead to increased distal swelling in the fingers; the individual should be referred immediately to a physician for further assessment 232 bf
boxer's fracture management
the management is the same as for a metacarpal fracture fractures should be immobilized in the position of function, with the palm face down and fingers slightly flexed; cold should be applied to reduce hemorrhage and swelling; an elastic compression bandage should not be applied to a swollen hand, because it may lead to increased distal swelling in the fingers; the individual should be referred immediately to a physician for further assessment 232 box
olecranon bursa
the subcutaneous ________________ is the largest bursa in the elbow region; bursitis may be acute or chronic; if the skin is warm to the touch, the individual should be referred to a physician
jersey finger management
treatment involves standard acute care with cold, compression, and elevation; immediate physician referral is necessary for accurate diagnosis and management 225 jf
glenohumeral extension
when extension is not resisted, the action is caused by gravity; eccentric contraction of the flexor muscles serves as a controlling or breaking mechanism; when resistance by extension is offered, the posterior GH muscles act, including the sternocostal pectoralis, latissismus dorsi, and teres major, with assistance provided by the posterior deltoid and long head of the triceps brachii 194
ulnar tunnel syndrome management
same as carpal tunnel syndrome 230 the coach should refer this individual to a physician for accurate diagnosis and treatment options; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potential spasm; use of a compression wrap should be avoided, because it adds additional compression on the already impinged structures 228 uts
physical conditioning
strengthening programs should focus on muscles acting on both the GH and scapulothoracic region; strength in the infraspinatus, teres minor, and posterior shoulder musculature is necessary to: begin the cocking phase of throwing fix the shoulder girdle during the acceleration phase provide adequate muscle tension, with eccentric contractions, for smooth deceleration through the follow-through phase a weakened supraspinatus is present in many chronic shoulder problems, particularly among throwers; concentric and eccentric contractions with light resistance in the first 30 degrees of abduction can strengthen this muscle; strengthening the scapular stabilizers can be accomplished by doing push-ups or moving the arm through a resisted diagnoal pattern of exertional rotation and horizontal abduction 195
hand
the CM joint of the thumb is a saddle joint that allows rotation along its long axis to perform flexion, extension, abduction, adduction, and opposition; the CM joints of the four fingers are essentially gliding joints; the CM and IM joints of the fingers are mutually surrounded by joint capsules that are reinforced by the dorsal, volar, and interosseous CM ligaments the knuckles of the ______________ are formed by the MCP joints, which are each enclosed in a capsule that is reinforced by strong collateral ligaments; the MCP joints of the fingers allow flexion, extension, abduction, adduction, and circumduction; among the fingers, abduction is defined as movement away from the middle finger, and adduction is movement toward the middle finger; the MCP joint of the thumb functions more as a hinge joint, and the primary movements are flexion and extension; the proximal interphalangeal and distal interphalangeal joints of the fingers, and the single IP joint of the thumb, are all hinge joints; an articular capsule joined by volar and collateral ligaments surround each IP joint; the IP joints permit flexion, extension, and in some individuals, slight hyperextension 213
acromioclavicular joint
the ________________ consists of the articulation of the medial facet of the acromion process of the scapula with the distal clavicle; as an irregular, diarthrodial joint, limited motion is permitted in all three planes; the joint is enclosed by a capsule, although the capsule is thinner than that of the SC joint; the strong superior and inferior _______________ ligaments cross the joint, providing stability; the coracocacromial ligament, sometimes referred to as the arch ligament, also attaches to the inferior lip of the _____________________ to serve as a buffer between the rotator cuff muscles and the bony acromion process the close-packed position of the __________________ occurs when the humerus is abducted at 90 degrees; injuries to the AC joint are common in athletes involved in throwing and other overhead activities 189
coracoclavicular joint
the __________________ is a syndesmosis at which the coracoid process of the scapula and the inferior surface of the clavicle are joined by the coracoclavicular ligament; this ligament resists independent upward movement of the clavicle, downward movement of the scapula, and anteroposterior movement of the clavicle or scapula; minimal movement is permitted at this joint; the ___________________ ligaments are frequently ruptured during contact sports, such as football, hockey, and rugby 189
glenohumeral joint
the ___________________ is the articulation between the glenoid fossa of the scapula and the head of the humerus; *although the joint enables a greater total ROM than any other joint in the human body, it is lacking in bony stability;* this primary results from the hemispheric head of the humerus, which has three to four times the amount of surface area compared with the shallow glenoid fossa; because the glenoid fossa is also less curved than the humeral head, the humerus not only rotates, but also moves lineraly across the surface of the glenoid fossa when humeral motion occurs, an action that predisposes the joint to impingement injuries 190
loose structure
the ______________________ of the shoulder complex enables extreme mobility, but provides little stability; as a result, the shoulder is much more prone to injury than the hip; common injuries include dislocations, clavicular fractures, muscle and tendon strains, rotator cuff tears, acromioclavicular sprains, bursitis, bicipital tendonitis, and impingement syndrome; shoulder injuries commonly occur in activities involving an overhead motion, such as baseball, swimming, tennis, volleyball, and weightlifting; in fact, shoulder pain is the most common musculoskeletal complaint among competitive swimmers, with 40 to 70% reporting a history of shoulder pain; disclocations of the shoulder articulations are not uncommon in contact sports, such as wrestling and football 189
acute posterior glenohumeral dislocations signs and symptoms
the arm is carried tightly against the chest and across the front of the trunk in rigid adduction and internal rotation; the anterior shoulder appears flat, the coracoid process is prominent, and a corresponding bulge may be seen posteriorly, if not masked by a heavy deltoid musculature; any attempt to move the arm into external rotation and abduction produces severe pain; because the biceps brachii is unable to function in this position, the individual is unable to supinate the forearm with the shoulder flexed 199
humeral fractures managaement
the arm should be immobilized in a sling and swathe; ice should be applied to control pain and swelling, and immediate referral to a physician or emergency care facility is warranted for further care; in some settings, this injury may warrant activation of the emergency action plan 205 hf
epiphyseal and avulsion fractuces management
the arm should be immobilized in a sling and swathe; ice should be applied to control pain and swelling, and immediate referral to a physician or emergency medical care facility is warranted for further care 205 eaf
carpal tunnel syndrome
the carpal tunnel is formed by the floor of the volar wrist capsule, with the roof formed by the transverse retinacular ligament traveling from the hook of the hamate and pisiform on the lateral side to the volar tubercle of the trapezium and tuberosity of the scaphoid on the medial side; this unyielding tunnel accommodates the medial nerve, finger flexors in a common sheath, and flexor pollicus longus in an independent sheath; any irritation of the synovial sheath covering these tendons can produce swelling or edema that puts pressure on the median nerve 228 cts
carpal tunnel syndrome management
the coach should refer this individual to a physician for accurate diagnosis and treatment options; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potential spasm; use of a compression wrap should be avoided, because it adds additional compression on the already impinged structures 228 cts
flexion and extension
the elbow flexors include those muscles crossing the anterior side of the joint; the primary elbow flexor is the brachialis; because of the distal attachment of the brachialis is the coronoid process of the ulna, the muscle is equally effective when the forearm is in supination and pronation; another elbow flexor, the biceps brachii, has both long and short heads attached to the radial tuberosity via a single common tendon; when the forearm is supinated, the biceps contributes effectively to flexion because it is slightly stretched; when the forearm is pronated, the muscle is less taut and consequently less effective the brachioradialis, which is also an elbow flexor, is most effective when the forearm is in a neutral position (i.e. midway between full pronation and full supination); other flexor muscles that cross the elbow are important dynamic stabilizers of the joint; in particular, the flexor carpi ulnaris and the flexor digitorum superficalis provide significant stability to the medial elbow during a variety of activities, including throwing the triceps is the major elbow extensor; although the three heads have separate origins, they attach to the olecranon process of the ulna through a common distal tendon; the small anconeus muscle also assists with extension at the elbow 217
coordination of shoulder movements
the extensive ROM afforded by the shoulder partially results from the loose structure of the GH joint, and partially from the proximity of the other shoulder articulations and the movement capabilities they provide; movement at the shoulder typically involves some rotation at the SC, AC, and GH joints; for example, as the arm is elevated past 30 degrees of abduction, or the first 45 to 60 degrees of flexion, the scapula also rotates, contributing approximately one-third of the total rotational movement of the humerus; this important coordination of scapular and humeral movements, known as scapulohumeral rhythm, enables a much greater ROM at the shoulder than if the scapula were fixed; also contributing to the first 90 degrees of humeral elevation is the elevation of the clavicle through approximately 35 to 45 degrees of motion at the SC joint; the AC joint contributes to overall movement capability as well, with rotation occurring during the first 30 degrees of humeral elevation, and then against as the arm is moved past 135 degrees 193
radial and ulnar deviation of wrist and hand
the flexor and extensor muscles of the wrist cooperatively develop tension to produce radial and ulnar deviation of the hand at the wrist; the flexor carpi radialis and extensor caradialis act to produce radial deviation, and the flexor carpi ulnaris and extensor carpi ulnaris cause ulnar deviation 218
biceps tendon rupture signs and symptoms
the individual often hears and feels a snapping sensation, and experiences intense pain; ecchymosis and a visible, palpable defect can be seen in the muscle belly when an individual flexes the biceps; if the muscle mass moves distally as a result of a proximal long-head rupture, a "popeye" appearnce is clearly visible; partial ruptures may produce only slight muscular deformity but are still associated with pain and weakness in elbow flexion and supination; distal biceps rupture results in marked weakness with flexion and supination of the forearm 202 btr
ulnar tunnel syndrome signs and symptoms
the lesion may present with motor, sensory, or mixed symptoms; coincident involvement of the median nerve is common; the individual complains of numbness in the ulnar nerve distribution, particularly in the little finger, and is unable to grasp a piece of paper between the thumb and index finger; slight weakness in grip strength and atrophy of the hypothenar mass may also be present 229 uts
glenohumeral abduction
the muscles superior to the GH joint produce abduction and include the middle deltoid and supraspinatus; during the contribution of the middle delthoid, from approximately 90 degrees through 180 degrees of abduction, the infraspinatus, subscapularis, and teres minor produce inferiorly directed force to neutralize the superiorly directed dislocating force produced by the middle deltoid; this action serves an important function i npreventing impingement of the supraspinatus and subacromial bursa; the long head of the biceps brachii provides GH stability during abduction 194
glenohumeral flexion
the muscles that cross the GH joint anteriorly are positioned to contribute to flexion; the anterior deltoid and clavicular pectoralis major are the primary shoulder flexors, with assistance provided by the coracobrachialis and short head of the biceps brachii; because the biceps brachii also crosses the elbow joint, it is capable of exerting more force at the shoulder when the elbow is in full extension 193
lateral epicondylitis management
the same as management of medial epicondylitis in assessing this condition, it should become apparent to the coach during the history component that the injury is overuse in nature and, as such, the coach should refrain from continuing assessment; rather the coach should refer this individual to a physician for accurate diagnosis and treatment options; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potential spasm 227 le
coach assessment
the shoulder complex is a complicated region to assess because of the many important structures located in such a small area; *while most injuries involving the shoulder complex will require physician referral, they are not typically life-threatening conditions*; even still, the coach should be aware that some conditions will require activation of the emergency plan, including summoning EMS as with other on-site injury assessments, it begins as the coach is approaching the individual; the focus should be on observing the individual's overall presentation, attitude, and general posture, with a particular focus on their willingness or ability to move and their apparent pain level; subsequent to the history and observation components of an assessment, the could should have established a strong suspicion of the structures that may be damaged; *as such, during the physical exam component, only tests that are absolutely necessary, if any, should be performed* 207
bursae
the shoulder is surrounded by several ______________, including the subcoracoid, subscapularis, and the most important, the subacromial; the subacromial bursa lies in the subacromial space where it is surrounded by the acromion process of the scapula and the coracoacromial ligament above and the GH joitn below; the ______________ cushions the rotator cuff muscles, particularly the supraspinatus, from the overlying bony acromion and provides the major component of the subacromial guiding mechanism; the bursa can become irritated when repeatedly compressed during overhead arm action 191
olecranon bursitis
the subcutaneous olecranon bursa is the largest bursa in the elbow region; the superficial location predisposes the bursa to either direct macrotrauma or cumulative microtrauma by repetitive elbow flexion and extension; the bursisits can be acute or chronic, aseptic or septic; common mechanisms of ______________ injury include: a fall on a flexed elbow constantly leaning on one's elbow (student's elbow) repetitive pressure and friction repetitive flexion and extension infection 221
glenohumeral joint
the tendons of four muscles, including the supraspinatus, infraspinatus, teres minor, and subscapularis, also joint the joint capulse; these muscles are referred to as the SITS muscles, after the first letter of each muscle's name; they are also known as the rotator cuff muscles because they all act to rotate the humerus and because their tendons merge to form a collagenous cuff around the joint; tension in the rotator cuff muscles helps to hold the head of the humerus against the glenoid fossa, further contributing to joint stability; the joint is most stable in its closed packed position, when the humerus is abducted and laterally rotated 190
elbow
the three associated joints at the _______________ allow motion in two planes; flexion and extension are sagittal plane movements that occur at the humeroulnar and humeroradial joints; pronation and supination are longitudinal rotational movements that take place at the proximal radioulnar joint 216
prevention of injuries
the very nature of many contact and collision sports places the wrist and hand in an extremely vulnerable position for injury; the elbow, wrist, and hand are often subjected to compressive forces; the hand, in particular, is usually the first point of contact to cushion the body during collisions, to deflect flying objects, or to lessen body impact during a fall 219
wrist and hand
the wrist is capable of sagittal and frontal plane movements; flexion occurs when the palmar surface of the hand is moved toward the anterior forearm extension involves the return of the hand to anatomical position from a position of flexion, and hyperextension occurs when the dorsal surface of the hand is brought toward the posterior forearm; *movement of the hand toward the radial side of the arm is radial deviation; movement in the opposite direction is known as ulnar deviation; movement of the hand through all four directions is termed circumduction* 217
phalangeal fractures management
this management is the same as for a metacarpal fracture 233 fractures should be immobilized in the position of function, with the palm face down and fingers slightly flexed; cold should be applied to reduce hemorrhage and swelling; an elastic compression bandage should not be applied to a swollen hand, because it may lead to increased distal swelling in the fingers; the individual should be referred immediately to a physician for further assessment 232pf
elbow sprain management
treatment involves standard acute care with ice, compression, and use of a sling; this injury requires physician referral for accurate diagnosis and treatment options 222
mallet finger management
treatment same as jersey finger: treatment involves standard acute care with cold, compression, and elevation; immediate physician referral is necessary for accurate diagnosis and management 225 mf
bicipital tendinitis management
______________ is the same for a rotator cuff strain or impingement syndrome 202 COPIED in assessing this condition, it should become apparent to the coach during the history component that injury is overuse in nature, and, as such, the coach should refrain from continuing assessment; rather, the coach should refer the individual to a physician for accurate diagnosis and treatment options; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potenital spasm 201 bt
signs and symptoms necessitating immediate referral to an emergency medical facility
_______________ include: obvious deformity suggesting a suspected fracture, separation, or dislocation significant loss of motion or weakness in the myotomes joint instability abnormal sensation in the shoulder, arm, or hand absent or weak pulse distal to the injury any significant, unexplained pain 205
common extensor tendinitis
_______________ produces severe pain on resisted wrist extension and supination, and with a varus stress 235
cyclist's palsy
_______________, also linked to ulnar nerve entraplemt, occurs when a biker leans on the handlebar for an extended period of time, leading to swelling of the hypothenar area; symptoms mimic the mroe serious ulnar nerve entrapment syndrome, but they usually disappear rapidly after completio nof the ride; properly padding the handlebars, wearing padded gloves, varying hand position, and properly fitting the bike to the rider can greatly reduce the incidence of this condition 230 cp
flexibility exercises for shoulder region
________________ include: posterior capsular stretch; horizontally adduct the arm across the chest while the opposite hand assists the stretch anterior and posterior capsular stretch; hold onto both sides of a doorway with hands behind the back; straighten the arms while leaning forward; repeat with the hand in front while leaning backward inferior capsular stretch; hold the involved arm over the head with the elbow flexed; use the opposite hand to assist in the stretching; add a side stretch medial and lateral rotators; using a towel, bat, or racquet, pull the arm to stretch it into lateral rotation; repeat in medial motion 195
pain
________________ may be referred to the shoulder from other areas of the body, particularly the heart, lungs, visceral organs, and cervical spine region 207
strengthening exercises for the shoulder complex
_________________ include: A. shoulder shrugs- elevate the shoulders toward the ears and hold; pull the shoulders back, pinch the ears shoulder blades together, and hold; relax and repeat B. scapular abduction (protraction)- lift the weight directly upward, lifting the posterior shoulder from the table; relax and repeat C. scapular adduction (retraction) perform bent-over rowing while flexing the elbows; when the end of the motion is reached, pinch the shoulder blades together and hold D. bench press or inline press- place the hands shoulder-width apart and push the barbell directly above the shoulder joint; this exercise should be performed with a spotter E. bent arm lateral flies, supine position- keeping the elbows slightly flexed, lift the dumbbells directly over the shoulders; lower the dumbbells until they are parallel to the floor, then repeat; an alternative method is to move the dumbbells in a diagnosal pattern; in the prone position, the exercise strengthens the trapezius F. lateral pull-downs- in a seated position, grasp the handle and pull the bar behind the head; an alternative method is to pull the bar in front of the body G. surgical tubing- secure the tubing; working in diagonal functional patterns similar to those skills experienced in a specific sport/ activity 196
medial epicondylitis
_________________ is a common chronic condition in activities involving pronation and supination, such as tennis, pitching, volleyball, or gold; often the individual reveals a pattern of poor technique, fatigue, and overuse; _____________________, common in adolescent athletes, is caused by repeated medial tension/lateral compression (valgus) forces placed on the arm during the acceleration phase of the throwing motion; valgus forces often produce a combined flexor muscle strain, ulnar collateral ligament sprain, and ulnar neuritis; if the medial humeral growth plate is affected, it may be called little-league elbow; however, this term negates that other individuals, such as golfers, gymnasts, tennis players, and wrestlers, are also susceptible to the condition; simultaneously, lateral compressive forces can damage the lateral condyle of the humerus and radial head; posterior stresses may lead to triceps strain, olecranon impingement, olecranon fractures, or loose bodies me
scapular fractures
_________________ may involve the body of the scapula, spine of the scapula, acromion process, coracoid process, or GH joint; avulsion fractures to the cracoid process result from direct trauma, or forceful contraction of the pectoralis minor or short head of the biceps brachii; fractures to the glenoid area are associated with shoulder subluxations and dislocations; *in this case, treatment is dictated by the shoulder dislocation rather than the fracture, and often requires open reduction and internal fixation or shoulder reconstruction* sf
repetitive throwing
_________________ motions place a tremendous tensile stress on the medial joint structures (medial collateral ligament, ulnar nerve, and common flexor tendons) and concomitant lateral compressive stress in the radiocapitellar joint 235
gamekeeper's thumb
_________________ occurs when the MCP joint is near full extension and the thumb is forcefully abducted away from the hand, tearing the ulnar collateral ligament at the MCP joint 224
chronic injuries
_________________ result form inadequate warm-up, excessive training past the point of fatigue, inadequate rehabilitation of previous injuries, or neglect of seemingly minor conditions that progress to major complications 235
humeral fractures
_________________ result from violent compressive forces from a direct blow, a fall on the upper arm, or a fall on an out stretched hand with the elbow extended; the surgical neck is the most common site for proximal humerus fractures, and *may display an appearance similar to a dislocation* 205 hf
schaphoid fractures
__________________ account for more than 70% of all carpal bone injuries in the general population, and are the most common wrist bone fracture in physically active individuals; peak incidence is between 12 and 15 years of age; in many cases, the individual falls on the wrist, has normal radiographs, and is discharged with a diagnosis of a wrist sprain without further care; however, several months later, the individual continues to experience persistent wrist pain; radiographs at this time may reveal an established nonunion fracture of the scaphoid; because of a poor blood supply to the area, aseptic necrosis, or death of the tissue, is a common complication with this fracture 230 sf
excessive varus/ valgus stress
__________________ and hyperextension can damage the collateral ligaments of the fingers; ligament failure usually occurs at its attachment to the proximal phalanx or, less frequently, in the midportion
bursitis
__________________ is not generally an isolated condition, but rather is associated with other injuries, such as an impingement syndrome or pre-existing degenerative changes in the rotator cuff; the large subacromial bursa is commonly injured in swimmers, baseball, softball, and tennis players; located between the coracoacromial ligament and the underlying supraspinaus muscle, this bursa provides the shoulder with some inherent gliding ability; during an overhead throwing motion, this bursa can become impinged in the subacromial space 201 b
mallet finger
__________________ occurs when an object hits the end of the finger while the extensor tendon is taut, such as when catching a pall; the resulting forceful flexion of the distal phalanx avulses the lateral bands of the extensor mechanism from its distal attachment 225 mf
epiphyseal and avulsion fractuces signs and symptoms
__________________: in an epiphyseal fracture, the individual complains of acute shoulder pain when attempting to throw hard, which, if ignored, may result in an acute displacement of the weakened physis; pain may be elicited with deep palpation in the axilla; in an avulsion fracture, pain can be elicited by deep palpation over the specific bony landmark 205 eaf
acromioclavicular joint sprains signs and symptoms
__________________: TYPE I injuries have no disruption of the AC or coracoclavicular ligaments; minimal swelling and pain are present over the joint line, and increase in abduciton past 90 degrees; the injury is inherently stable and pain is self-limiting TYPE II injuries result from a more severe blow to the shoulder; the AC ligaments are torn but the coracoclavicular ligament, only minimally sprained, is intact; vertical stability is maintained, but sagittal plane stability is compromised; the clavicle rides above the level of the acromion, and a minor step or gap is present at the joint line; pain increases when the distal clavicle is depressed or move in an anterior-posterior direction, and during passive horziontal adduction TYPE III injuries have complete disruption of the AC and coracoclavicular ligaments, resulting in visible prominence of the distal clavicle; there will be obvious swelling and bruising and, more significantly, depression or drooping of the shoulder girdle TYPE (IV to VI) are caused by more violent forces; extensive mobility and pain in the area may signify tearing of the deltoid and trapezius muscle attachments at the distal clavicle; these rare injuries must be carefully evaluated for associated neurologic injuries 198
bicipital tendinitis signs and symptoms
__________________: pain and tenderness are present over the bicipital groove when the shoulder is internally and externally rotated; in internal rotation, the pain stays medial; in external rotation, the pain is located in the midline or just lateral to the groove; pain may also be elicited when the tendon is passively stretched in extreme shoulder extension with the elbow extended and forearm pronated; pain could also be present with resisted supination and elbow flexion 202 bt
lateral epicondylitis
___________________ *is the most common overuse injury in the adult elbow;* the condition is typically caused by eccentric loading of the extensor muscles, predominantly the extensor carpi radialis brebis, during the deceleration phase of the throwing motion or tennis stroke; gripping a racquet too tightly, improper grip size, excessive string tension, excessive racquet weight or stiffness, faulty backhand technique, putting topspin on backhand strokes, or hitting the ball off-center all contribute to this condition 227 le
thumb and finger sprains
___________________ are common; the thumb is exposed to more forces than all the fingers because of its position on the hand; integrity of the five ulnar collateral ligmaents at the MCP joint is critical for normal hand function because it stabilizes the joint as the thumb is pushed against the index and middle fingers while performing many pinching, grasping, and gripping motions 224
rotator cuff and impingement injuries factors
___________________ include: excessive amount of overhead movement (i.e. overuse) limited subacromial space under coracoacromial arch and limited flexibility of coracoacromial ligament thickness of the supraspinatus and biceps brachii tendon lack of flexibility and strength of the supraspinatus and biceps brachii weakness of the posterior cuff muscles (e.g. infraspinatus or teres minor) tightness of the posterior cuff muscles hypermobility of the shoulder joints imbalance in muscle strength, coordination, and endurance of the scapular muscles (e.g. serratus anterior or rhomboids) shape of the acromion training devices (e.g. use of hand paddles or tubing) 201 rc
sternoclavicular joint sprain (anterior) signs and symptoms
___________________: FIRST DEGREE injuries are characterized by point tenderness and mild pain over the SC joint, with no visible deformity; characteristics of SECOND DEGREE include: a joint subluxation leading to bruising, swelling, and pain inability to horizontally adduct the arm without considerable pain holding the arm forward and close to the body, supporting it across the chest pain with scapular protraction and retraction can reproduce pain THIRD DEGREE sprains involve a prominent displacement of the sternal end of the clavicle and may involve a fracture; there is a complete rupture of the SC and costoclavicular ligaments; in a third-degree sprain, the movement limitations present in a second-degree sprain are greater and produce more pain; pain is severe when the shoulders are brought together by a lateral force 197
thoracic outlet compression syndrome
____________________ is a condition in which nerves and/or vessels become compressed in the proximal neck or axilla; there are *two clearly defined forms* of this condition; one is a *neurologic syndrome*, accounting for about 90% of all cases, that involves the lower trunk of the brachial plexus and is caused by abnormal nerve stretch or compression; another is a *vascular form* that involves the subclavian artery and vein, and is more common in men than women; thoracic outlet compression syndrome often is aggravated in activities that require overhead rotational stresses while muscles are loaded, such as weight lifting and swimming BOTH FORMS; DISORDERS ASSOCIATED with _______________________ include: compression of the medial cord of the brachial plexus compression of the subclavian artery and vein cervical rib syndrome scalenus-anterior syndrome Hyperabduction snydrome costoclavicular space syndrome poor posture with drooping shoulders 202 to
contusions to elbow, hand, and wrist signs and symptoms
____________________: ecchymosis may be present is hemorrhage is superficial; significant trauma can lead to internal hemorrhage, rapid swelling, and hematoma formation that can limit ROM chronic blows to the anterior arm can result in the development of ectopic bone in either the belly of the muscle (i.e. myositis ossificans) or as a bony outgrowth (i.e. exostosis) of the underlying bone; the deltoid and brachialis muscle belly are common sites for the development of myositis ossificans after trauma; a particularly vulnerable site is just proximal to the deltoid's insertion on the lateral aspect of the humerus where the bone is least padded by muscle tissue; standard shoulder pads to not extend far enough to protect the area, and the edge of the pad itself may contribute to the injury; the developing mass can become painful and disabling if the radial nerve is contused, leading to transitory paralysis of the extensory forearm muscle 219
nerve entrapment syndromes
_____________________- or compressive neuropathies, can be subtle and are often overlooked; they occur in activities, such as bowling, cycling, karate, rowing, baseball/ softball, field hockey, lacrosse, rugby, weight lifting, and handball, and wheelchair athletics; mechanisms of injuries most commonly involve repetitive compression, contusion, or traction; a compressive neuropathy may also be caused by anatomical structures, such as anomalous muscles or vessels, fibrous bands, osteofibrous tunnels, or muscle hypertrophy; pathologic structures, such as ganglia, lipomas, osteophytes, aneurysms, and localized inflammation, can also compress a nerve; *the two most common ________________________ are carpal tunnel syndrome and ulnar entreapment* 228 nes
sternoclavicular joint sprain (posterior) signs and symptoms
______________________: the individual has a palpable depression between the sternal end of the clavicle and the manubrium, is unable to perform shoulder protraction, and may have difficulty swallowing and breathing; the individual may also complain of numbness and weakness of the upper extremity secondary to the compression of structures in the thoracic inlet; if the venous vascular vessels are impinged, the patient may have venous congestion or engorgement in the ispilateral arm and a diminished radial pulse 197
bursitis management
_______________________ is the same as for a rotator cuff strain or impingement syndrome 201 COPIED in assessing this condition, it should become apparent to the coach during the history component that injury is overuse in nature, and, as such,* the coach should refrain from continuing assessment; rather, the coach should refer the individual to a physician for accurate diagnosis and treatment options*; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potenital spasm 201 b
carpal tunnel syndrome
_________________________ is the most common compression syndrome of the wrist and hand, although it is not commonly seen in the physically active population; movement of tendons and nerves during prolonged repetitive hand movement may contribute to the development of __________________; in addition, _________________ may be caused by direct trauma or anatomical abnomalies; it is typically seen in the dominant extremity; sporting activities that predispose an individual to ________________ *include activities that involve repetitive or continuous flexion and extension of the wrist, such as cycling, throwing sports, racquet sports, archery, and gymnastics; * etiologies for _________________ other than traumatic causes include those of infectious origin (e.g. diptheria, mumps, influenza, pneuomnia, meningitis, malaria, syphilis, typhoid, dysentery, tuberculosis, or gonococcus), or metabolic causes (e.g. hypothyroidism, diabetes, rheumatoid arthritis, gout, vitamin deficiency, heavy meatals poisonining, and carbon monoxide poisoining) 228 cts
moderate SC sprain
a _______________- is characterized by pain and swelling over the joint and an inability to horizontally adduct the arm without increased pain; the arm is typically held forward and close to the body 207
boutonniere deformity
a ____________________ is caused by blunt trauma to the dorsal aspect of the PIP joint, or by rapid, forceful flexion of the joint against resistance; the central slip of the extensor tendon ruptures at the middle phalanx, leaving no active extensor mechanism intact over the PIP joint; an injury to the volar plate also can lead to a flexion deformity of the PIP joint that resembles a boutonniere deformity 226 bd
jersey finger
a ____________________ typically occurs when an individual grips an opponent's jersey while the opponent simultaneously twists and turns to get away; this jerking action may force the fingers to rapidly extend, rupturing the flexor digitorum profundus tendon from its attachment on the distal phalanx, so the name __________________; *the ring finger is more commonly involved *225 jf
volkman's contracture complication
a catastrophic complication from a forearm fracture is a condition called Volkman's contracture; this condition is caused by increased pressure and swelling inside one of the forearm compartments that compromise circulation to the surrounding muscles and nerves; as the pressure builds unabated, ischemic necrosis can lead to permanent loss of nerve and muscular function; as a result, the hand is cold, white, and numb, passive extension of the fingers leads to severe pain; these symptoms indicate a serious problem 230 vcc
carpal tunnel syndrome signs and symptoms
a common sign is pain that awakens the individual in the middle of the night and is often relieved by shaking out the hands; pain, numbness, tingling, or a burning sensation may be felt only in the fingertips on the palmar aspect of the thumb, index, and middle finger; generally, only one extremity is affected; grip and pinch strength may be limited; a common complaint is difficulty manipulating coins 228 cts
sternoclavicular joint sprain (posterior)
although rare, posterior, or retrosternal, displacement is more serious because of the potential injury to the esophagus, trachea, internal thoracic artery and vein, and the brachiocephalic and subclavian artery and vein; the *most common* mechanism of injury is a blow to the posterolateral aspect of the shoulder with the arm adducted and flexed, such as a fall on the should displacing the distal clavicle posteriorly; this action may occur during a piling-on injury in football; less commonly, the injury may be caused by a direct blow to the anteromedial end of the clavicle 197
elbow
although the ____________ may be generally thought of as a simple hinge joint, the _______________ actually encompasses three articulations- the humeroulner, humeroradial, and proximal radioulnar joints the largest joint at the elbow, the *humeroulnar joint *is a hinge joint with motion capabiliies of primarily flexion and extension; in some individuals, particularly women, a small amount of over extension 5 to 15 degrees is allowed; the *humeroradial joint* is a gliding joint, which binds the proximal head of the sagittal plane by the adjacent humeroulnar joint; the *annular ligament* binds the proximal head of the radius to the radial notch of the ulna forming the proximal *radioulnar joint*; this is a pivot joint with forearm pronation and supination occurring as the radius rolls medially and laterally over the ulna several strong ligaments, primarily the ulnar (medial) and radial (lateral) collateral ligaments, bind the three articulations together and a single joint capsule surrounds all three joints; the two collateral ligaments are strong and fan-shaped 211
acute anterior glenohumeral dislocations signs and symptoms
an initial dislocation presents with intense pain; tingling and numbness may extend down the arm into the hand; in a first-time anterior dislocation, the injured arm is often held in slight abduction (20 to 30 degree) and external rotation, and is stabilized against the body by the opposite hand; visually, a sharp contour on the affected shoulder, with a prominent acromion process, can be seen when compared with the smooth deltoid outline on the unaffected shoulder; the individual will not allow the arm to be brought against the chest 199
sternoclavicular joint
as the name suggests, the ____________ consists of the articulation of the superior sternum, or manubrium, with the proximal clavicle; the _________________ is surrounded by a joint capsule that is thickened anteriorly and posteriorly by four ligaments, including the interclavicular, costoclavicular, and anterior and posterior SC ligaments the ________________ enables rotation of the clavicle with respect to the sternum; the joint allows motion in the distal clavicle in superior, inferior, anterior, and posterior directions, along with some forward and backward rotation of the clavicle; as such, rotation occurs at the ____________________ during motions, such as shrugging the shoulders, reaching above the head, and in most throwing-type activities; because the first rib is jointed by its cartilage to the manubrium just inferior to the joint, motion of the clavicle in the inferior direction is restricted; the close-packed position for the SC joint occurs with maximimal shoulder elevation 189
glenohumeral adduction
as with extension, adduction in the absence of resistance results from gravatational force, with the abductors controlling the speed of motion; when resistance is present, adduction is accomplished through the action of the muscles positioned on the inferior side of the GH joint, including the latissimus dorsi, teres major, and sternocostal pectoralis; the short head of the biceps and long head of the triceps contribute minor assistance; when the arm is elevated above 90 degrees, the corocaobrachialis and subscapularis also assist 194
schaphoid fractures signs and symptoms
assessment reveals a history of falling on an outstretched hand; pain is present during palpation of the anatomical snuff box, which lies directly over the scaphoid, or with inward pressure along the long axis of the first metacarpal bone; pain increases during wrist extension and radial deviation 231 sf
wrist sprain signs and symptoms
assessment reveals point tenderness on the dorsum of the radiocarpal joint; pain increases with active or passive extension; because of the shape of the lunate and its position between the large capitate and lower end of the radius, this carpal bone is particularly prone to dislocation during axial loading; the dorsum of the hand is point tender, and a thickened area on the palm can be palpated just distal to the end of the radius if not obscured by swelling; passive and active motion may not be painful; if the bone moves into the carpal tunnel, compression of the median nerve leads to pain, numbness, and tingling in the first and second fingers 223
medial epicondylitis signs and symptoms
assessment reveals swelling, ecchymosis, and point tenderness directly over the humeroulnar joint, or on the medial epicondyle; pain is usually severe and aggravated by resisted wrist flexion and pronation and by a valgus stress; if the ulnar nerve is involved, tingling and numbness may radiate into the forearm and hand, particularly the fourth and fifth finger 227 me
scapulothoracic joint
because muscles attaching to the scapula permit its motion with respect to the trunk or thorax, this region is sometimes described as the _____________________; the scapular muscles perform two functions; the first is stabilization of the shoulder region; for example, when a barbell is lifted from the floor, the levator scapula, trapezius, and rhomboids develop tension to support the scapula, and, in turn, the entire shoulder through the AC joint; the second function is to facilitate movements of the upper extremity through appropriate positioning of the GH joint; during an overhand throw, for example, the rhomboids contract to move the entire shoulder posteriorly as the arm and hand move backward during the preparatory phase; as the arm and hand then move forward to execute the throw, tension in the rhomboids is released to permit forward movement of the shoulder, enabling medial rotation of the humerus 191
exercises to prevent injury to the elbow region
begin all exercises with light resistance using dumbbells or surgical tubing: 1. biceps curl- support the involved arm on the leg, and fully flex the elbow; this can also be performed bilaterally to a standing position with a barbell 2. triceps curl- raise the involved arm over the head; extend the involved arm at the elbow; this can also be performed bilaterally in a supine or standing position with a barbell; 3. wrist flexion- support the involved forearm on a table or your leg with the hand off the edge; with the palm facing up, slowly perform a full wrist curl and return to the starting position 4. wrist extension- support the involved forearm on a table or your leg with the hand off the edge; with the palm facing down, slowly perform a full reverse wrist curl and return to the starting position 5. forearm pronation/supination- support the involved forearm on a table or your leg with the hand over the edge; with surgical tubing or a hand dumbbell, roll the forearm into pronation then return to supination; adjust the surgical tubing and reverse the exercise, stressing the supinators; the elbow remains stationary 6. ulnar/radial deviation- support the involved forearm on a table or your leg with the hand over the edge; with surgical tubing or a hand dumbbell, perform ulnar deviation; reverse directions and perform radial deviation; an alternate method is to stand with the arm at the side holding a hammer or weighted bar; raise the wrist in ulnar deviation; repeat in radial deviation 7. wrist curl-ups- exercising the wrist extensors is performed by gripping the bar with both palms facing down; slowly wind the cord onto the bar until the weight reaches the top; then slowly unwind the cord; reverse hand position to work the wrist flexors 220
rotator cuff and impingement injuries
chronic _______________ to the SITS muscles result from repetitive microtraumatic episodes that primarily impinge on the supraspinatus tendon just proximal to the greater tubercle of the humerus; partial tears are usually seen in young individuals, with total tears typically seen in adults older than 30 years; *in older age groups, chronic tears can lead to cuff thinning, degeneration, and total rupture of the supraspinatus tetndon* 200 rc
ulnar tunnel syndrome
compression of the ulnar nerve may occur as the nerve enters the ulnar tunnel or as the deep branch curves around the hook of the hamate and traverses the palm; this condition is frequently seen in cycling, racquet sports, and in baseball/softball catchers, hockey goalies, and handball players who experience repetitive compressive trauma to the palmar aspect of the hand; distal ulnar nerve palsy may also be seen as push-up palsy, following fractures of the hook of the hamate, or as a result of a missed golf shot or baseball swing 229 uts
overuse conditions
during abduction, the strong deltoid muscle pulls the humeral head superiorly, relative to the glenoid fossa; the rotator cuff muscles are critical in counteracting this migration; if the tendons are weak, they are incapable of depressing the humeral head in the glenoid fossa during overhead motions; this can lead to impingement of the supraspinatus tendon and subacromial bursa between the acromion, the coracoacromial ligament, and the greater tubercle of the humerus; this compressive action can lead to a *rotator cuff strain, impingement syndrome, bursitis, or bicipital tendinitis, or a combination of these injuries *200 oc
metacarpal fractures management
fractures should be immobilized in the position of function, with the palm face down and fingers slightly flexed; cold should be applied to reduce hemorrhage and swelling; an elastic compression bandage should not be applied to a swollen hand, because it may lead to increased distal swelling in the fingers; the individual should be referred immediately to a physician for further assessment 232 mf
distal radial and ulnar fractures management
fractures should be suspected in all forearm injuries, particularly in adolescents; a suspected fracture should be immobilized and the individual should be referred to a physician immediately 230 druf
distal radial and ulnar fractures
fractures to the distal radius and ulna present a special problem; in adolescents, eiphyseal and metapheal fractures are common; these fractures usually heal without residual disability; in older individuals, one or both bones may be fractured, or one bone may be fractures with the other bone dislocated at the elbow or wrist joint; a COLLE's Fracture occurs within 1 1/2 in of the wrist joint, and results in a dinner fork deformity when the distal segment displaces in a dorsal and radial direction; a reverse of this fracture is SMITHS fracture, which tends to move toward the palmar aspect (volar); a MONTEGGIA fracture is characterized by a fracture of the proximal one-third of the ulna accompanied by a dislocation of the radial head in a GALEZZI fracture, the distal radioulnar dislocation is secondary to the marked shorteninig of the radius caused by the severe ulnar displacement and dorsal angulation of the distal radial fragment 230 druf
bursitis signs and symptoms
frequently, sudden shoulder pain is reported during the initiation and acceleration of the throwing motion; point tenderness can be elicited on the anterior and lateral edges of the acromion process; a painful arc exists between 70 and 120 degrees of passive abduction; inability to sleep, especially on the affected side, occurs because of forced scapular protraction that leads to further impingement of the bursa; *pain is often referred to the distal deltoid attachment 201* b
elbow strains management
if a grade I injury is suspected, management involves standard acute care with cold and compression; if the signs and symptoms do not resolve within 2 to 3 days, the coach should require the individual to obtain approval for return to participation from a qualified healthcare professional; if a grade 2 or 3 injury is suspected, cold should be applied and the arm placed in a sling; this injury requires immediate physician referral 225
thoracic outlet compression syndrome signs and symptoms
if a nerve is compressed, an aching pain, pins-and-needles sensation, or numbness in the side or back of the neck extends across the shoulder down the medial arm to the ulnar aspect of the hand; weakness in grasp and atrophy of the hand muscles may also be present; if arterial or venous vessels are compressed, signs and symptoms vary depending on the specific structure being obstructed; blockage of the subclavian vein produces edema, stiffness (especially in the hand), and venous engorgement of the arm with cyanosis; if untreated, this may result in THROMBOPHLEBITIS; the individual may present these signs and symptoms several hours after a bout of intense exercise; occlusion of the subclavian artery results in a rapid onset of coolness, numbness in the entire arm, and fatigue after exertional overhead activity; a detailed history is needed, and it is essential to evaluate the cervical spine, shoulder, elbow, and hand for evidence of neurovascular compression 203 to
anatomic snuff box
if pain is present during palpation of the __________________________, suspect a fracture of the scaphoid and refer the athlete immediately to a physician 235
coach assessment
if the coach elects to perform the tesing component of hte assessment, it should begin with active ROM of the neck; because pain is frequently referred from the cervical region into the shoulder, neck flexion, extension, rotation, and lateral flexion should be assessed for fluid motion and presence of pain; *if pain is present at the neck, the coach should consider the possibility of a neck injury and refer the individual to a physician or emergency medical facility *207
mallet finger signs and symptoms
if the common extensor mechanism is avulsed, a characteristic mallet deformity is present, and the individual is unable to fully extend the DIP joint with the forearm pronated 225 mf
chronic dislocations management
if the injury does not reduce, the individual should be placed in a sling and swathe, or the arm may be stabilized next to the body with an elastic wrap; ice should be applied to control pain and inflammation; the individual should be referred immediately to a physician for reduction of the injury and further costs 200
elbow sprain signs and symptoms
if the ulnar collateral ligament is injured, a history of pain localized on the medial aspect of the elbow during the late cocking and acceleration phases of throwing is common; point tenderness can be palpated directly over the ligament and increases is a valgus force or stress is applied; if the radial collateral ligament is injured, pain is localized on the lateral aspect of the elbow and increases with varus stresses 222
rotator cuff and impingement injuries
impingement syndrome implies an actual mechanical abuntment of the rotator cuff and the subacromial bursa against the coracoacromial ligament and acromion; this injury is caused from the force overload to the rotator cuff and bursa that occurs during the abductiton, forward flexion, and medial rotation cycle of shoulder movements; in addition to injury to the supraspinatus tendon and subacromial bursa, the glenoid labrum and long head of the biceps brachii may also be injured; this condition is also sometimes called painful arc syndrome or swimmer's shoulder 200 rc
medial epicondylitis management
in assessing this condition, it should become apparent to the coach during the history component that the injury is overuse in nature and, as such, the coach should refrain from continuing assessment; rather the coach should refer this individual to a physician for accurate diagnosis and treatment options; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potential spasm 227 me
ulnar nerve entrapment
in the elbow, the ulnar nerve passes behind the medial epicondyle of the humerus via the ulnar groove, through the cubital tunnel, and underneath the ulnar collateral ligament to enter the forearm; the nerve is vulnerable to compression and tensile stress on the site; the ulnar nerve can also become entrapped between the hook of the hamate and pisiform; this condition is frequently seen in cycling, racquet sports, and in baseball or softball catchers who experience repetitive trauma to the palm 229 une
tendinitis and stenosing tenosynovitis
individuals involved in strenuous and repetitive training often inflame tendons and tendon sheaths in the WRIST AND HAND; in the wrist, the abductor pollicis longus and extensor pollicis brevis are commonly affected; these two tendons share a single synovial tendon sheath that turns sharply, as much as 105 degrees, to enter the thumb when the wrist is in radial deviation; *friction between the tendons, the stenosing sheath, and bony process leads to a condition called de Quervain's tenosynovitis* 227 tst
rotator cuff and impingement injuries signs and symptoms
initially, pain is described as deep in the shoulder as present at night; activity increases the pain, but only in the impingement position; as repetitive trauma continues, pain becomes progressively worse, particularly between 70 and 120 degrees of active and resistance abduction; because forced scapular protraction leads to further impingement and pain, the individual may be unable to sleep on the involved side; if a full-thickness tear has been sustained, atrophy may be apparent in the supraspinatus or infraspinatus fossa 201 rc
acromioclavicular joint sprains type II second degree
injured structures: rupture of AC ligament and partial strain of coracoclavicular ligament 197
coach assessment
injuries to the elbow, wrist, hand, and in particualr, the fingers are sometimes dismissed as minor in the absence of an appropriate assessment; the coach should ensure that injuries to these areas are not overlooked and anticipate that most injuries will require physician referral while the coach should restrict their assessment of injuries to those that are acute in nature, it may be appropriate to ask questions as part of the history component of an assessment that addresses chronic scenarios; in doing so, the coach can confirm the presence of an acute or chronic/overuse injury and proceed accordingly; when it becomes apparent that an injury is overuse in nature, the coach should refrain from any continued assessment and, instead, refer the individual to an appropriate healthcare practitioner 233
bicipital tendinitis
injury to the biceps brachii tendon often occurs from repetitive overuse during rapid overhead movements involving excessive elbow flexion and supination activities, such as those performed by racquet sport players, shot-putters, baseball/softball pitchers, football quarterbacks, swimmers, and javelin throwers; irritation of the tendon occurs as it passes back and forth in the intertubercular (bicipital) groove of the humerus; the tendon may partially sublux because of laxity to the transverse humeral ligament, a poorly developed lesser tubercle, or both; a direct blow to the tendon or tendon sheath can lead to bicipital tenosynovitis; anterior impingement snydrome associated with overhead rotational activity may also damage the tendon 202 bt
lateral and medial rotation of the humerus
lateral rotators of the humerus lie on the posterior aspect of the humerus, including the infraspinatus and teres minor, with assistance provided by the posterior deltoid; muscles on the anterior side of the humerus contribute to medial rotation; these include the subscapularis and teres major, with assistance from the pectoralis major, anterior deltoid, latissimus dorsi, and short head of the biceps 194
fractures
most _______________ o the shoulder region result from a fall on the point of the shoulder, rolling over onto the top of the shoulder, or indirect forces caused by falling on an outstretched arm; clavicular fractures are more common han fractures to the scapula and proximal humerus, with nearly 80% occurring in the midclavicular region 203 f
scapular fractures signs and symptoms
most fractures result in minimial displacement and exhibit localized hemorrhage, pain, and tenderness; the individual is reluctant to move the injured arm and prefers to maintain it in adduction; arm abduction is painful; it is critical to note any signs or symptoms that would suggest underlying pulmonary injury (E.g. pneumothorax or hemothroax) 204 sf
physical conditioning
most of the muscles that move the elbow also move the shoulder or wrist; therefore, flexibility and strength exercises must focus on the entire arm; exercises can improve general strength at the elbow and wrist and can be combined with strengthening exercises of the shoulder complex; other exercises, such as squeezing a tennis ball or a spring-loaded grip device, can be used to strengthen the finger flexors 219
elbow dislocations
most ulnar _______________ occur in individuals younger than 20 years, with a peak incidence in the teenage years; the mechanism of injury is usually hyperextension or a sudden, violent unidirectional valgus force that drives the ulna posteriorly or posterolateral; approximately 60% of patients have assocoiated fractures of the medial epidoncyle, radial head, coronoid process, or olecranonon process; when the dislocation is associated with both radial head and coronoid fractures, it has been termed the* terrible triad of the elbow *because of the difficulties inherent in the treatment and consistently poor reported outcomes as compared to a simple elbow dislocation; the injury may also involve disruption of the anterior capsule, tearing of the brachialis muscle, injury to the ulnar collateral ligament, and rarely, brachial artery compromise or nerve injury to the median or ulnar nerves 222
acute glenohumeral dislocations management
muscle spasm sets in very quickly following dislocation and makes reduction more difficult; management of a first-time dislocation requires immediate referral to a physician; as such, in some settings, it may be necessary to activate the emergency plan; the injury should be treated as a fracture; the arm should be immobilized in a comfortable position; in order to prevent unnecessary movement of the humerus, a rolled towel or thin pillow can be placed between the thoracic wall and humerus prior to applying a sling; ice should be applied to control hemorrhage and muscle spasm; in evaluating this injury, if possible, the coach should assess both the axillary nerve and artery, because both structures can be damaged in a dislocation; a pulse may be taken on the medial proximal humerus over the brachial artery or on the radial pulse at the wrist; the axillary nerve can be assessed by stroking the skin on the upper lateral arm to assess sensation; deficits with pulse or sensation definitely warrant activation of the emergency plan, including summoning of EMS 199
bennett's fracture signs and symptoms
pain and swelling are localized over the proximal end of the first metacarpal, but deformity may or may not be present; inward pressure exerted along the axis of the first metacarpal elicits increased pain at the fracture site 232 bf
lateral epicondylitis signs and symptoms
pain is anterior or just distal to the lateral epicondyle and may radiate into the forearm extensors during and after activity; pain increases with resisted wrist extension or in an action similar to picking up a full cup of coffee 227 le
chronic dislocations signs and symptoms
pain is the major complaint, with crepitation and/or clicking after the arm shifts back into the appropriate position; however, recurrent dislocations may be less painful than an initial dislocation; many individuals voluntarily reduce the injury by positioning the arm in flexion, adduction, and internal rotation 199
humeral fractures signs and symptoms
pain, swelling, hemorrhage, discoloration, an inability to move the arm, inability to supinate the forearm, and possible paralysis may be present; the arm is often held splinted against the body 205 hf
elbow sprain
repetitive tensile forces irritate and tear the ligaments, particularly the *ulnar collateral ligament;* when this occurs, pain can be palpated directly over the involved ligament; when forces are excessive, the resulting injury may be an elbow dislocation 222
elbow sprains and dislocations
*most common ligament tears in the elbow result from repetitive tensile forces that irritate and tear the ligaments, particularly the ulnar collateral ligament*; traumatic elbow sprains are usually caused by hyperextension or a sudden, violent, unidirectional valgus force that drives the ulna in a posterior or posterolateral direction; in the wrist and hand, hyperextion is also the leading mechanism of injury, although hyperflexion or rotation may also lead to injury; when caused by a single episode, the severity of the injury depends on characteristics of the injury force (its point of application, magnitude, rate, and direction); position of the hand or elbow at impact; and relative strength of the bones and supporting ligaments *unfortunately most individuals do not allow ample time for healing because they need to perform simple daily activities; consequently, many sprains are neglected, leading to chronic instability 222*
compression of the ulnar nerve
_________________ leads to weakness in grip strength, atrophy of the hypothenar mass, and loss of sensation over the little finger 235
