Musculoskeletal Upper Limb

Craniovertebral Instability

Symptoms: Neck pain, wry neck posture, headache, myelopathy bowel/bladder dysfunction, ataxia, neurological symptoms

Diagnosis: Sharp-Purer test, neurological exam, Imaging, UMNL signs

Risk Factors: acute trauma, degeneration, congenital conditions

“Excessive movement at C1-C2 vertebrae as a result of bony or ligamentous abnormality”

Cervical Arterial Dissection (CAD)

Symptoms: acute onset neck pain, headache,

Diagnosis: Horners syndrome (constricted pupils, droopy eyelids, inability to sweat), neuro exam

Treatment: refer to ED immediately!

Risk Factors: minor trauma, infection, genetics, younger population

“Tear in the wall of the vertebral artery which may result in a cerebrovascular accident/stroke”

Vertebro-basilar Insufficiency (VBI)

Symptoms: 5 D’s and 3 N’s, lightheadedness, blurriness of vision, vomiting, P&N, pallor

Diagnosis: VBI positional tests, Positive test → dizziness, nystagmus, unwell feeling

Treatment: refer to ED immediately!

Risk Factors: older patients, chronic neck pain/stiffness, atherosclerosis, spondylolysis, trauma

“Decrease blood flow to the posterior portion of the brain via the basilar artery”

Cervical Myelopathy

Symptoms: bilateral neuro symptoms, weakness, bladder/bowel dysfunction, saddle anesthesia.

Treatment: ED or specialist, diagnostic imaging, surgery

Risk Factors: older age

“Compression to the spinal cord from trauma or stenosis”

Whiplash Syndrome (Whiplash Associated Disorders= WAD)

Symptoms: neck pain, headache, decrease neck mobility, arm pain, 5Ds/3Ns,

Diagnosis: history taking, MOI in detail, palpation, ROM, neuro exam

Treatment: stay active, pharmacology, manual therapy

“Acceleration-deceleration injuries to cervical spine“

Acute Wry Neck (Zygapophyseal/Discogenic)

Symptoms of Zygopophyseal:

• young children/adults, Upper Cx, locking of C0-C2, limited ROM, sudden movement = sharp pain, trauma

  Treatment

• joint mobilization, AROM/PROM, posture, traction

Symptoms of Discogenic:

• gradual onset, older generation, lower Cx, refer to scapular region

Treatment:

• gentle traction, heat, posture, collar, soft tissue mobilisations

Risk Factors: sudden quick movement or waking from sleep

“Sudden onset of sharp neck pain with protective deformity and limitation of movement”

Non-specific Cervical Spine Pain - Spondylosis

“degeneration of the spine”

Symptoms: neck pain, stiff neck, headaches, radiculopathy

Diagnosis: patient Hx, imaging

Treatment: soft tissue, strengthening, medication, ROM, surgery

Risk Factors: age

Disc Prolapse

Symptoms: neck pain, painful AROM/PROM, arm pain

Diagnosis: imaging, patient Hx

Treatment:

Risk Factors: acute trauma, insidious→ degeneration, 51-60yrs, females

Cervical Radiculopathy

Symptoms: neck pain, arm pain, neurological symptoms, tingling/P&N, reflex changes

Diagnosis: patient Hx, Neuro exam, diagnostic imaging, Spurlings test

Treatment: traction, immobilization, soft tissue, manual therapy, steroids, ROM

Stinger and Burner Syndrome

Symptoms: radicular type burning, shooting, stinging, numbness, weakness

Diagnosis: neuro exam, AROM/PROM, MMT

Treatment: treat the deficits, stretching, postural restraining, strength training

Risk Factors: rugby league, contact sports

“brachial plexus traction injury → pulling arm and neck away”

What are the 5D’s and 3N’s for VBI symptoms?

1. Dizziness (vertigo or lightheadedness)

2. Diplopia (double vision)

3. Dysarthria (slurred or impaired speech)

4. Dysphagia (difficulty swallowing)

5. Drop attacks (sudden loss of postural control without loss of consciousness)

1. Nausea (or vomiting)

2. Nystagmus (involuntary eye movements)

3. Numbness (especially facial or perioral paresthesia)

Migraine without Aura

Sudden onset - recurrent headache disorder lasting 4-72 hours

Management: Sleep, hydrate, drugs, exercise, diet, lifestyle

Migraine with Aura

Buildup for the migraine - recurrent attacks, symptoms build up followed by headache/migraine

Management: Sleep, hydrate, drugs, exercise, diet, lifestyle

Tension-type Headache - Episodic and Chronic

Symptoms: bilateral, pressing/tightening, mild-moderate, not agg by physical activity

Cause: stress, poor posture, muscular, nutrition, concentration, environmental

Management: Pharmacology, NSIADS< physical activity, CBT, treatment of the cranio-cervical-mandibular region

Trigeminal Autonomic Cephalagias - Cluster or Episodic (TAC)

Symptoms: intense one-sided pain centered by the eye/temple

• Ipsilateral pain, lacrimation, rhinorrhea, nasal congestion, sweating, restlessness, miosis

• Lasts 15-180 minutes

Management: Triptans, oxygen, pharmacology, physiotherapy, electrostimulation

Primary Cough Headache

Cause: coughing or other Valsalva/straining maneuver

Primary Exercise Headache

Cause: exercise in the absence of any intercranial disorder, hot weather, short duration

HA due to Trauma - Persistent

Symptoms: Dizziness, fatigue, reduced concentration, memory loss, insomnia, anxiety, personality changes

Time frame: HA more than 3 months caused by trauma to the head

HA due to Trauma - Acute

Symptoms: Dizziness, fatigue, reduced concentration, memory loss, insomnia, anxiety, personality changes

Time Frame: less than 3 months caused by trauma to head

Acute HA due to Whiplash

Symptoms: Dizziness, fatigue, reduced concentration, memory loss, insomnia, anxiety, personality changes

Time Frame: Less than 3 months due to whiplash

Persistent HA due to Whiplash

Symptoms: Dizziness, fatigue, reduced concentration, memory loss, insomnia, anxiety, personality changes

Time Frame: HA more than 3 months due to whiplash

Cervicogenic Headache

Symptoms: Unilateral headache, ipsilateral neck/shoulder/arm pain, migraine-like features

Physical Signs: Anesthetic blockades (gold standard), reduced cervical AROM/PROM, dysfunction, impaired muscle function

Treatment: sleep, drugs, exercise, posture, psych, mobilization

“C1-C3 nerve roots converge in same brain region”

Headache attributed to TMJ disorder

“Referral between Cervical and TMJ - anatomical, neurophysiological, biomechanical, function

Symptoms: Muscle pain, headaches, joint related issues

Headache Differentiation

Myalgia (TMJ)

Symptoms: pain in the jaw, temple, in ear or front of ear AND pain modified with jaw movement, function or parafunction, headaches, difficult to localise, dull pressure, multifactorial

Diagnosis: confirmation of pain in temporalis or masseter on palpation, maximal unassisted/assisted opening

Risk Factor: dental occlusion, molar removals, genetics, depression

Muscle as the primary source of pain

Disc Displacements - Ant. displacement without reduction (ADDwoR)

• “Closed lock” limited opening + absence of click

• traumatic onset, sudden crack, clicking

• painful limited protrusion + deflection to affected side

• restricted lateral deviation to contralateral side

Disc Displacement - Ant. displacement with reduction (ADDwR)

• click, no lock

• deviation to unaffected side during early opening

• may achieve full rom

Disc Displacement - Post. disc displacement without reduction

• “Open lock” “subluxation”

• much less common

Non-specific Thoracic Spine Pain (x3) (mechanical)

Conditions: joint dysfunction, paraspinal muscle sprain. posture related, structural pathologies

Facet Joint:

• unilateral/post pain, acute onset, dull pain at rest

• reduced AROM, hypomobility of involved facet, muscle spasm guarding

• management: manual therapy, gentle ROM

IVD:

• central/post/ant pain felt through chest, postural loading, dull and diffuse pain

• limited AROM, hypomobility of involved segments

• management: manual therapy, gentle ROM, exercises

CVJ/CTJ:

• unilateral pain along rib line, conjunction with facet joint injury, respiratory signs,

• limited trunk motion, multiple segments involved

• Management: manual therapy, gentle ROM

Specific Thoracic Spine Pain - Scheuremann’s Disease (Kyphosis)

Type 1: Thoracic, produces more deformity than pain

Type 2: more pain than deformity in thoracolumbar

Presentation on Imaging: irregularity of end plates, Schmorls nodes, wedge-shaped VB’s, hyperkyphosis

Diagnosis: after long posture, tight hamstrings, respiratory limitation, curvatures,

Risk Factors: adolescents, males, taller/skeletally mature, 13-16 yrs

Management: Education, braces, Tx-Lx-pelvic-hip mobility

Conditions: rib fracture, central canal stenosis, disc prolapse, syndromes

Serious Pathologies of the Thoracic Spine (x4) (PVoPT)

Pyrogenic Spinal Infections

• septic discitis, vertebral osteomyelitis, epidural abscess, occurs more in males over 50

Vertebral Osteomyelitis (an infection)

• triad of pain, fever and local tenderness, paraspinal abscesses, jaggered N plates

• Risks involve malnutrition, IV use, infection, renal failure, spinal surgery

Pyrogenic Discitis

• can occur with vertebral osteomyelitis, antibiotics can fix, surgical intervention

Tumors

• primary, benign or metastatic, (metastatic spinal disease common)

Specific Thoracic Spine Pain - Scoliosis

Type: Structural: idiopathic (known cause)

• usually painless, respiratory issues can be present, lateral curvature

• Managment: exercise, bracing, operation

Type: Non-structural (adaptive/maladaptive posture)

• leg length differences, hip add/abd deformity, poor lumbar-hip control, muscle asymmetry

Risk Factors: females

Specific Thoracic Spine Pain - Spondyloarthropathies

Inflammatory spinal pain with ONE or more of:

• Positive family history in first- or second-degree relatives of patients with ankylosing spondylitis, psoriatic arthropathy, acute iritis, reactive arthritis or IBD.

• Psoriasis

• Inflammatory bowel disease

• Alternating buttock pain

• Enthesitis

• Acute diarrhoea

• Urethritis

• Sacro-iliitis: bilateral grade 2-4 changes or unilateral 3-4 changes.

Symptoms: LBP, IT aching, sharp, worse after activity, AM stiffness, limited chest wall excursion

Management: aerobic exercises, manual therapy

Risk Factors: Males, 16-25 years

Specific Thoracic Spine Pain - Central Canal Stenosis

Signs: intermittent aching and clumsiness of both legs, worse with walking, neurogenic intermittent claudication, ataxia, incoordination of LL, cauda equina symptoms, “shopping trolley” sign

Risk factors: older age

Specific Thoracic Spine Pain - IVD protrusion -/+ radiculopathy

Symptoms: localized back pain, radiates around chest wall, myelopathy, +/- cord compression, bladder/bowel changes → UMN

Management: Physio, education, activity, manual therapy, postural control, trunk strengthening

Risk Factors: disc degeneration, disc calcification, below T7

Specific Thoracic Spine Pain - Fractures (x3)

Vertebral body compression #

• trauma, high compression

Rib #

• blunt trauma (pneumo/hemothorax), ribs 5-10 most common, symptomatic, >3-week recovery

Rib stress injury

• shear forces created by muscle contraction, activity related chest wall pain, confirmed by MRI or bone scan

Specific Thoracic Spine Pain - T4 Syndrome

Upper extremity paresthesia and pain +/- symptoms into the neck and/or head

• MOI reaching, felt click in thoracic spine, constant thoracic pain, constant glove distribution of paresthesia, altered sensation in the upper limb

• Autonomic nervous system role → dysfunctions expressed over lower Cx spine and down the UL

• Hypomobility upper Tx region common = responds to joint mobilizations

Thoracic Outlet Syndrome

Mechanical compression/entrapment of the cords of the brachial plexus +/ subclavian artery + vein

3 anatomical tunnels → Superior thoracic outlet, Costo scalene hiatus, costoclavicular passage

Neurogenic type: most common, pain, ± paraesthesia in Ulnar nerve, hypothenar atrophy

Vascular type: rare, discoloration, swelling and weakness of fingers/hand

Symptoms: hand weakness/tingling, swelling, atrophy, shoulder pain, ant chest pain, C8/T1 radiculopathy, fatigued gripping

Diagnosis: Roo’s test, Adson’s maneuver, costoclavicular maneuverer

Management: address mechanical interface, address neural mechanosensitivity, identify/reduce agg factors

Risk Factors: congenital, traumatic, overhead athletes, depressed protracted shoulders, scapular dyskinesia

Specific Thoracic Spine Pain - Costochondritis and Tietze Syndrome

Costochondritis:

• systemic cause, no local swelling, multi-joint, usually chronic, Inflammation of the costochondral junctions (cartilage attaching ribs to sternum).

Tietze Syndrome

• inflammatory disorder of the costochondral, costosternal, or sternoclavicular joints, single joint, idiopathic, local pain and swelling, may occur after chronic coughing, vomiting, viral or trauma

Specific Thoracic Spine Pain - Ankylosing Spondylitis

Symptoms: Hereditary link to HLA-B27, Insidious onset of hip/buttock to LBP, IT aching +/- sharp, Worse after activity, AM stiffness, Limited chest wall excursion, Global limitation of trunk/Tx ROM

Radiographic changes– Sacroiliitis; bamboo spine

Management: exercise, physio, NSAIDs,

Risk factors: 16-25 years, males

Shoulder Impingement

• Influenced by thoracic posture and mobility

External (Subacromial)- mechanical encroachment of the soft tissue in the subacromial space between the humeral head and subacromial space, occurs mid-range (60-120 deg “painful arc”)

Internal (post/sup)- Encroachment of the RC tendons in the glenohumeral joint

Primary cause- Structural narrowing of subacromial space (arthritis, AC enlargement, soft-tissue swelling)

Secondary cause- functional problems in shoulder positions (RC weakness, instability)

• A cluster of symptoms, NOT a pathology

Shoulder Impingement: Rotator Cuff Related Shoulder Pain (SCRSP)

Supra > Infra > Subscap

• Tears: can’t sleep on affected side, pain/weakness with RC testing,

• Tendinopathy: multifactorial etiology, chronic pain, pain free past 90deg elevation

Diagnosis:

• Tears: MRI, Ultrasound

• Tendinopathy: MRI arthorgram

Treatment:

• Tears: Conservative treatment surgery, strength, balance/control

• Pain relief, RC rehab

Risk Factors: athletes, overhead workers, traumatic event

Shoulder Impingement: Scapular Dyskinesia

Clinical Manifestations: reduced scap upward rotation, post tilt, ER, increased clavicle elevation, decreased strength, Pec minor/post capsule reduced length

Treatment: pain relief, flexibility, muscle training, thoracic spine and STJ mobility, muscle control

Shoulder Impingement: Shoulder Instability - TUBS

^ 3 Types: A.R.P

(Traumatic Unidirectional (+/‐ Bankart lesion) instability +/‐ Surgery (TUBS)

1. Anterior dislocation

   • forced shoulder abd + ER, usually a traumatic injury

2. Recurrent dislocation

   • chronic shoulder instability

3. Posterior dislocation

   • Fall on outstretched hand (FOOSH)

   • pain, tightening, clicking, decreased ER

Treatment: Scapular rehab, RC control/strengthening, open/closed chain exercises, kinetic chain exercises

Shoulder Impingement: Shoulder Instability - AIOS

(Acquired sport‐specific instability (AIOS))

Symptoms: laxity of ant capsule caused by excessive anterior translation of humeral head

Clinical Manifestations: excessive PROM ER vs IR, recurrent shoulder pain during overhead activity

Diagnosis: “dead arm syndrome,” apprehension/relocation tests positive

Treatment: Scapular rehab, RC control/strengthening, open/closed chain exercises, posterior shoulder stretching, kinetic chain exercises

Risk Factors: overhead athletes, laxity

Shoulder Impingement: Shoulder Instability - AMBRI

(Atraumatic multidirectional instability with bilateral laxity (AMBRI)

Symptoms: pain, repeated subluxation or full dislocation

Clinical Manifestations: dynamic/muscle patterning instability, congenital joint hyperlaxity, repetitive overuse,

Diagnosis: laxity tests positive, altered muscle activation

Treatment: therapeutic exercises ongoing, surgery may be needed, closed/open chain exercises,

Risk Factors: 2-3 atraumatic instabilities

Shoulder Impingement: Biceps-related

Symptoms: All present with shoulder pain

Risk factors: Repetitive overhead activities

1. Partial tears long head of biceps brachii (LHBB)

2. Instability of the bicep tendon in the bicipital groove

3. Superio Labrum Anterior to Posterior (SLAP)

^ Stable/unstable - 4 SLAP sub-types

• Degeneration

• Superior Labrum and LHB detachment

• SL detached, LHB intact

• Tear SL +LHB, displaced in the GHJ

Caused By: carrying, dropping, throwing

Symptoms: popping, catching, grinding

Treatment: Conservative treatment for most clients, surgery for traumatic injuries

AC joint - Acute sprain-dislocation

Clinical Presentation: pain at rest over antero-lateral shoulder region, “step down” deformity, swelling, crepitus, possible hematoma

Objective Assessment: TOP over ACJ, hypermobility, pain with all shoulder ROM, check opposite ACj and clavicle length

Diagnosis: X-body abduction test, resisted extension test, X-ray

Management: POLICE, sling, ice, isometrics early, restore ROM, taping

AC joint - Atraumatic Osteolysis

Clinical Presentation: stress reaction of distal clavicle, worse at night, ull ache at rest, bone-stress injury, hypomobile, crepitus

Objective Assessment: TOP, swollen, agg by loading ACJ and pec major

Diagnosis: X-ray, bone scan

Management: conservative treatment

Risk Factors: overuse/overtraining, younger athletes, UL training

Adhesive Capsulitis (frozen shoulder)

“Loss of glenohumeral AROM and PROM resulting from progressive fibrosis and contracture of GHJ capsule”

Phase 1: less than 3 mths, synovitis, no contracture

• pain into deltoid insertion, night pain, loss of passive ER with intact RC

Phase 2: 3-9 mths, freezing phase, acute synovitis, contracture

• severe night pain, stiffness

Phase 3: 9-15mths, frozen phase

• profound stiffness, pain at EOR of motion

Phase 4: thawing phase

• profound stiffness, minimal pain

Management: pharmacological, NSAIDS, physical therapy (4 stages), non-operative is favoured, operative → (hydrodilation, manipulation under anaesthetic MUA, arthoscopic release)

Risk Factors: inflammation, fibrosing, female, 40-60, sedentary lifestyle, diabetes, dominant side

Cx as the Source of Pain

Somatic Neck Pain

• proximal UL or shoulder girdle pain, C5-7 presents as Upper trap and posterolateral shoulder pain

• any structure innervated by the same spinal level will have same distribution

• IVD as source (Cloward’s signs), Z-joint as source

Facet Joints

• C1-3 = pain in the head

• C4-7 = neck -back-shoulder pain, no head pain

Nerve Roots

• “Radiculopathy,” scapular, neck, thoracic & shoulder-arm pain (C6-8 only), dermatomes

IVDs

Risk Factors: sustained awkward neck postures, low-level trauma, wry neck

Agg→ looking-reaching behind shoulder, neck flexion, sleeping on unaffected side

Easing → sleeping of affected side, holding arm overhead

Tx as the Source of Pain

Somatic Thoracic Pain

• localized to trunk 1-2 levels, disc=central/bilatera/vague, facet= unilateral/local

• refer into post shoulder, anterolateral chest wall and iliac crest

• C7-T3: pos shoulder > suprascap > medial scapular

Radicular/neurogenic thoracic pain

• Tx radiculopathies rare

• T4 syndrome can present with bilateral UL paranesthesia, common in ulnar distribution, upper traps/UL pain, P&N

Risk Factors: history of sustained Tx flexion, posture related disc pain, sudden trunk rotation/extension

Agg → deep breathing, looking reaching behind

Easing → lying prone

Shoulder as the Source of Pain

Clinical Presentation: dull aching ± IT aching pain with movement, lateral deltoid pain, upper anterior arm (LHBB tendinopathy), headaches, light-headedness, peripheral nerve entrapments around shoulder

• Sternoclavicular joint

• Subacromial space

• Acromioclavicular joint

Joint sounds:

• Glenoid labral tears – ‘deep painful clunk’

• Instability – ‘click/clunk’ often not-painful

• ACJ degeneration – ‘crunching/grinding’

• Impingement/LHBB tendinopathy – ‘click’ +/- pain

Risk Factors: repeated overhead activity, slowly progressing pain and loss of ROM, lifting pain, FOOSH

Agg → overhead activities, reaching behind head/back

Easing → sleeping on unaffected side with affected arm supported

Osteochondritis Dissecans

Clinical Manifestations: insidious onset, acute injury, pain, swelling, poorly localized, catching/clicking/locking, decreased elbow ROM

Diagnosis: crepitus, grip&grind test, valgus stress test, imaging

• Differential: Panners Disease

Treatment: rest, NSAIDs, surgery, activity modification, rehab

Risk Factors: children, adolescents, overhead athletes, weight-bearing athletes

“Lesion of the bone and overlying cartilage”

Elbow Fractures (S.L.M.R.O.C)

Clinical Manifestations: acute trauma MOI, pain and swelling, deformity, inability to move elbow

• Supracondylar fracture: distal humerus, 60% prevalence, ext/flx type fractures, neurovascular compromise

• Lateral condyle Fracture: capitellum fracture, 15-20% prevalence, Milch 1&2

• Medial epicondyle fracture: extra-articular fracture, 10% prevalence, repetitive sports, avulsion

• Radial head fracture: FOOSH, athletes common, Salter-Harris type 2

• Olecranon Fracture: FOOSH or direct contact, limited ability to extend elbow

• Coronoid Fracture: combination with radial head # and post dislocation (terrible triad), Regan&Morrey classification

Treatment: immobilization, splint/sling, rehab (strength, ROM, functional) , screws/wires, pinning

Risk Factors:

Elbow Dislocation

Clinical Manifestations: acute trauma, pain, swelling, deformity, inability to move elbow, Two Types (Simple & Complex)

3 Types:

1. Subluxation of elbow in posterolateral direction (clicking/snapping)

2. Incomplete dislocation with coronoid perched on trochlea

3. Complete posterolateral dislocation

Diagnosis: ligamentous stability, vascular supply, palpation, imaging

Treatment: relocation MUA, surgery, bracing/stabilization, rehab (strength, ROM, functional)

Risk Factors: FOOSA injuries, males, young children

Elbow Tendinopathy

“Overuse tendon injury”

• Reactive tendinopathy → non-inflammatory (acute overload)

• Tendon disrepair → greater matrix breakdown (Chronic overload)

• Degenerative → matrix and cell breakdown (ageing, chronic overload, cell death)

Lateral Elbow Tendinopathy (Tennis Elbow)

• Factor workers, repetitive gripping sports, Extensor-carpi-radialis-brevis tendon

• Resisted wrist extension, resisted finger extension, pain-free grip strength, TOP lateral epicondyle, test ROM

• Managed by therapeutic exercise, manual therapy, soft tissue mobilizations, taping/orthosis, cryotherapy, electrotherapy, ergonomics

  Medial Elbow Tendinopathy (Golfers Elbow)

• Pain over medial epicondyle, adduction movements, pronator teres primarily involved

• Pain on palpation, epicondylitis medialis test, Polks test, resisted pronation

• Managed by exercises, soft tissue therapy, manual therapy, bracing/taping, stretching

Biceps and triceps Tendinopathy

Clinical Manifestations:

Biceps: pain with resisted elbow flexion or forearm supination, proximal radio-ulnar joint, pain in cubital fossa

Triceps: posterior elbow pain, pain with resisted elbow extension, olecranon tender

Factors: weight lifting, javelin

Bi/Tri Muscle/tendon Rupture

Clinical Manifestations: weakness, altered appearance, bruising, swelling, Limited ROM

Biceps rupture: Hook test, biceps squeeze test, sup-pro test, passive forearm pronation test

triceps rupture: triceps squeeze test

Risk Factors: lifting with high loads, traumatic onset

Treatment: surgery usually

Medial Collateral Ligament Sprain

Diagnosis: Valgus stress test, moving valgus stress test, milking maneuver, POP, instability

Management: education, rest, technique correction, soft tissue therapy, strengthening exercises, strapping, surgery

Risk factors: acute trauma, FOOSH, overuse, throwers

metacarpophalangeal (MCP) joint injury

Little Leaguers Elbow (Apophysitis)

“Affects growth of medial epicondyle”

Clinical Manifestations: POP, deformity, valgus stress test, contraction or forearm muscle that inserts into CFO

Management: education, rest, technique correction, strengthening, strapping, surgery

Risk Factors: overuse, throwing, young children

Olecranon Bursitis (students’ elbow)

Clinical Manifestations: trauma/falling onto elbow, insidious onset (leaning on elbow for too long)

Management: POLICE, aspiration, injection

Posterior Impingement

3 Main Hypotheses:

1. Younger person – ‘hyperextension valgus overload syndrome’

2. Valgus instability – olecranon no longer fits in olecranon fossa

3. Older person – early OA – osteophyte formation

Diagnosis: osteophyte formation, AROM/PROM, valgus instability tests

Management: minimize hyperextension, strengthening, flexibility, surgery

“Impingement of the posterior capsule/bone deformation”

Peripheral Neuropathies and Nerve Entrapments (UMR)

“Pathology/compression to the peripheral nerves”

Clinical Manifestations: ulnar, median, radial nerves & Stingers and Burners

Ulnar Nerve Entrapment (C8-T1)

• Cubital tunnel location, pain at elbow, weakness with gripping and wrist flexion, paranesthesia in little and ring finger

Median Nerve Entrapment (C6-T1)

• Pain at elbow, paresthesia in digits 1-3 palmer aspect and tips of digits 2-3 (carpal tunnel syndrome), weakness with finger flexion, pronation and wrist flexion

Radial Nerve Entrapment (C5-T1)

• pain/altered sensation over dorsal aspect of wrist and digits, common in repetitive pro/sup, TOP of supinator muscle, pain on restricted 90deg flexion, no sensory loss

Diagnosis: neuro assessment, Tinel’s sign, Phalen’s sign, palpation, location of symptoms

Treatment: advice/education, address cause, stretch, neural mobilisation, NSAIDS, surgery, ice, foam pads

Wrist Tenosynovitis (Soft Tissue Classification)

Clinical Presentation: ECU, FCU, FCR, ECR inflammation and swelling

Diagnosis: POP, pain with AROM + resistance, PROM pain

Risk factors: repetitive tasks, Raquet sports, rowers, golfers

De Quervain’s Tenosynovitis (Soft Tissue Classification)

Clinical Presentation: APL and EPB (thumb) inflammation and swelling, pain and tenderness, crepitus

Diagnosis: Patient history, palpation, Finkelstein’s test, AROM/PROM painful

Treatment: Progressive stretching, bracing, corticosteroids, ergonomic adaptations

Risk factors: Raquet sports, rowers, golfers, repetitive tasks

Intersection Syndrome (Soft Tissue Classification)

APL, EPB, ECR

Clinical Presentation: Abductor pollucis longs/Extensor pollucis brevis & Extensor carpi radialis tendinitis/inflammation/swelling

Objective Assessment: pain and tenderness, swelling, crepitus, repetitive movements

Diagnosis: Patient history, palpation, AROM/PROM painful, Finkelstein’s test

Management: Braces, NSAIDs, strengthening, decompression surgery

Risk factors: friction and overuse, rowers, canoeing, weight training, Raquet sports

Wrist Ganglions Cysts (Soft Tissue Classification)

Clinical Presentation: Fluid filled sack arising from joint space, fluid (mucin) creating a soft rubbery ball

Diagnosis: Visible lump, muscle wasting, pain, neurosensory loss

Management: splinting, ice massage, aspiration injection, surgery

Risk factors: repetitive use? ligamentous damage? Females

TFCC Injuries

Clinical Presentation: Ulnar side wrist pain, forced pronation pain, weak wrist rotation, swelling, loss of grip strength, crepitus

Diagnosis: Ulnar foveal sign (point tenderness distal to ulnar styloid), pain with pro/sup/ulnar deviation, +ve TFCC load test, compression test, press test, piano key test, X-ray/MRI/arthroscopy

Management: Splint, dynamic stabilization, progressive WB rehab, early surgical intervention

Risk factors: FOOSH, gymnastics, weightlifting, surfing, increases with age, increased load bearing ulnar side

Distal Radius Fracture #

2 Types: Dorsal angulation of distal radius (Colle’s) and Volar angulation of distal radius (Smith’s)

Clinical Presentation: Pain, swelling, visible deformity

Diagnosis: Traumatic MOI, limited ROM, X-ray

Risk factors: low level trauma, ~61 years, FOOSH

Management: casting, conservative (depending on degree of displacement), surgical stabilization, Physio → ROM, strength, control

Scaphoid Fracture #

Diagnosis: Traumatic MOI, pain, swelling, TOP over snuff box, compression test, squeeze test, X-ray

Risk factors: FOOSH, Males

Management: casting, conservative (depending on degree of displacement), surgical stabilization, Physio → ROM, strength, control

Hook of Hamate Fracture #

Diagnosis: MOI, POP, swelling, concomitant ulnar nerve injury, reduced grip and volar/palmar wrist pain

Risk factors: MOI forceful swing when Raquet hits ground

Management: casting, conservative (depending on degree of displacement), surgical stabilization, Physio → ROM, strength, control

Ulnar Styloid Fracture #

Diagnosis: POP ulnar styloid process, DRUJ instability

Management: casting, conservative (depending on degree of displacement), surgical stabilization, Physio → ROM, strength, control

Risk factors: FOOSH, MIO

Keinbock’s Disease

Clinical Presentation: Pain over dorsal wrist, POP of lunate, limited ROM, weakness, wrist swelling

Diagnosis: POP, limited ROM, weakness, confirmed with radiography/CT and/or MRI

Management: Prioritize pain relief, ROM, strength/grip

Stage 1: Immobilization to allow time to heal

Stage 2: Immobilization if necrosis is incomplete

Stage 3-4: surgical intervention

Risk factors: repetitive trauma, increase load on lunate, radial inclination angle, smaller lunate bone, poor vascular supply, males, 20-40 years

“Avascular necrosis of lunate”

Scapulolunate Dissociation

Injury/rupture of scapulolunate ligament complex

Clinical Presentation: MOI/FOOSH, carpal instability, posterior pain, popping, clicking, pain increased with wrist ext/radial dev, swelling, decreased grip strength

Diagnosis: TOP dorsally, consider past trauma, Watsons test, X-ray, MRI

Management: Immobilization with physio, ROM, strengthening, surgical repair, early referral for orthopedic review

Risk factors: In conjunction with a distal radius #,

Lunotriquetral Dissociation

Rupture of lunotriquetral ligament

Clinical Presentation: second common carpal instability, MOI/FOOSH, Ulnar sided wrist pain, pain with pro/ulnar dev, decreased grip strength, clicking w/ movement

Diagnosis: consider fractures, lunate tenderness, pain on pro/ulnar dev, Shuck test, Kelinman’s Shear test, LT compression test, Click Provocation test

Management: Immobilization, injections, bracing, ROM, strengthening, arthroscopy, early referral for orthopedic review

Risk factors: young athletes, high impact sports

Nerve - Neuropathic wrist pain (CUW)

• Criterion 1 & 2: subjective examination

• Criterion 3: physical tests (sensation, motor as required)

• Criterion 4: Objective tests (nerve conduction)

Common Clinical Pathologies

• Carpal tunnel syndrome (median nerve)

• Ulnar nerve entrapment

• Wartenberg’s syndrome Radiculopathy C6-8

Carpal Tunnel Syndrome

Clinical Presentation: Central volar wrist pain, paranesthesia, weakness and atrophy of thenar eminence muscles

Diagnosis: Neuropathic pain criterion, neuro testing, +ve Tinel’s test, +ve Phalen’s test, Nerve conduction tests

Management: Depends on severity - splinting, corticosteroids, medication, physio, surgery

Risk factors: mechanical trauma, increased pressure, ischemic damage to nerve, females 40-60, diabetes, use of flexor muscles, exposure to vibration

Compression of median nerve within carpal tunnel

Ulnar Nerve Entrapment

Clinical Presentation: Medial volar wrist pain, paresthesia, weakness and atrophy of hypothenar muscles

Diagnosis: Neuropathic pain criterion, Neurological testing, +ve Tinel’s test, Wartenberg sign, X-ray, Nerve conduction

Management: Depends on severity - conservative treatment best, external padding, night splinting, hand therapy, corticosteroids, hand therapy, surgery

Risk factors: mechanical trauma, males, gymnastics

Compression of the ulnar nerve within Guyons canal (pisiform & hook of hammate)

Wartenburgs Syndrome

“Cherialgia paresthetica” - superficial radial nerve compression

Clinical Presentation: Vague lateral wrist pain, paresthesia, night pain, no motor weakness signs

Diagnosis: neuropathic pain criterion, neuro testing, +ve Tinel’s sign, Finkelstein’s test +ve, Nerve conduction tests, imaging

Management: depends on severity - conservative treatment best, removal of compression factors, splinting, corticosteroids, hand therapy

Risk factors: males, 40-70 years, wearing watches/wrist bands or injury to radial forearm

Dupuytren’s Contracture

Progressive contracture of flexor tendons → flx deformity

Clinical Presentation: 4th digit + isolated muscles, painful nodules/cords, limited extension ROM, blanching of the palm

Diagnosis: POP flexor tendons, AROM/PROM, Heuston’s tabletop test, imaging, radiograph

Management: Conservative, splint, injection, surgery, ROM, strength/control

Risk factors: genetic disorders (diabetes, seizures, smoking, alcoholism, HIV, vascular disease), males

Mallet Finger

Traumatic terminal extensor tendon injury (EDC) Rupture or Avulsion, forced DIPJ flexion

Clinical Presentation: Pain, swelling, fixed flexion deformity, lump, inability to extend, subungual hematoma?

Diagnosis: MOI, observation, TOP to DIPJ, inability to extend DIP, radiograph, palpation of nail bed

Management: Conservative, full time splint, strength & control, surgery, tendon reconstruction, bracing following surgery

Risk factors: cricket, basketball, volleyball, slammed in door, males, dominant side, Swan-neck deformity

Jersey Finger

Traumatic terminal flexor tendon injury (FDP) Rupture/Avulsion

Clinical Presentation: Pain, swelling at DIPJ, inability to flex DIPJ, palpation deformity, pain during gripping

Diagnosis: Acute MOI, inability to actively flex DIPJ, POP, passive finger flexion okay, radiograph

Management: Early surgery, tendon re-insertion, K-wire, splinting post op, ROM, strength & control

Risk factors: trapped in a jersey/shorts/waist band during a tackle, MOI

Skiers Thumb

• The thumb is forcefully hyper abducted away from the hand

Clinical Presentation: Localized pain to 1st MCPJ, swelling, weak grip, limited ROM

Diagnosis: MOI, TOP radial side, valgus stress test, weak pincer grip, radiograph

Management: Splinting, ROM, strengthening, surgery

Risk factors: skiing, baseball, javelin, males

Ulnar collateral ligament injury 1st MCPJ (thumb)

Phalangeal, Metacarpal, Boxers, Bennets and Hand Fractures

Phalangeal Fracture

Clinical Presentation: pain, swelling, deformity, unwillingness to move, instability, can occur on any digit

Risk factors: Contact injury, ball sports, crush injury

Metacarpal Fracture

Risk Factors: contact injury, high impact, punch, crushed

Boxers Fracture

Clinical Presentation: Localized pain, swelling, physical deformity, reluctance to move, instability

Risk Factors: Punch injury → axial load with flexion

Location: Fracture of neck of 5th MC

Bennett’s Fracture

Clinical Presentation: localized pain, swelling, physical deformity, reluctance to move, instability

Risk Factors: Punch Injury

Location: fracture of 1st CMC joint

Hand Fractures

Diagnosis: Consider MOI< deformity, POP, pain, imaging

Treatment: Orthopedic referral early, conservative, rehab, surgery

Finger Dislocation

Dislocation of DIP, PIP or NCP joints

Clinical Presentation: Deformity, pain, swelling, discoloration, altered sensation

Diagnosis: MOI, radiograph, imaging, neurovascular exam

Management: PIP focus → splinting, surgery? rehab, physios do NOt “put them back in”

Risk factors: ball or contact sports, MOI= hyperextension and/or axial loads, netball, basketball, consider “Ehlers-Danlos syndrome”

Hand Osteoarthritis

Clinical Presentation: Bouchard’s nodes, Herberden’s nodes, Squaring of 1st CMC, pain, swelling, weakness during grip

Diagnosis: Pt history, deformity, AROM/PROM affected, weakness, radiograph

Management: Strengthening, pharmacological, improve function, surgery

Risk factors: chondral pathology, osteophyte formation, joint space narrowing, older age, female, obesity, weakness

Rheumatoid Arthritis

Clinical Presentation: Joint pain, swelling, AM stiffness, Swan-neck deformity, ulnar deviation/drift, Boutonniere deformity

Diagnosis: Pt history, pain on movement and POP, boggy feeling on palpation, weak grip, deformity, lab testing

Management: Early intervention, lifestyle changes, NSAIDs, anti-inflammatories

Risk factors: HLA-DRB1 gene, female, <30 ears, higher level of autoantibodies