Therex II Exam 2

What 3 bones make up the elbow complex?

1.) Ulna

2.) Radius

3.) Humerus

What are the 4 articulations of the elbow joint?

1.) Humeroulnar

2.) Humerodial

3.) Proximal radioulnar

4.) Distal radioulnar

What are the prime movers in elbow flexion? (2)

1.) Biceps brachii (elbow flexor with forearm supinated)

2.) Brachialis (elbow flexor with forearm pronated)

What are the prime movers in elbow extension? (2)

1.) Triceps

2.) Anconeus

One kind of joint is the humeroulnar joint?

Diarthrodial with one degree of freedom (flexion & extension)

What muscles attach at the medial epicondyle and act on the humeroulnar joint?

-flexor-pronator muscle group

-UCL (anterior, posterior, and transverse bundles)

• resists valgus force

When is the UCL the most taught?

between 60-120° flexion

What kind of joint is the humeroradial joint?

hinge/pivot joint (allows for flexion/extension and pronation/supination)

During weight bearing exercise, how much force is placed on the humeroradial joint?

60%

What assists with lateral elbow stabilization?

-RCL, LCL complex (UCL, RCL, annular), and capsule

• resists varus force

What type of joints are the proximal/distal radioulnar joints?

diarthrodial joints (supinate/pronate wrist)

What is the articulation of the proximal radioulnar joint (PRUJ)

-radial head and radial notch of ulna (radius crosses over ulna during motion)

What is the articulation of the distal radioulnar joint (DRUJ)

-head of ulna, ulnar notch on radius

What is the “third joint” in the elbow?

-shafts of radius & ulna and interosseous membrane

What are some stretching and ROM exercises for the elbow?

-biceps stretch

-triceps stretch

-wrist extensor stretch

-wrist flexor stretch

-supinator stretch

-pronator stretch

-mobs

-transverse friction massage

What are strength exercises that work the flexors of the elbow?

-biceps curls

-slot curls

-Zotman curls

-hammer curls

-pronated curls

What are strength exercises that work the extensors of the elbow?

-triceps extension push-down

-diamond push-up

-close grip bench press

-standing overhead triceps

What are strength exercises that work the forearm?

-supination

-pronation

-wrist extension

-wrist flexion

-wrist rolls

-ulnar deviation

-radial deviation

What are the causes of lateral epicondylitis and the s/s?

-Cause:insidious (change in training), repetitive gripping activities (extension & supination), traumatic

-S/S: pain on lateral elbow, tenderness over lateral epicondyle, pain with (extending fingers & wrist, shaking hands, gripping objects, making fist), weakness with resisted wrist/finger extension

What is the treatment for lateral epicondylitis?

-fix cause of injury (equipment, mechanics, technique, repetitive motion)

-exercises should be progressed with no pain

-ice, rest NSAIDs

-US & ionto with dexamethasone

-establish normal soft tissue mechanics (transverse friction massage, mobs, stretching)

What are the causes of medial epicondylitis and the s/s?

-Etiology: insidious cause (change in training), repetitive motions (painting, hammering, rowing), traumatic, overuse of wrist flexors, improper technique

-S/S: tenderness and pain over medial epicondyle, pain with finger and wrist flexion & pronation, pain with (shaking hands, gripping objects, making fist), weakness with resisted wrist/finger flexion

What is the treatment for medial epicondylitis?

-modalities to control pain & inflammation (cryotherapy, US, e-stim, ionto)

-pain-free elbow & wrist stretching (focusing on wrist flexors & pronators)

-pain-free elbow & wrist strengthening (focusing on wrist flexors & pronators)

-use of UE kinetic chain exercises (PNF, medicine ball)

-functional/athlete-specific exercises

What are the bursae of the elbow?

-olecranon

-deep intratendinous

-deep subtendinous

-bicipital-radial

-subcutaneous medial

-lateral epicondylar

What is the etiology & S/S of bursitis?

-Etiology: direct trauma, prolonged pressure, infection

-S/S: swelling, pain, heat

What is the treatment for bursitis?

-cryotherapy

-e-stim

-compression sleeve

-elbow pad

-RTA (activity only restricted by patient’s pain)

What is the etiology & S/S of an elbow dislocation?

-Etiology: FOOSH with twisting motion, partial or complete, associated fx (radial head, coronoid, medial epicondyle)

-S/S: Pain, loss of motion, deformity

What is Phase I treatment and how long does it typically last for an elbow dislocation?

-0-2 weeks

-immobilization (posterior splint, 90° elbow flexion)

-no PROM

-gradual progression of AROM activities

What is Phase II treatment and how long does it typically last for an elbow dislocation?

-2-8 weeks

-full pain-free ROM & return to light ADLs

-grade 1 & 2 mobs & AAROM if needed

What is Phase III treatment and how long does it typically last for an elbow dislocation?

-2-6 months

-progressive strengthening program (prescribed by operating physician)

-RTP

What is the etiology & S/S of ulnar nerve entrapment?

-Etiology: direct blow to inside of elbow, prolonged compression of elbow, repetitive activity with bent elbow, excessive valgus force

-S/S: pain/ache on medial aspect of elbow and forearm, heaviness & tingling in hand/4th digits/5th digits, weakening of grip

What is the conservative management of ulnar nerve entrapment?

-takes about 3-6 months

-rest, activity modification, NSAIDs, corticosteroid injections

-night splint (elbow extended)

What is the surgical management of ulnar nerve entrapment?

-ulnar nerve transposition

-subcutaneous transposition

-intermuscular transposition

-submuscular transposition

What is Phase I post-surgical rehabilitation and how long does it typically last for an ulnar nerve entrapment?

-0-3 weeks

-management of edema & pain; increase elbow ROM

-initiation of active elbow ROM exercises

-week 1: posterior splint at 90°

-week 2: hinged elbow brace set at 30-100°

-week 3: hinged elbow brace set at 15-100°

What is Phase II post-surgical rehabilitation and how long does it typically last for an ulnar nerve entrapment?

-4-8 weeks

-increase in AROM to 0-145°

-increase in UE strength

-hinged brace set at 10-120° (add 5° each week)

-intro of PROM exercises

-ulnar nerve glides

-hand exercises (pinch to light grip)

-elbow exercises (mid-range isometrics to lightweight isotonics)

What is Phase III post-surgical rehabilitation and how long does it typically last for an ulnar nerve entrapment?

-2-3 months

-removal of brace; full AROM & PROM

-gradual RTA, return to light sports

-progressive strengthening (UBE, PNF, free weights, tubing exercise, plyos)

What is Phase IV post-surgical rehabilitation and how long does it typically last for an ulnar nerve entrapment?

-4-6 months

-gradual return to full unrestricted activity

-throwing program

-competitive sports 5-7 months post-op

What are causes of a UCL injury?

-valgus torque during the late cocking and acceleration phases of throwing

-in acute cases, “pop” is heard & felt along medial aspect of elbow

-in chronic cases, edema, scarring, calcification, ossification of UCL occur

-poor pitching mechanics & overuse place added stress on UCL

S/S of UCL injury?

-pain over medial elbow

-especially anterior band of UCL

-pain with valgus stress

-pain and weakness with throwing

What is the conservative treatment for a UCL injury?

-option for nonthrowing athletes

-active rest

-strengthening of RC & shoulder girdle

What are the pitching guidelines for adolescent players?

1.) no more than 10 pitches x their age per week

2.) maximum 8 innings per week for 8-12 year olds

3.) maximum 180 pitches per week

4.) limit 80 pitches per game

5.) do not pitch with arm pain/fatigue

6.) do not pitch more than 8 months a year

7.) do not throw more than 2,500 pitches per year

What is the etiology & S/S for biceps tendon rupture?

-Etilogy: eccentric load

-S/S: swelling/ecchymosis in cubital fossa, palpable defect over distal biceps tendon, weakness with elbow flexion/forearm supination, lump in upper part of arm

True or False: surgical intervention is typically preferred when someone ruptures their biceps tendon?

True

What is phase I of protocol for biceps tendon rupture?

-1-3 weeks

-elbow ROM from 30-120°

-elbow braced at 90° at all times except during exercise

-active pronation & supination with elbow locked at 90°

What is phase II of protocol for biceps tendon rupture?

-3-6 weeks

-goal:full elbow & forearm ROM

-brace locked from 20-120° (extension increase 10° each wee)

-initiation of gripping exercises

-massage of scar 3-4x/day; discontinuation of brace at 6 weeks

-initiation of passive extension and light strengthening

What is phase III of protocol for biceps tendon rupture?

-2-6 months

-progression of exercise based on pain

-implementation of PNF, shoulder plyos, free weight, functional exercises according to surgeon

-RTP

What structures make up the wrist?

-distal radius & ulna

-carpal bones

-TFCC

What does the distal radius & TFCC/ulnar complex form and how does it function?

-forms a concave surface

-articulates with convex proximal carpal row

What are the 3 ulnar variances?

1.) Neutral ulnar variance: smooth concavity formed by radius & TFCC/ulna complex

2.) Positive ulnar variance: ulna is longer extends more distally than radius (pathology: ulnar impaction)

3.) Negative ulnar variance: ulna is shorter, extends less distally than radius (pathology: Kienbock’s disease)

Which rows of carpal bones are convex and concave?

-Distal carpal row (convex)

-Proximal carpal row (concave)

What is the carpal tunnel?

-bony framework-carpal arch

-enclosed by flexor retinaculum/transverse carpal ligament

-structures within:flexor 4 digitorum profundus tendons, 4 flexor digitorum superficialis tendons, flexor pollicis longus tendon, median nerve

What kind of joints are the CMC joints?

plane synovial (thumb & 5th are saddle joints)

What kind of joints are the MCP joints?

multi-axial (flexion/extension, abduction/adduction, rotation)

What kind of joints are the IP joints?

synovial hinge joints (flexion/extension)

What are the muscles that primarily act on the wrist? (6)

1.) Extensor carpi radialis longus

2.) extensor carpi radialis brevis

3.) extensor carpi ulnaris

4.) flexor carpi radialis

5.) flexor carpi ulnaris

6.) palmaris longus

What are the muscles that primarily act on the distal radioulnar joint? (5)

1.) supinator

2.) biceps

3.) pronator teres

4.) pronator quadratus

5.) brachioradialis

What are the wrist and hand extrinsic extensor muscles? (6)

1.) Extensor digitorum communis

2.) Extensor indicis

3.) Extensor digiti minimi

4.) Extensor pollicis longus

5.) Extensor pollicis brevis

6.) abductor pollicis

What are the wrist and hand extrinsic flexor muscles? (3)

1.) Flexor digitorum superficialis

2.) Flexor digitorum profundus

3.) Flexor pollicis longus

What is the function of synovial sheaths?

-nourish tendons and decrease friction with movement

-no direct contact with skin at palmar skin creases

-open wounds at skin crease make synovial sheaths prone to infection

What are the function of pulleys?

-improve efficiency of the flexor tendons

-prevent bowstringing of the tendons with muscular contractions

What are the 2 types of retinaculum and what are their functions?

1.) Flexor retinaculum (encloses FDP, FDS tendons with carpal tunnel, maintains bony arch, protected median nerve)

2.) Extensor retinaculum (cores extensor tendon synovial sheaths, has 6 distinct compartments of extensor sheaths)

What are the functions of the intrinsic ligaments of the wrist?

-stabilize relationship between individual carpal bones

-ligament injury results in instability between carpals (carpal instability dissociative)

What are the functions of the extrinsic ligaments of the wrist?

-run from radius or metacarpals to the carpals

-instability results in excessive motion of entire proximal carpal row (carpal instability nondissociative)

What are the major blood suppliers in the wrist/hand?

1.) Radial artery: enters hand at volar, radial wrist, travels on floor of anatomical snuffbox

2.) Ulnar nerve: enters hands through Guyon’s tunnel;, formed superficial palmar arch

Which supplies the most blood to the hand?

Ulnar nerve (60%), radial nerve supplies 40%

What are the 3 peripheral nerves?

1.) Radial nerve (sensory only): posterior cord (C5-C8 & T1), Wartenberg’s syndrome

2.) Median nerve: lateral and medial cord (C6, C7, C8), entrapment of median nerve-carpal tunnel syndrome

3.) Ulnar nerve (“nerve of fine movements”), medial cord (C7, C8, T1), handlebar or cyclist’s palsy

What are the arthrokinematics of the wrist?

1.) Wrist flexion (dorsal glide of proximal carpal row)

2.) Wrist extension (proximal carpal row, palmar glide, rotation of scaphoid)

3.) Radial deviation (proximal carpal row: flexion, dorsal glide, ulnar glide; distal row: extended, volar glide, radial glide)

4.) Ulnar deviation (reverse of radial deviation)

What are some strengthening exercises for the wrist/hand?

-TheraBand/rubber tubing (easy progression, important to monitor form of exercises)

-Digiflex system (preferred device for carpal tunnel strengthening, full finger flexion doesn’t occur using device)

-Putty exercises (preferred exercises for full ROM strengthening)

-Biometrics system

What are some proprioception exercises for the wrist/hand?

-rhythmic stabilization

-ball rolls

-body blade

How are wrist/hand splints named?

-Descriptive categories to name the splint:

1.) articular vs. nonarticular

2.) location (joint or long bone)

3.) direction splint is intending to produce

4.) purpose of the splint

5.) other classifications (static splints, static progressive splints, serial static splints, dynamic splints)

What can cause some proximal origins of pain?

-TOS
-cervical disorders

What is the etiology and S/S of a Colles’ Fracture?

-etiology: FOOSH, fx of distal radius (dorsal displacement of distal radius), possible involvement of ulna, Smith’s fx (fx of distal radius, volar/palmar displacement)

-S/S: pain, swelling, tenderness, deformity (dinner fork), loss of ROM

What is the treatment for a Colles’ Fx?

-reduction & stabilization of the fx (long arm cast 3 weeks, followed by short arm cast 3 weeks, external or internal fixation)

-approximate anterior tilt to pre injury angulation (normal: 10-15°, increased anterior tilt= increased wrist flexion/decreased extension, neutral or distal tilt= loss of wrist flexion/excessive extension)

-Smith’s fx: open, internal fixation

What rehabilitation can be done for a Colles’ fx while wrist is casted?

-elevation

-tendon gliding

-fingers wrapped with Coban

-dexterity exercises

What rehabilitation can be done for a Colles’ fx once cast is removed?

-loss of isolated wrist extension must be addressed

-exercises: isolated wrist extension with finger flexion

What rehabilitation is performed for a Colles’ fx?

-initially address pain, swelling, stiffness, and increase finger ROM

-with full finger ROM, focus on wrist ROM

-address ROM with aggressive stretching, tendon glides, muscle strengthening, and mobs

-begin proprioception exercises once sufficient strength achieved

-avoid possible complications (malunion, carpal tunnel, complex regional pain syndrome (CRPS), TFCC, EPL rupture)

What is the etiology and S/S of a thumb collateral ligament sprain?

-etiology: ulnar collateral (Gamekeeper’s thumb, Skier’s thumb), MOI: forceful abduction and/or radial deviation of thumb MCP joint, radial collateral

-S/S: pain, joint edema, tenderness, limited ROM, limited function

What is the treatment for a thumb collateral ligament sprain?

-complete rupture requires surgical intervention

-immobilize incomplete ruptures with splint to allow for controlled ROM

-initiate RICE

-begin finger & wrist strengthening while splinted

-begin strengthening of thumb with putty after ligament is stable

-perform dexterity exercises

What is the etiology and S/S of carpal tunnel syndrome?

-etiology: compression of median nerve/FDP/FDS/FPL, repetitive exercises which cause friction & lead to tenosynovitis, chronic trauma that causes increase in volume of tunnel or decrease in canals cross-sectional area

-S/S: decreased sensation of median nerve distribution, pain/paresthesia, lack of coordination, night pain, positive special tests (Phalen’s test, reverse phalen’s test, tinel’s sign)

What is the conservative treatment for carpal tunnel syndrome?

-splinting, tendon gliding, nerve gliding, ionto, US, activity modifications

-splinting (neutral for least amount of pressure within tunnel, nighttime)

-during exercise, avoidance of finger flexion >50% to prevent lumbricals from entering tunnel

-education in proper hand position with computer use

What is the post-surgical treatment for carpal tunnel syndrome?

-rest, edema, control activities

-early ROM- important

-no resistive wrist flexion for 2 weeks

-scar management once incision is healed

-initiation of strengthening 4-8 weeks post-op

What is the etiology & S/S of DeQuervain’s Tenosynovitis?

-etiology: inflammation of synovial lining of sheath containing the: APL, EPB; often associated with metabolic disorders, MOI: overuse, repetitive trauma

-S/S: pain just proximal to radial styloid process, swelling, tenderness, possible crepitus with thumb motion, positive Finkelstein’s test

What is the treatment for DeQuervain’s Tenosynovitis?

-rest through splinting (thumb spica, long opponens splint)

-modalities to reduce pain and inflammation

-pain-free gentle ROM, AROM; avoidance of extreme end ranges

-as symptoms decrease, decrease in splint use and increase in exercise progression

-corticosteroid injection & surgical release if conservative treatment fails

What is the etiology and S/S for trigger finger tenosynovitis?

-etiology: thickening of the A1 pulley area

-S/S: hear/feel “snap"“, swelling, tenderness, decreased ROM (stuck in flexion)

What is the treatment for trigger finger tenosynovitis?

-anti-inflammatory modalities

-steroid injections

-PROM

-splinting (keep MCP joint in extension, PIP, DIP joints free)

-compression using Coban

-if conservative treatment fails, consideration of trigger release surgery

What is the etiology and S/S for mallet finger?

-etiology: extended finger abruptly forced into flexion at DIP joint, forceful flexion that causes avulsion of distal EDC insertion, distal dorsal finger laceration, fx of base of distal phalanx

-S/S: DIP joint rests in flexion, pain, swelling, point tender at DIP

What is the treatment for mallet finger?

-continuous splinting in 5° hyperextension for 6 weeks (distal finger must be kept straight at all times)

-2 weeks night splinting after initial 6 weeks

-ROM (avoid passive flexion)

-strengthening, can begin when DIP joint extension can be maintained

-consideration of operative management for open mallet fingers, complex wounds

What is the etiology and S/S for jersey finger?

-etiology: avulsion of FDP tendon, MOI: forced extension against actively flexed finger, most common in ring finger

-S/S: DIP joint rests in flexion & can’t extend, often missed because FDS can flex MCP, PIP joints

What is the treatment for jersey finger?

-surgical intervention to reattach tendon (complication: tendon can retract into palm)

-splinting in position to block extension of fingers through wrist

-ROM at 6 weeks after surgery

-rehab that follows surgeon’s protocol

What is the etiology and S/S for TFCC tear?

-etiology: forearm rotation with force loaded through ulnar wrist, FOOSH

-S/S: ulnar-sided pain that is unrelieved with therapy & rest, pain with gripping/wrist deviation & forearm rotation, ulnar click, inability to push off chair, positive TFCC load test

What is the conservative treatment for TFCC tear?

-modalities to decrease swelling & inflammation

-possible splinting

-strengthening not emphasis of rehab (neutral position, isometrics kept at mid-range of motion)

What is the surgical treatment for TFCC tear?

-0-4 weeks: immobilization

-4-6 weeks: splint modification to allow elbow ROM

-6 weeks: initiation of AROM in mid-range

-10 weeks: full ROM & strengthening

How many vertebrae does the lumbar spine consist of?

5

How many nerve roots does the lumbar spine consist of?

10

How many facet joints does the lumbar spine consist of?

10

How many main ligaments does the lumbar spine consist of?

6

How many IVD are in the lumbar spine?

5

What exercises should be limited when designing exercise program for disc herniation?

Those requiring full spinal flexion (full sit-ups, knee to chest stretches, standing toe touches)