MSK UE

Neurological Thoracic Outlet Syndrome

Most common

C8-T1 paresthesia, numbness, weak grip and loss of manual dexterity

Arterial Thoracic Outlet Syndrome

Pulselessness, poor endurance, pallor, cold extremities

Venous Thoracic Outlet Syndrome

Edema, warm, cyanosis, swelling, mottled appearance

Thoracic Outlet Syndrome

Compression of neurovascular bundle- brachial plexus, subclavian artery and vein, phrenic nerve in the thoracic outlet at 3 sites

TOS Interscalene Triangle

Special test: Adson’s Maneuver

Intervention: Stretch the scalene muscles

TOS Costoclavicular Space

Special test: Costoclavicular test/ Military Brace Test

Intervention: Mobilization of the first rib

TOS Axillary Interval (Pec Minor space)

Special test: Wright Test/ Roos Test/ Allen Test

Intervention: Stretch the pectoralis minor

Coracoacromial is the key site of what pathology?

Superior Labrum Anterior Posterior (SLAP) lesion is superior labrum tearing or pulling away by the biceps insertion, which is under the subacromial arch

SLAP Lesion Repair

When biceps tendon is detached, progress cautiously

Limit passive or assisted elevation of UE to 60 deg for 2 weeks and limit to 90deg at 3-4 weeks

Only perform passive humeral rotation with shoulder in scapular plane for first 2 weeks

Progress to 30 deg ER and 60 IR at 3-4 weeks

Avoid tension on the biceps ( elbow extension with shoulder extension) for the first 4-6 weeks

No active biceps contraction for 6 weeks

Rotator Cuff Rehabilitation

Initiate with isometrics

Resisted exercises should NOT cause pain

Rotator cuff strength must be addressed before large primary movers

AROM for shoulder flexion and abduction must be done without shoulder hiking

Dynamic strengthening may begin at 8 weeks for small tear and 12 weeks for a large tear

Light functional activities for 6+ weeks

TMJ Hypomobility

Decreased mouth opening and deviation to same side

TMJ Hypermobility

Increased mouth opening and deviation to opposite side

Disc displacement with reduction

Clicking heard. No deviation, no difficulty with mouth opening

Synovitis

Pain and limited mouth opening, no deviation

Capsulitis

Pain, limited mouth opening and deviation to same side

Opening of mouth (depression of mandible)

Normal ROM: 35-55 mm

Lateral Pterygoid

Can’t say L without opening your mouth

Closing of Mouth (Elevation of mandible)

Temporalis, Masseter, Medial pterygoid

Can’t close your mouth without M

Protrusion of Mandible

ROM: 7 mm

Medial and lateral pterygoid

Retraction of mandible

ROM: 3-4 mm

Temporalis-posterior fibers

Lateral deviation of mandible

Lateral pterygoid (contralateral)

Medial pterygoid (contralateral)

Cubital Tunnel Syndrome

Ulnar nerve entrapment between 2 heads of FCU

MOI: Prolonged elbow flexion, fractures, spurs, arthritis

Sensory (first): Pain/sensory at 4th/5th digits (dorsal and palmar): hypothenar

Motor symptoms: weakness in FDP 3/4, hypothenar muscles, ulnar, interossei, adductor pollicis

Test: Symptoms worse with elbow flexion test, positive froment’s (FPL substitutes for weak adduct pollicis), wartenberg sign, positive tinel at elbow

Guyon’s Canal Syndrome

Ulnar nerve entrapment between hook of hamate and transverse carpal ligament

MOI: history of heavy gripping, twisting, activities involving pressure (bicycling)

Motor: weakness in hypothenar muscles, ulnar interossei, adductor pollicis. NO FDP

Sensory: Pain/sensory symptoms at 4th/5th digits (ONLY Palmer), hypothenar

Tests: Froment’s, Wartenberg sign, Tinel’s sign positive wrist

Boutonniere Deformity

Extension of MCP and DIP joint and flexion of PIP joint (primary deformity)

This deformity is the results of a rupture of the central tendinous slip of the extensor hood and is most common after trauma or in RA

Swan Neck Deformity

Extension of PIP, flexion of MCP and DIP

Due to contracture of intrinsic muscles or tearing of Volar plate (common in RA)

Mallet finger

Due to rupture or avulsion of the extensor tendon at distal phalanx of finger, distal phalanx rest in flexed position

Always traumatic

Tx: splint with a finger extension splint for 6-8 weeks

De Quervain’s Tenosynovitis

Tenderness over lateral wrist and thumb

Abductor pollicis longus and extensor pollicis brevis are muscles affection

Severe pain with wrist ulnar deviation and thumb flexion and adduction

Special test; Finkelstein Test

Carpal Tunnel Syndrome

Tingling/numbness in the median nerve distribution of hand

Repetitive activities and sustained positioning of wrist aggravates pain

Thenar muscle atrophy in later stages

Night pain

Special test: Phalen’s and reverse phalens, tinel sign

Colles Fracture

Dorsal displacement of the distal fragment of radius

Due to FOOSH injury

Leads to dinner fork deformity

Smith Fracture

Volar displacement of distal fragments of radius

Due to fall on flexed wrist

Leads to garden spade deformity

Lateral Epicondylitis

Lateral aspect of elbow pain

Extensor carpi radialis brevis involved-activities involving repeated wrist extension/grasping increases pain (gradual overuse)

Special test: Cozen’s, Mills, Maudsley test

Tx: Offload to reduce pain and gradual progressive strengthening of wrist extensors

Medial Epicondylitis

Anteromedial aspect of elbow pain

Pronator teres+flexor carpi radialis involved-activities involving repeated wrist flexion increased pain (gradual overuse)

Special test: Medial Epicondylitis test

Treatment: offload to reduce pain and gradual progressive strengthening of wrist flexors

Nursemaid’s Elbow

Age: 2-3 yrs

Longitudinal traction on an extended elbow partial slippage of Annular ligament over the head of radius

Position of arm-arm at side with hand pronated, radial nerve can get injured

Tx: Manipulation

Adhesive Capsulitis Stage 1

0-3 months

Mild signs and symptoms-achy at rest and sharp at extremes of ROM

Capsular pattern-loss of ER and ABD is present

Synovitis more than contracture of capsule

Adhesive Capsulitis Stage 2

Freezing/Painful stage

2-9 months with progressive loss of ROM and persistence of pain

The motion loss in stage 2 reflects a loss of capsular volume and response to the painful synovitis

Loss of motion in all planes, as well as pain in most of the range

Adhesive Capsulitis Stage 3

Frozen Stage

9-15 months

Painful stiffening of the shoulder and a significant loss of ROM

Pain only with movements

Atrophy of rotator cuff muscles, deltoid, biceps, triceps

Poor scapulohumeral rhythm with scapular hike

Loss of axillary fold and ROM with capsular restriction

Adhesive Capsulitis Stage 4

Thawing phase

Pain lessens but stiffness persists

Slow and steady recovery

Best Treatments for Adhesive capsulitis

Corticosteroid injection by MD + PT stretching determined by patient irritability

Joint mob-posterior and inferior glide

Subacromial Impingement

Anterior/lateral shoulder pain

Pain at night

Painful arc 60-120 deg

Special test: Neer, Hawkins, Yocum, Empty can/Jobe

Rotator Cuff

Age: >40 (overuse cases) or traumatic

Anterior/posterior/superior should pain with loss of strength

Pain that wakes the during sleep, worse at night

Weakness and atrophy

Special test: ER lag sign, drop arm, Hornblower’s sign, IR lag sign, lift off sign, belly press, bear hug

SLAP-Labrum tear

Traumatic sudden onset

Deep anterior shoulder pain

Clicking/clunking/joint locking, pain with throwing or biceps loading (shoulder flexion and arm supination)

Special test: O’Brien test, biceps load, clunk test

AC joint injury

Trauma that displaces the shoulder girdle inferiorly or heavy weighting

Pain at top of the shoulder

Painful arc (170-180 deg) and pain with horizontal adduction

Step deformity

Special test: Horizontal adduction, Paxinos sign, AC sheer test

Bicipital Tendinitis

Age: 20-45 yrs

Pain with overhead movements

Pain with full extension to flexion. Active LR is limited when arm is at 90deg abduction

Special test: Speed’s test, Yeargason’s test

Median nerve: Hand LOAF

L: lateral 2 lumbricals

O: Opponens policis

A: Abudctor policis brevis

F: Flexor pollicis brevis

Median nerve: Superior layer

Pronator teres, FCR, palmaris longus

Median nerve: intermediate layer

FDS

Median nerve: Deep layer or AIN

FPL, FDP (lateral 2) PQ

Ulnar nerve: Superficial layer

FCU

Ulnar nerve: Deep layer

FDP (medial 2)

Ulnar nerve: Hypothenar AI LOAF

A: Adductor pollucis

I: Interossei PAD/DAB

L: medial 2 lumbricals

O: opposite digiti mini

A: Abductor digi mini

F: flexor dig mini

MOI: over use, between 2 heads of pronator teres

Pronator teres syndrome

What are the positive tests for pronator teres syndrome?

Positive pronator teres test

Positive ULTT

Positive tinels forearm

How do you treat pronator teres syndrome?

Off load and activity modification

What aggravates pronator teres syndrome and what are the symptoms?

Pain, weakness and heaviness

Aggravates: resisted pronation, passive stretching into supination

NO NIGHT PAIN

Is sensory impacted in Pronator teres syndrome?

Entire sensory distribution, thenar, lateral 3 ½ palmar and dorsal tips

MOI: Overuse, fluid retention, wrist flexion pain, under the transverse carpal lig-compression

Carpal tunnel syndrome

What muscles are affected in carpal tunnel syndrome?

L Lateral 2 lumbricals

O Opponens pollicis

A Abductor pollicis brevis

F flexor pollicis brevis

Is sensory affected in carpal tunnel?

Thenar sensory is not affected! Rest of it is affected, palmar cutaneous branch does not cross the carpa tunnels

What are carpal tunnel tests?

Phalen, Reverse phalens, Tinel wrist, ULTT

Cardinal symptoms of carpal tunnel syndrome

Flicks maneuver, shaking hand relieves pain, NIGHT PAIN

MOI: fracture of elbow, supracondylar fracture and elbow dislocation

AIN syndrome

Is sensory affected in AIN syndrome?

NO

What motor is affected in AIN syndrome?

FPL, 2 FDP, PQ

What is the Kiloh nevin sign for?

AIN syndrome, they cannot make the O.K sign

What causes Ape hand Colles fracture?

Median nerve lesion, thenar atrophy no opposition...can’t touch the pinky

What is this called and what nerve is affected?

Median Nerve

Hand of Benediction

What condition is this called and what nerve is affected?

Claw hand

Ulnar nerve

Wrist Drop

Radial nerve

What does Extensor carpi radialis brevis do?

Wrist extension, radial deviation and grip stabilization

What condition is ECRB involved in?

Lateral epicondylitis, tennis elbow

What is the muscle that causes cubital syndrome?

FCU