UE Conditions

Carpal Tunnel Syndrome (CTS)

• Anatomy and Pathophysiology:

  • Defined as the compression of the median nerve within the carpal tunnel.

  • Occurs when the carpal tunnel becomes narrowed or when tissues surrounding the flexor tendons swell, placing direct pressure on the median nerve.

  • When the synovium swells, it encroaches upon space in the carpal tunnel and progressively crowds the nerve over time.

• Epidemiology and Etiology:

  • More common in women than in men.

  • Peak incidence occurs between $30\text{--}50$         $\,\text{years}$ of age.

  • Frequently associated with occupations involving repetitive wrist flexion and extension.

  • Etiology is multifactorial, involving a combination of:

    • Heredity.

    • Repetitive hand use.

    • Specific hand and wrist positions.

    • Pregnancy.

    • Underlying health conditions.

• Clinical Presentation and Symptoms:

  • Pain and numbness distributed from the thumb to the ring finger.

  • Numbness, tingling, burning sensations, and pain.

  • Weakness of grasp.

  • Edema.

  • Exacerbation of symptoms during the night (nighttime symptoms).

• Physical Examination Tests:

  • Tinel's sign: Provocative test performed by tapping directly over the median nerve to elicit tingling or pain.

  • Phalen's Maneuver: Positive test indicated when holding hands such that they push slightly against each other (wrist flexion) reproduces symptoms.

• Conservative OT Management:

  • Rest.

  • Splinting.

  • Activity modification.

  • Nerve gliding exercises.

  • Steroid injections.

  • Range of Motion (ROM) exercises.

  • Strengthening exercises.

  • Edema control.

  • Physical Agent Modalities (PAMs).

• Surgical Management:

  • Carpal Tunnel Release (CTR) surgery reduces pressure on the median nerve by releasing the transverse carpal ligament.

  • Surgical Procedures:

    • Open carpal tunnel release.

    • Endoscopic carpal tunnel release.

• Prognosis:

  • Only $1\%$ of patients develop permanent nerve injury.

  • Many individuals experience residual weakness post-operatively.

  • Prevention of re-injury requires utilizing proper body mechanics.

  • Occupational therapy plays a key role in managing and healing scar tissue.

De Quervain's Tenosynovitis

• Pathology and Symptoms:

  • Pain localized over the thumb provoked by hand and thumb motions, particularly forceful grasping or twisting.

  • Tenderness directly over the thumb region.

  • Pain character may be sharp or dull.

  • Presence of localized edema.

  • Loss of thumb strength.

• Etiology:

  • Sudden changes in overall hand use.

  • Repetitive hand use characterized by forceful, sustained thumb abduction combined with wrist ulnar deviation.

  • Hormonal changes.

• Diagnostic Examination:

  • Finkelstein's Test: Performed by placing the thumb inside the palm, closing the fingers over it to form a fist, and pulling the wrist down into ulnar deviation.

• Intervention and Treatment:

  • Rest.

  • Splinting.

  • Ice application.

  • Anti-inflammatory medications.

  • Cortisone injections.

  • Surgical intervention is rare and generally reserved for persistent inflammation following at least one unsuccessful cortisone injection.

• Prognosis:

  • Patients often return to functional tasks after cortisone injection, but symptoms may recur.

  • Permanent relief is typically achieved following surgical release.

Epicondylitis

• General Features:

  • Inflammation of the elbow tendons caused by muscle and tendon overuse from repetitive injuries.

  • Prevalence is higher in women than men ($\text{Women} > \text{Men}$).

  • Peak incidence occurs in individuals in their $40\text{s}$.

• Medial Epicondylitis (Golfer's Elbow):

  • Pain centered at the medial epicondyle of the elbow (inside aspect).

  • Pain may radiate downwards into the forearm.

  • Associated with decreased grasp strength.

• Lateral Epicondylitis (Tennis Elbow):

  • Pain centered at the lateral epicondyle of the elbow (outside aspect).

  • Pain may radiate downwards into the forearm and wrist.

  • Associated with decreased grasp strength.

• Treatment Modalities:

  • Rest.

  • Physical Agent Modalities (PAMs).

  • Range of Motion (ROM) exercises.

  • Ergonomic adaptations.

Peripheral Nerve Injuries

• General Principles:

  • Nerves function as the body's "telephone wiring," transmitting signals between the brain and the body.

  • Etiology of nerve injuries includes trauma (lacerations, fractures), mechanical compression, stretching, and disease processes.

  • Prognosis depends directly on whether the nerve was severed, bruised, or stretched.

  • Surgical solutions include nerve grafting and tendon transplants.

  • Timelier treatment correlates with superior outcomes.

  • Splinting and proper positioning are required to prevent secondary deformities.

  • Once muscle atrophy has occurred, it cannot be corrected.

• Median Nerve Injury:

  • Sensory loss, burning, or tingling involving the first $2$         $\text{fingers}$.

  • Impaired thumb pinch function.

  • Decreased ability to grip items.

• Radial Nerve Injury:

  • Total loss of extension in the wrist, fingers, and thumb.

  • Inability to perform functional object grasp.

  • Clinical presentation of wrist drop.

• Ulnar Nerve Injury:

  • Controls most small intrinsic muscles of the hand responsible for fine movements, as well as larger forearm muscles contributing to grip strength.

  • Symptoms include numbness and tingling of the ring and little finger.

  • Weakness in overall grip strength and impairment of fine motor coordination.

  • High risk of muscle atrophy.

  • Clinical presentation of claw hand.

Rotator Cuff Pathology

• Types and Conditions:

  • Includes strains, tendonitis, and partial or complete tears.

  • Impingement Syndrome / Shoulder Bursitis:

    • Typically seen in individuals aged $30\text{--}80$             $\,\text{years}$.

    • Associated with mild to moderate weakness.

    • Occurs when the rotator cuff becomes irritated beneath the under surface of the acromion.

  • Chronic Tear:

    • Most common form of rotator cuff tear.

    • Typically occurs in individuals with a history of tendonitis who experience progressive shoulder weakness.

  • Acute Tear:

    • Results from lifting an excessively heavy load, often accompanied by an audible or tactile "pop" in the shoulder.

• Symptoms and Clinical Presentation:

  • Atrophy or thinning of muscles surrounding the shoulder.

  • Pain during active arm elevation.

  • Pain when lowering the arm from a fully elevated position.

  • Weakness during arm elevation or rotation.

  • Presence of crepitus or a crackling sensation during shoulder motion.

  • Specific motion deficit: Lack of active movement between $0^\text{o}\text{--}90^\text{o}$, but capable of movement beyond $90^\text{o}+$         $\text{degrees}$.

  • Significant pain along with loss of strength and overall upper extremity function.

• Diagnostic Examination:

  • Drop Arm Test: Evaluated by passively abducting the patient's arm to $90^\text{o}$         $\text{degrees}$ and instructing them to lower it slowly.

• Conservative Treatment:

  • Rest and activity modification.

  • Nonsteroidal anti-inflammatory medications.

  • Physical therapy.

  • Modalities: Heat, cold, ultrasound, electrical stimulation, and massage.

  • Structured therapeutic exercise plan.

• Surgical Management:

  • Small Partial Tear: Bone is smoothed down to create adequate subacromial space, and the affected tendon is debrided/cleaned up.

  • Large Tear: The severed tendon is reattached directly to the upper arm bone (humerus).

• Prognosis:

  • Return to full athletic and work activities occurs within $5\text{--}6$         $\,\text{months}$.

  • Rotator cuff repair achieves $80\text{--}95\%$         $\text{good-to-excellent}$ outcomes.