common biomechanical dysfunctions upper extremity

8/10/2019 Common Biomechanical Dysfunctions upper Extremity

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Robert Schneider, DO, FAAFP

Assistant Professor of OMM

Medical Director, Gutensohn Clinical Associates

Clinical Faculty Kirksville Family Medicine Residency

Objectives

Diagnosis of common upper extremity complaints byphysical examination

Other considerations

Biomechanics that may lead to dysfunction

Review traditional treatments

Osteopathic Manipulative Techniques

Common Upper Extremity

Complaints

Carpal Tunnel Syndrome

Biceps Tendonitis

Epicondylitis

DeQuervains Tenosynovitis

Carpal Tunnel Syndrome

It results from compression/injuryof the median nerve atthe wrist within the compartment defined by thetransverse carpal ligament (aka flexor retinaculum).

Epidemiology & Demographics

Carpal Tunnel Syndrome is the most commonentrapment neuropathy

2-3 Million in U.S

10% Lifetime Incidence

1% of Adult Population, 15% of High Risk Pop

Female (30-60); Male Industrial (35-40)

Prevalent sex: Females 5xs > Males

Bilateral up to 50%

Carpal Tunnel Syndrome Sensory component involved earlier than

motor component

Autonomic disturbances are common

55 % of CTS

Occurring with increasing severity of electrophysiologicfindings

Consisted of swelling of the fingers, dry palms,Raynauds phenomenon, and blanching of the hand


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Natural Hx:

Duration of Symptoms

32% less than 6 months

20% 6 months to 2 years

48% greater than 2 years

History & Physical Findings Nocturnal pain

Median nerve paresthesia (often only index & long finger)

Positive Tinels at wrist

Two-point discrimination >5mm

Positive Phalens (1 min. of gentle flexion)

Wormser(Reverse Phalen)

Carpal compression

Thenar atrophy: long standing cases

Mild/Moderate CTS Intermittent pain and numbness in the fingers

(1st2nd)

Pain and numbness: Often occurs at night

Diminishes with gentle hand activity but rapidly returns with grasping or pinching

Constant numbness

Severe pain Pinch becomes clumsy and weak

Thenar/thumb muscle atrophy

Severe CTS


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Treatment of CTS Standard

1. NSAIDs-oral/topical2. Orthoses3. Rest4. Steroids (oral, injection)5. Surgery

Osteopathicmanipulation

Activity modification -work site, ergonomics, etc

Stretching exercise1. Manual, self-stretch,

devices

2. Nerve and tendon gliding

Physical medicinemodalities:1. Ultrasound - 3mhz; around

edges of canal

Osteopathic Manipulation

C-spine

Upper T-spine

Thoracic Inlet

Ribs

Upper extremity

Clavicle (SC & AC)

Scapula

Glenohumeral joint

Elbow

Interosseousmembrane

Wrist

Palpation Palpate for tension in transverse carpal ligament by

inducing hyperextension at the proximal and distal carpalrows.

Direct Techniques1. Transverse carpal extension

2. Thenarmyofascial release

3. Hyperextension of wrist and fingers

4. Guy wire

5. Combined technique

Techniques involve direct stretch for 1-2 mins

Transverse Carpal Extension

Apply three pointpressure Medial border of the

carpal ligament Lateral border of

carpal ligament Radial abduction

(post) with extension(lat) of the thumb

May be performed atproximal or distalcarpal rows

Abd

Ext

Thenar Myofascial Release

Add the following:

Lateral axial rotation(opponens roll)


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Hyperextension of wrist and fingers

Add the following: Hyperextension of

wrists and fingers

Guy-Wire Technique

Adds additionalextension andabduction of fifth digit

Without axialrotation of the thumb

Abd

Ext

Combined Technique

Maintain extensionand abduction offifth digit

Addswith axialrotation of thethumb

Osteopathic Research

Sucher, et. al., JAOA, Dec. 93

Myofascial release of CTS:

Documentation with MRI

Showed improvement in nerve conduction velocity(NCV), MRI and subjective symptoms

Small study (larger study in progress)

Self Stretches - Wall

Fingers together - Target the forearm Fingers apart -Target the wrist

Self Stretches September 1995, Journal of Hand Surgery

1 minute of hand and wrist exercises Significantly decreased carpal tunnel pressures Authors rec. brief intermittent wrist and hand exercises before,

during and after work

Researchers in a 1996 study at the Orthopedic andResearch Center in Oklahoma City taught these pain-relieving hand and wrist exercises to 81 carpal tunnelsyndrome sufferers. One minute of exercise was enough to reduce the pressure on the

victim's median nerve -- and the pain.


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Biceps Tendinitis Definition

Inflammation, pain, or tenderness in the region of the biceps

tendon May be due to degenerative tendinosis

Symptoms Anterior shoulder pain, worse with activity

Especially elbow flexion and shoulder flexion (lifting, carrying)

Pain with prolonged rest, especially at night Early stages, may present as fatigue with shoulder movement Throwing athletes may describe snap as tendon subluxates

in groove Can be difficult to distinguish from impingement or rotator

cuff syndrome

Biceps TendinitisPrimary biceps tendinitis Secondary bicipital tendinitis

Isolated inflammation oftendon in intertuberculargroove

Young, athletic patients

Precipitating forces: Repetitive overuse

Multidirectional shoulderinstability

Calcifications of the tendon Direct trauma

Rare

Older population

95% associated with rotatorcuff disease

Post-total shoulderarthroplasty

Focal chondromalacia nearbicipital groove (biceps

tendon footprint) increasesrisk for tendinitis

Glenohumeral joint

Ball-and-socket joint

Great mobility at expenseof stability

Interdependent effects ofmuscle strength & function

Compromise of singlestabilizing muscle canimpair function of entireshoulder joint

Biceps helps preventsuperior translation ofhumeral head

Differential Diagnosis Rotator cuff tendinitis and tears Multidirectional instability Biceps brachii rupture Acromioclavicularjoint sprain Glenohumeral or acromiclavicular degenerative joint disease Rheumatoid arthritis Crystalline arthropathy Adhesive capsulitis Cervical spondylosis Cervical radiculopathy Brachial plexopathy Peripheral entrapment neuropathy Referral from visceral organs Diaphragmatic referred pain

Clinical Exam Inspection

Scars

Structural deformities

Posture

Muscle bulk

Palpation

Tenderness over bicipital groove

Side-to-side comparison

Lateral aspect of shoulder

Tenderness suggests tendinitis/strain of deltoid or bursa


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Clinical Exam Range of Motion

Passive shoulder motion: Flexion 180 Extension 60 Abduction 180 Internal rotation 70 External rotation 90

No limitation in isolated tendinopathies If limited, consider:

Rotator cuff involvement Degenerative joint diseases Impingement syndromes Tendon tears Adhesive capsulitis

Diagnostic Studies Diagnosis usually by clinical exam alone Plain radiographs

Usually normal with biceps tendinitis

Can show predisposing tendon calcifications and joint degeneration Arthrography

Helpful only in full-thickness tears MRI

Assess partial-thickness tears, soft tissue abnormalities, labral diseases,masses

Ultrasonography Cost-effective but operator-dependent, no widespread acceptance

Electrodiagnosis Used for assessment of concomitant peripheral neuropathies

Arthroscopy Useful only for evaluating intra-articular disease

Treatment Activity modification

Avoid overhead lifting &abduction early in healing

Anti-inflammatory NSAIDs

Heat & cold Moist head before activity Ice after activity

Exercise to promote strength &flexibility of shoulder stabilizers Shoulder stretching to

maintain ROM Address all concomitant

shoulder disease Progressive resistance

exercises

Ultrasound over focal tendinitis

Steroid injections

Diminish inflammation tofacilitate rehab

Overuse can weaken tendon

Surgery

Not for isolated bicepstendinitis

Biceps tenodesis withacromioplastyin chronic

refractory cases OMT

Counterstrain

Dx- UlnaraBduction with medial glide

1. Physician grasps patients distal

forearm with the hand opposite the

patients dysfunction; pts elbow is

supported in the palm of other hand.

2. Physicians thenar eminence is

against the medial side of the

olecranon; fingers are over the lateral

condyle

3. Physician flexes patients elbow 90 &

adducts ulna to its restrictive barrier

4. Activation is an articulatory sweep

guiding the ulna into full extensionthrough the barrier

5. Recheck

Caution: Dont over extend ulnohumeral

joint.

Ulnohumeral Joint: Direct Articulatory Glenohumeral Joint: Seated Indirect patientcooperation, respiratory force

Dx

Humeral head anterior and superior

1. Physician monitors humeral head withposterior hand; anterior hand inducesmotion at the GH joint to the point ofbalanced ligamentous tension

2. Patient grasps elbow with opposite armto support weight, create superior glide,gap GH by pulling elbow in to chest, &relax shoulder joint

3. Physician localizes internal or externalrotation to point of BLT

4. Respiratory phases are tested; patientholds breath at point of maximal BLT;repeat until best motion is obtained

5. Recheck


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Epicondylitis Definition Inflammation, pain, or

tenderness in the medial orlateral epicondyle of thehumerus Lateral epicondylitis: origin

of forearm extensor muscles Extensor carpiradialisbrevis Extensor carpiradialislongus Extensor digitorum

communis

Medial epicondylitis: originof forearm flexor muscles Flexor carpi radialis Flexor carpi ulnaris Flexor digitorum superficialis Palmaris longus

Symptoms

Pain in area just distal to lateralepicondyle

Pain in area just distal to medialepicondyle

Pain may radiate proximally ordistally

Pain with wrist/hand movement:

Gripping doorknob

Carrying briefcase

Shaking hands

Typing on computer keyboard

Etiology Tendinosis: fibroplasiaresulting from failure of the

musculotendinousattachment

Postulated primary lesions Angiofibroblastic tendinosis

Periostitis

Enthesitis

Repetitive stress

Poor throwing mechanics, excessive throwing

Overuse from tennis backhand (lateral epicondylitis, tenniselbow)

Repetitive wrist flexion (medial epicondylitis, golfers elbow)

Differential Diagnosis Posterior interosseus nerve

syndrome

Bone infection or tumors

Median or ulnarneuropathy around theelbow

Osteoarthritis

Acute calcification aroundthe lateral epicondyle

Osteochondral loose body

Triceps tendinitis

Degenerative arthrosis

Elbow synovitis

Lateral ligamentinstability

Radial head fracture

Bursitits

Collateral ligament tears

Hypertrophic synovialplica

Physical Examination Motor and sensory findings usually

absent

Lateral epicondylitis

Pain localized at origin of extensormuscles one f ingerbreadth belowlateral epicondyle

Pain with resisted wrist extension

Pain with extension of 3rd digit

Medial epicondylitis

Pain localized at origin of flexormuscles one f ingerbreadth belowmedial epicondyle

Pain with resisted wrist flexion If resistant tendinitis, consider MRI

to rule out occult fractures, arthritis,osteochondral loose body

Treatment

Relative rest Avoidance of repetitive motions Activity modifications Anti-inflammatory medications Heat/ice for acute pain

Counterforce brace Worn distal to flexor or extensor

group origin Dissipates forces over larger area;

less focal force on attachment site Wrist immobilization splints

Set in neutral: relieves tension onflexors & extensors

Set in 30 extension: relievestension on extensors (lateralepicondylitisonly)

Rehab 1st phase: decrease pain, decrease

disability

2nd phase: gradual improvement ofstrength, stretching, and endurance

Procedures

Corticosteroid injection

Botox injection

Chronic tx-resistant lateralepicondylitis

Caution with injecting for medialepicondylitis due to risk of ulnarnerve injury

OMT

Counterstrain


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CounterstrainDe QuervainsTenosynovitis Definition

Tenosynovitis: inflammation of tendon & enveloping sheath De Quervains: stenosing tenosynovitis of synovial sheath of

tendons due to repetitive use

Abductor pollicis longus

Extensor pollicis brevis

Degeneration and thickening of tendon sheath due tofriction; not inflammatory

Often related to overexertion & fast repetitive manipulations

Gradual onset; usually no hx of acute trauma

Primarily affects women (10:1) age 35 to 55

Tenosynovitis Symptoms

History of chronic overuse ofwrist & hand

Pain in medial wrist duringgrasp and thumb extension

Pain with palpation overmedial wrist

Symptoms persist for severalweeks or moths

Occasional complaints ofstiffness/neuralgia

True parasthesia indistribution of superficialradial nerve is uncommon

Functional Limitations

Impaired gliding oftendons due to narrowedfibroosseus canal Abductor pollicis longus Extensor pollicis brevis

Functional impairment ofthumb due toimpingement

Difficulty dressing,

fastening buttons Limited recreation: sewing,

knitting, bowling, fishing

Differential Diagnosis Carpal joint arthritis

Rheumatoid arthritis

Radial nerve injury

Ganglion cyst

Cervical radiculopathy

Scaphoid fractures

Carpal tunnel syndrome

Radioscaphoid arthritis Extensor pollicis longus tenosynovitis

Physical Exam

Inspection

Compare bilaterally Edema of hand Symmetry of bony structures Bony deformities Functionality of hand Muscle wasting Scars, abrasions, calluses,

nodules Color, hair grown patterns,

nails Texture, moisture of skin Skin creases

Palpation

Carpal bones: Scaphoid,

Radial styloid process

Anatomical snuffbox

Flexor carpi radialis

Extensor retinaculum

Carpal tunnel

Radial artery

Nails

Physical Exam First perform comprehensive

evaluation of neck and upperextremity to rule outproximal pathology

Local tenderness & moderateswelling at radial styloid

Possible decreased grip &pinch strength due to disusefrom pain

Strength and sensationexpected to be normal

Positive Finkelstein test Patient grasps thumb in fist

and abducts hand in ulnardeviation

Pain = positive result


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Treatment Conservative Treatment

Current literature:

Ice NSAIDs

Heat

Splints

Rest

Massage

Splinting appears more helpfulthan rest and NSAIDs alone

Rehabilitation

Goal: reduce pain, improve

function Thumb spica splint to

immobilize thumb

Inhibits gliding of tendonthrough fibro-osseus canal

Best results in pts with mildsymptoms

Treatment Procedures

Steroid injections: most frequent treatment

Local anesthetic injections

Must inject into first extensor compartment; avoidinjecting tendon

Repeated injections may weaken tendon, predispose torupture

OMT

Counterstrain Counterstrain

CounterstrainCounterstrain

I would like to thank my colleagues inOsteopathic Manipulative Medicine for their

assistance in the production of this presentation.

Kayaking in the

Queen Charlotte

Sound, New Zealand

Views of Queen

Charlotte Sound


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Queen Charlotte

Sound, South Island,New Zealand Skydiving over the

Abel Tasman National

Park, South Island,

New Zealand

Young Fern, New Zealand

National Symbol

Fern Trees, Bushy Park,

North Island

common biomechanical dysfunctions upper extremity

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