common dysfunctions within the upper extremity

10/20/2015

1

Common Dysfunctions within the

Upper Extremity

Mark Coalson, MSPT, OCS

Outline

• Tensegrity• Continuous Compression - Continuous Tension

• Joint by Joint Approach• Mobile - Stable

• Performance Pyramid• Movement - Performance - Skill

• Movement Patterns• Mucle vs movement

• Shoulder Impingement• Internal Impingement - External Impingement

• Neural Entrapment• TOS - Carpal Tunnel - Cubital Tunnel

• Epicondylitis• Medial - lateral

10/20/2015

2

The Other Side

I want a clinic

with therapists that think just like me, who

believe the same thing and learn the same way.

everyone has to have their act together

I want a clinic that focuses its efforts

on me. Therapist who don’t measure up

will be looked down on. If you want to

work in this clinic, perfect, nothing will

change

The Other Side

I want a clinic

with therapists that think just like me, who

believe the same thing and learn the same way.

everyone has to have their act together

I want a clinic that focuses its efforts

on me. Therapist who don’t measure up

will be looked down on. If you want to

work in this clinic, perfect, nothing will

change

that isn’t filled

don’t all

I don’t want a place where

because none of us actually do.

on our patients, not focused

will be respected. Nobody

learn and grow, not just

be more rewarding. I will embrace

10/20/2015

3

Growth and Change

• With growth comes change

Growth and Change


• With change comes loss

10/20/2015

4

Growth and Change



• With loss comes pain

Growth and Change



• With loss comes pain

Pain of staying the same > Pain of changing

10/20/2015

5

Compression & Tension


• Seri Wawasan Bridge

10/20/2015

6


• Seri Wawasan Bridge


• Cable

10/20/2015

7


• Muscle


Compression resistant Tension resistant

beams soft tissues

(fascia)

10/20/2015

8



• https://www.youtube.com/watch?v=otHZwjElXwQ

10/20/2015

9


• Bone fracture


Muay Thai - Melchor Menor

• https://www.youtube.com/watch?v=O0_mrDbKlns

10/20/2015

10


Basketball - Kevin Ware

• https://www.youtube.com/watch?v=6PSV0AV1BI0

Soccer

• https://www.youtube.com/watch?v=KvrqG5CqoVY

Continuous Compression

10/20/2015

11

Continuous Tension - Tensegrity

• Buckminster Fuller

• Geodesic dome

• Balanced compression and tension in building

Tensegrity

• Kenneth Snelson

• An American contemporary

sculptor and photographer.

• “Father of Tensegrity”

• Studied with Buckminster Fuller

• His sculptural works are

arranged according to the idea

of 'tensegrity'.

• Snelson prefers the descriptive

term floating compression.

10/20/2015

12

Tensegrity

Continuous Tension with Discontinuous Compression

Tensegrity

10/20/2015

13

Tensegrity

https://www.youtube.com/watch?v=8ajowL0T4bM

https://www.youtube.com/watch?v=N_sndY-

Aqvk&list=PL0A8DB4B74B8DAF44

https://www.youtube.com/watch?v=KE0wGpigCBE

Stephen Levin Tom Flemons

Tensegrity

10/20/2015

14

Tensegrity

• Donald E. Ingber

Tensegrity

• Tensegrity and the human body?

10/20/2015

15

Tensegrity

• “It is possible that fully triangulated

tensegrity structures may have been

selected through evolution because of their

structural efficiency and their high

mechanical strength using a minimum of

materials.”

The architecture of life. Scientific American 1998; January: 48-57

Anatomy Trains

• Thomas W. Myers – Anatomy Trains

• Myofascial Meridians for Manual and Movement

Therapies

10/20/2015

16

Anatomy Trains

• Tensegrity and Fascia

• https://www.youtube.com/watch?v=BzgxYpDyO0M

Myers Video on what is fascia

• https://www.youtube.com/watch?v=wL1ZVarr1R8

Myers are you ageing or just drying out

• https://www.youtube.com/watch?v=-uzQMn87Hg0

Myers on the fascial system

Anatomy Trains

• The Arm Lines

10/20/2015

17

Anatomy Trains

• The Arm Lines

• Scapular positional dysfunction

• Cardinal & Spiral & Deep Front Lines

Anatomy Trains

• Deep Front Arm Line

• Pectoralis minor

• Clavipectoral fascia

• Biceps brachii

• Radial periosteum

• Radial collateral ligaments

• Thenar muscles

10/20/2015

18

Anatomy Trains

• Superficial Front Arm Line

• Pectoralis major

• Latissimus dorsi

• Medial intermuscular septum

• Flexor group

• Carpal tunnel

Anatomy Trains

• DFAL stretch & SFAL stretchhttps://www.youtube.com/watch?v=eNCCrCSuW24

10/20/2015

19

Anatomy Trains

• Deep Back Arm Line

• Rhomboids

• Levator scapulae

• Rotator cuff

• Triceps brachii

• Ulnar periosteum

• Ulnar collateral ligaments

• Hypothenar muscles

Anatomy Trains

• Superficial Back Arm Line

• Trapezius

• Deltoid

• Lateral intermuscular septum

• Divides flexors and extensors

• Extensors

10/20/2015

20

Anatomy Trains

• DBAL stretch & SBAL stretchhttps://www.youtube.com/watch?v=GJdwm3QWrw4

Anatomy Trains• Scapular position and postural balance

Scapular X• Rhoboid – Serattus

• Trapezius – Pec. Minor

10/20/2015

21

Tensegrity / Anatomy Trains

Muscle vs Movement

vs

10/20/2015

22

Muscle vs Movement

• Reductionism

• Examining things by breaking them

down into smaller and smaller parts to

examine each parts role

• Aristotle

• Isaac Newton

• Complex system is nothing but the

sum of its parts.

• Goniometric angles

• Force vectors

• This typically creates one perspective

while destroying another

Muscle vs Movement

• Gestaltism

• Kurt Koffka - The whole is other

than the sum of the parts. The

whole has an independent

existence.

• Myers Anatomy Trains: What can

we learn from looking at

synergetic relationships –

stringing our parts together rather

than dissecting them further

10/20/2015

23

Muscle vs Movement

• Is there such a thing as organic exercise?

• Just as bodies are destroyed by dissection, movement

patterns are destroyed by reductionism.

Muscle vs Movement

• Orchestrated Movement

• The brain thinks in terms of whole

motions not individual muscles”

- Irwin M. Korr

10/20/2015

24

Joint-by-Joint Approach

• Fingers - Stable

• Wrist - Mobile

• Elbow - Stable

• Glenohumeral / Shoulder - Mobile

• Scapulothoracic - Stable

• Subcranial - Mobile

• Cervical Spine - Stable

• Thoracic Spine - Mobile

• Pelvis/Sacrum/Lumbar Spine - Stable

• Hip - Mobile

• Knee - Stable

• Ankle - Mobile

• Foot - Stable

Gray Cook & Michael Boyle’s joint-by-joint approach

Concept by: Michael Boyle & Gray Cook



• Wrist - Mobile

• Elbow - Stable







• Hip - Mobile

• Knee - Stable

• Ankle - Mobile

• Foot - Stable


Concept by: Michael Boyle & Gray Cook

10/20/2015

25



• Wrist - Mobile

• Elbow - Stable







• Hip - Mobile

• Knee - Stable

• Ankle - Mobile

• Foot - Stable



10/20/2015

26

The Performance Pyramid

Functional Movement System-Gray Cook

• It is important to understand:

• The distinct difference between stability and strength.

• Need to establish proper movement prior to

conditioning.

10/20/2015

27

Shoulder Impingement

• Most frequent cause of shoulder pain

• Diagnosis waste basket for the expert

• Voplin G, Stahl S, Stien H. Impingement syndrome following direct injuries of the shoulder joint. Harefuah 1996; 130:244-7;295

• Michner LA, McClure PW, Karduna AW. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clin blomech;18369-79


• Causes:

• Anatomy

• Acromion Types - Direction & Length - Shape - Thickness -

Defect – Coracoid Slope

• Biomechanical

• Glenohumeral Joint Instability

• Diablo effect

• Scapulothoracic Instability

• Scapular Positioning

• Resting

• Dynamic

10/20/2015

28


• Causes:

• Anatomy



• Biomechanical


• Diablo effect



• Resting

• Dynamic


• Causes:

• Anatomy

• Acromion Types

10/20/2015

29


• Causes:

• Anatomy

• Acromion Direction & Length

• Edelson JG, Taitz C. J Anatomy of the coraco-acromial arch. Relation

to degeneration of the acromion. Bone Joint Surg Br. 1992

Jul;74(4):589-94.

• http://www.sciencedirect.com/science/article/pii/S0002934305000847


• Causes:

• Anatomy




Jul;74(4):589-94.

10/20/2015

30


• Causes:

• Anatomy




Jul;74(4):589-94.


• Causes:

• Anatomy

• Acromion Shape



Jul;74(4):589-94.

10/20/2015

31


• Causes:

• Anatomy

• Acromion Thickness



Jul;74(4):589-94.


• Causes:

• Anatomy

• Acromion Defect

– (Os Acromiale)

• Fail of fusion

• Fibrocartilaginous

• Degeneration - RCT

• 8% of population

• Blacks / Males• Wright RW et al. Arthroscopic decompression for impingement syndrome secondary to an

unstable os acromiale. J Arth Rel Surg 2000; 16;595-9

• Swain RA, Wilson FD, Harsha DM. The os acromiale: another cause of impingement. Med

Sci Sports Ex 1996;28:1459-62

• Kurtz CA, Humble BJ, Rodosky MW, Sekiya JK. Symptomatic os acromiale. J Acad Orthop

Surg 2006;14(1):12-19

10/20/2015

32


• Causes:

• Anatomy

• Acromion Defect

(Os Acromiale)

• X-ray / MRI

• Non-operative 6 mo

• SAD

• Excision (<3cm)

• ORIF - autograft - PT• Mudge MK, Wood YE, Frykman GK. Rotator cufftears associated with Os acromiale. J Bone

Joint Surg [Am] 1984; 66-A :427-9.

• Youm T, Hommen JP, Ong BC, Chen AL, Shin C.Am J Orthop (Belle Mead NJ). 2005

Jun;34(6):277-83. Os acromiale: evaluation and treatment.

• Edelson JG, Taitz C. J Anatomy of the coraco-acromial arch. Relation to degeneration of

the acromion. Bone Joint Surg Br. 1992 Jul;74(4):589-94.


• Causes:

• Anatomy

• Coracoid Slope



Jul;74(4):589-94.

10/20/2015

33


• Causes:

• Anatomy



• Biomechanical


• Diablo effect



• Resting

• Dynamic


• Causes:

• Biomechanical


– �� Acromio-humeral space = �� pressure

– In many cases, the primary diagnosis is subtle glenohumeral

instability even though impingement and subacromial bursitis

are evident.

• Bigliani LU, Levine WN, Current concepts review subacromial impingement

syndrome. J Bone Joint Surg 1997; 79A:1854-67

10/20/2015

34


• Causes:

• Biomechanical

• Diablo effect

– Above 30 degrees elevation

– Posterior capsule tightness prevents

inferior transition

– Change in Acromio-humeral interval

– Superior migration of the humeral head


• Sizer PS, Phelps V, Gilbert K.Diagnosis and Management of the Painful Shoulder. Part 1:

Clinical Anatomy and Pathomechanics. Pain Practice 2003 3(1) 39–57

• Warner JJ. Patterns of flexibility, laxity, and strength in normal shoulders and shoulders

with instability and impingement. Am J Sports Med 1990 8(4): 366-75

• Flatow El, Soslowsky LJ, Ticker JB, Pawluk RJ, Helper M, Ark J, Mow VC, Bigliani LU.

Excursion of the rotator cuff under the acromion. Patterns of subacromial contact. Am J

Sports Med 1994; 22:779-88


• Causes:• Biomechanical

• ScapulothoracicInstability

– Serratus & Middle trap Dysfunction

– �� scap upward rot. And �� scap IR.


• Morais Faria CD, Teixeira-Salmela LF, de Paula Goulart FR, de Souza Moraes GF. Scapular muscular activity with shoulder impingement syndrome during lowering of the arms. Clin J Sport Med. 2008; 18(2):130-6

• Struyf F, Nijs J, Baeyens JP, Mottram S, Meeusen R. Scapular positioning and movement in unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability. Scand J Med Sci Sports. 2011 Jun;21(3):352-8.

10/20/2015

35


• Causes:

• Anatomy



• Biomechanical


• Diablo effect



• Resting

• Dynamic


• Causes:


• Resting

• Struyf F, Nijs J, Baeyens JP, Mottram S, Meeusen R. Scapular positioning and movement in

unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability.

Scand J Med Sci Sports. 2011 Jun;21(3):352-8.

Picture: mikereinold.com

10/20/2015

36


• Causes:


• Dynamic

• Struyf F, Nijs J, Baeyens JP, Mottram S, Meeusen R. Scapular positioning and movement

in unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability.

Scand J Med Sci Sports. 2011 Jun;21(3):352-8.



• Causes

• Static vs Dynamic Scapular Positioning

• Resting position ≠ poor movement patterns

• Unable to identify shoulder injuries

• Alexis AW, Craig AW, Mason F, Lori AM, Eric JH. Diagnostic accuracy of scapular physical examination

tests for shoulder disorders: a systematic review. Br J Sports Med2013;47:886-892 doi:10.1136/bjsports-

2012-091573

• Struyf F, Nijs J, Meeus M, Roussel NA, Mottram S, Truijen S, Meeusen R. Does scapular positioning

predict shoulder pain in recreational overhead athletes? Int J Sports Med. 2014 Jan;35(1):75-82.

10/20/2015

37

• Causes

• Purpose to compare:

• 3-dimensional scapular kinematics

• Shoulder range of motion

• Shoulder muscle force

• Posture in subjects with and without primary shoulder

impingement syndrome.

• Conclusion: Kinematic differences may represent

compensatory strategies for GH weakness or loss of ROM

• Philip WM, Lori AM, Andrew RK. Shoulder Function and 3-Dimensional Scapular Kinematics in

People With and Without Shoulder Impingement Syndrome. Phys Ther. 2006 Aug;86(8):1075-90.



• Causes• Scapular Dyskinesis Test (SDTs)

• Winging or dysrythmia• Med. Inf. border winging

• Lack of smoother mvt. early scap elevation or shrugging during flex.

• Rapid downward rot. with arm lowering from flexion

• Uhl TL, Kibler WB, Gecewich B, et al. Evaluation of clinical assessment methods for scapular dyskinesis. Arthroscopy 2009;25:1240–8.

• Philip M, Angela RT, Stephen K, Dominic I, Erica Z. A Clinical Method for Identifying Scapular Dyskinesis, Part 1: Reliability. J Athl Train. 2009 Mar-Apr; 44(2): 160–164.

• Angela RT, Philip M, Stephen K, Dominic I, Mary FB. A Clinical Method for Identifying Scapular Dyskinesis, Part 2: Validity. J Athl Train. 2009 Mar-Apr; 44(2): 165–173.

10/20/2015

38


• Causes

• Scapular Stability

• Clinical Implications of Scapular Dyskinesis in

Shoulder Injury. The 2013 Consensus Statement

From the 'Scapular Summit'

• W Ben Kibler; Paula M Ludewig; Phil W McClure; Lori A

Michener; Klaus Bak; Aaron D Sciascia. Br J Sports Med.

2013;47(14):877-885.


• Causes

• Scapular Stability

• Clinical Implications of Scapular Dyskinesis in

Shoulder Injury. The 2013 Consensus Statement

From the 'Scapular Summit'

• W Ben Kibler; Paula M Ludewig; Phil W McClure; Lori A

Michener; Klaus Bak; Aaron D Sciascia. Br J Sports Med.

2013;47(14):877-885.

10/20/2015

39


• Causes:

• Anatomy



• Biomechanical


• Diablo effect



• Resting

• Dynamic


• Classifications/Testing

• External GH impingement

• Subacromial

– SAD Bursa, SSP, ISP, LHB

• Subcoracoid

– SC Bursa, SSC, LHB

• Internal GH impingement– SSP, ISP

10/20/2015

40




• Subacromial


• Panni AS, Milano G, Lucania L, Fabbriciani C, Logroscino CA. Histological analysis of the

coracoacromial arch: correlation between age-related changes and rotator cuff tears.

Arthroscopy. 1996 Oct;12(5):531-40.




• Subacromial


Neer test Hawkins testPassive Elevation 90 ABD with IR

Pictures: mikereinold.com

10/20/2015

41


• Classifications/Testing• External GH impingement

• Subcoracoid


• Gerber C, Terrier F, Ganz R. The role of the coracoid process in the chronic impingement syndrome. J Bone Joint Surg 1985, 67B, 703-8

• Goldthwait JE. An anatomic and mechanical study of the shoulder joint, explaining many of the cases of painful shoulder, many of the recurrent dislocations and many of the cases of brachial neuralgias or neuritis. Am JOrthop Surg l909;6(4):579-606.




• Subcoracoid


• Okoro T, Reddy VRM, Ashvin P. Coracoid impingement syndrome: a literature review.

Curr Rev Musculoskelet Med. 2009 Mar; 2(1): 51–55.

10/20/2015

42




• Subcoracoid


Coracoid Impingement Sign

– 90 ABD, Horiz ADD, Max IR





• Panni AS, Milano G, Lucania L, Fabbriciani C, Logroscino CA. Histological analysis of the

coracoacromial arch: correlation between age-related changes and rotator cuff tears.

Arthroscopy. 1996 Oct;12(5):531-40.


10/20/2015

43


• Classifications/Testing• Internal GH impingement

– SSP, ISP

Internal Resisted Strength Test (IRRST)

• Zaslav KR. Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. J Shoulder Elbow Surg. 2001 Jan-Feb;10(1):23-7.




• Subacromial


• Subcoracoid



10/20/2015

44


• Presentation


• Subacromial


• Subcoracoid




• Presentation


• Subacromial


– Painful arc 80-130 degrees

– Pain anterior and lateral shoulder

– Limited IR likely

10/20/2015

45


• Presentation


• Subcoracoid


– Pain anterior shoulder

– Painful arc of motion

– Pain &limitation with horizontal adduction

– Pain with internal rotation

– Limited IR Possible


• Presentation


– Pain end ranges of motion

– Pain with ABD and ER

– Limited IR possible

10/20/2015

46


• Presentation


• Subacromial


• Subcoracoid




• Treatment

• Anatomy Trains

https://www.anatomytrains.com/wp-content/uploads/2012/09/bodyreading1.pdf

10/20/2015

47


• Treatment

• Scapular X


• Treatment

• Functional Lines

https://www.anatomytrains.com/wp-content/uploads/2012/09/bodyreading1.pdf

10/20/2015

48


• Treatment

• Manual Therapy

• Results: Both groups experienced significant decreases in

pain and increases in function. Significantly more

improvement in the manual therapy group compared to the

exercise group.

• Michael D.B, Gail D.D. Comparison of Supervised Exercise With and Without Manual Physical

Therapy for Patients With Shoulder Impingement Syndrome. Journal of Orthopaedic & Sports

Physical Therapy, 2000; 30: 126-137


• Treatment

• Manual Therapy

• 21 studies

• Conclusion: Small affect for reduction of pain

• Ariel DC, Jean-SR, Clermont ED, Pierre F, Joy CM, François D. The Efficacy of Manual Therapy

for Rotator Cuff Tendinopathy: A Systematic Review and Meta-analysis. J Orthop Sports Phys

Ther 2015;45(5):330-350.

10/20/2015

49


• Treatment

• Manual Therapy

• RESULTS: Both groups 50% improvement Pain & Disability

Index scores maintained through 1 year

• CSI > SIS-related Dr. visits (60% vs. 37%) & required

additional steroid injections (38% vs. 20%), and 19% needed

physical therapy.

• Rhon DI, Boyles RB, Cleland JA. One-year outcome of subacromial corticosteroid

injection compared with manual physical therapy for the management of the unilateral

shoulder impingement syndrome: a pragmatic randomized trial. Ann Intern Med.

2014 Aug 5;161(3):161-9.


• Treatment

• Posterior capsule stretching

• 60 overhead athletes with GIRD; 30

with pain, 30 without

• Angular or non-angular stretching

groups

• 3x/week x 3 weeks

• Significant improvement in ROM,

pain, and Modified Rowe Scores

• Ann MC, Fredrik RJ, Barbara C, Dirk CC, Erik EW. Stretching the

Posterior Shoulder Structures in Subjects with Internal Rotation

Deficit: Comparison of Two Stretching Techniques. Shoulder &

Elbow January 2012 vol. 4 no. 1 56-63

10/20/2015

50


• Treatment

• Significant increase in IR, Horiz Add and AHD

• Annelies M, Valerie VE, Lieselot VD, Aagje V, Ann C. Quantifying Acromiohumeral Distance in

Overhead Athletes With Glenohumeral Internal Rotation Loss and the Influence of a Stretching

Program. Am J Sports Med September 2012 vol. 40 no. 9 2105-2112


• Treatment

• External Impingement

• Group 1: AROM, Stretching, strengthening cuff, rhomboids,

levator and serratus HEP x 7/week 10-15 min

• Group 2: Joint & STM, ice, stretching and strengthening

exercises and patient education in clinic 3x/week for 4

weeks.

• Both improved, Group 2 > Group 1

• Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual

physical therapy for patients with shoulder impingement syndrome: a prospective, randomized

clinical trial. Knee Surgery, Sports Traumatology, Arthroscopy. July 2007, Volume 15, Issue 7, pp

915-921

10/20/2015

51


• Treatment

• Thoracic Manipulation

• Conclusion: Shoulder pain in individuals with SIS

immediately decreased after a TSM. The observed changes

in scapular kinematics following TSM were not considered

clinically important.

• Haik MN, Alburquerque-Sendín F, Silva CZ, Siqueira-Junior AL, Ribeiro IL, Camargo PR. Scapular

Kinematics Pre– and Post–Thoracic Thrust Manipulation in Individuals With and Without Shoulder

Impingement Symptoms: A Randomized Controlled Study

Published: Journal of Orthopaedic & Sports Physical Therapy, 2014, Jul; 44(7): 475-487


• Treatment

• Thoracic Manipulation

• Conclusion: Overall, patient-reported outcomes improved in

both groups without meaningful changes to thoracic or

scapular motion.

• Kardouni JR, Pidcoe PE, Shaffer SW, Finucane SD, Cheatham SA, Sousa CO, Michener LA.

Thoracic Spine Manipulation in Individuals With Subacromial Impingement Syndrome Does Not

Immediately Alter Thoracic Spine Kinematics, Thoracic Excursion, or Scapular Kinematics: A

Randomized Controlled Trial. J Orthop Sports Phys Ther 2015;45(7):527-538.

10/20/2015

52

Thoracic Outlet Syndrome

• Defined • TOS represents a spectrum of disorders

encompassing four related syndromes: arterial compression, venous compression, neurogeniccompression, and a poorly defined pain syndrome. (Disputed/Nonspecific Neurogenic)

• TOS may be the most underrated, overlooked, and misdiagnosed, and the most important and difficult to manage peripheral nerve compression in the upper extremity.

• Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurgery Clinics of North America [2001, 12(2):295-309]


• Categories• Vascular

• Difficult to treat conservatively = Surgery

• Venus (5%-10%)

• Arterial (2%-5%)

• Neurogenic TOS• True Neurogenic (3.5%)

• Disputed/Nonspecific Neurogenic (85%-95%)

– Responds to conservative care• Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J.

2012; 39(6): 842–843

• Sanders, RJ, Hammond SL, Rao NM. Thoracic Outlet Syndrome: A Review Neurologist: November 2008 - Volume 14 - Issue 6 - pp 365-373

• Likes K, Rochlin DH, Salditch Q, T Dapash T, Baker Y, DeGuzman R, Selvarajah S, Freischlag JA. Diagnostic Accuracy of Physician and Self-referred Patients for Thoracic Outlet Syndrome Is Excellent. Annals of Vascular Surgery. Volume 28, Issue 5, July 2014, Pages 1100–1105

10/20/2015

53


• 4 Passages

• Narrow

• Dynamic with movement

• Anterior Triangle

• Posterior Triangle

• Costoclavicular

• Thoraco-coraco-pectoral


• 4 Passages

• Narrow

• Dynamic with movement

• Anterior Triangle

• Posterior Triangle

• Costoclavicular

• Thoraco-coraco-pectoral

10/20/2015

54


• Ant. Triangle• SCM – Ant. Scalene – 1st Rib

• Post Triangle• Ant. Scalene – Middle Scalene – 1st Rib

• Costo-Clavicular• Dorsal: Scap. & Subscapularis

• Ventral: Clavicle, subclavius mm, fascia

• Caudal: 1st rib, upper seratus

• Cranial: Clavicle

• Thoraco-Coraco-Pectoral• Ventral: Pectoralis minor

• Medial: Thoracic wall

• Cranial / Lateral: Coracoid process


• Vascular TOS• Subclavian artery or vein

• Young athletic

• Vigorous overhead activities

• Mackinnon SE, Novak CB. Thoracic outlet syndrome. Curr Probl Surg. 2002 Nov. 39(11):1070-145.

• Hood DB, Kuehne J, Yellin AE, Weaver FA. Vascular complications of thoracic outlet syndrome. Am Surg. 1997 Oct. 63(10):913-7

10/20/2015

55


• Vascular TOS• Arterial

• Subclavian artery compression (scalene triangle)

• Pectoralis minor tendon

• Color changes

• Claudication

• Arm & hand pain

• Mild ache & fatigue


• Duwayri YM, Emery VB, Driskill MR, Earley JA, Wright RW, Paletta GA Jr, Thompson RW. Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete. J Vasc Surg 2011;53(5):1329–40


• Vascular TOS• Veinious

• Subclavian Vein compression

– Clavicle - costoclavicular ligament

– First rib - subclavius muscle

• Swelling

• Venous distention

• Cyanotic discoloration

• Arm and hand pain• Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J.

2012; 39(6): 842–843.

• Thompson RW. Comprehensive management of subclavian vein effort thrombosis. SeminIntervent Radiol 2012;29(1): 44–51.


• Hood DB, Kuehne J, Yellin AE, Weaver FA. Vascular complications of thoracic outlet syndrome. Am Surg. 1997 Oct. 63(10):913-7

10/20/2015

56


• Neurogenic TOS

• Young healthy individuals

• Heavy lifting

• Repetitive overhead use of the upper extremities

• Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J.

2012; 39(6): 842–843.


• Neurogenic TOS

• Symptoms (neck, upper back, shoulder, arm, hand)

• Pain

• Numbness

• Paresthesia

• Variable & dynamic

• Positional exacerbation during arm elevation

• Tenderness over the supraclavicular or subcoracoid space

• + Special tests (EAST/ROOS, etc)

• Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J.

2012; 39(6): 842–843.

10/20/2015

57


• Neurogenic TOS• Characterized by compression and irritation of the

brachial plexus nerve roots (C5 to T1).• Typically within the scalene triangle at the level of the first rib

• Subcoracoid space underneath pec. minor muscle tendon

• Neurogenic TOS

– Congenital variations in anatomy

» Anomalous scalene musculature

» Aberrant fascial bands

» Cervical ribs

– Coupled with injury that has resulted in scalene muscle spasm, fibrosis, or other pathologic changes

• Thompson RW, Driskill M. Thoracic outlet syndrome: neurogenic. In: Cronenwett JL, Johnston KW, editors. Rutherford's vascular surgery. 7th ed. Philadelphia: Elsevier; 2010. p. 1878–98

• Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J. 2012; 39(6): 842–843.


• Neurogenic TOS• True Neurogenic = rare

• Overhead activities

• Intrinsic muscle atrophy in hand

– Gilliatt-Sumner hand

• Weakness in hand

• Pain

• Possible sensory loss Ulnar distribution

• Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery. 2004 Oct. 55(4):897-902; discussion 902-3

10/20/2015

58


• Neurogenic TOS

• Disputed/Nonspecific Neurogenic = Majority of TOS

• Unexplained pain

• Trauma related

• Weakness

• Decreased sensation

• Difficult to quantify

• Roos DB. Thoracic outlet syndrome is underdiagnosed. Muscle Nerve. 1999 Jan. 22(1):126-9;

discussion 137-8.

• Wilbourn AJ. Thoracic outlet syndrome is overdiagnosed. Muscle Nerve. 1999 Jan. 22(1):130-6;

discussion 136-7.


• Causes

• Bony factors

• Anatomic abnomalaities

– Cervical ribs

– Hypoplastic first thoracic ribs

– Exostoses of the first rib or clavicle

• Mackinnon SE, Novak CB. Thoracic outlet syndrome. Curr Probl Surg. 2002 Nov.

39(11):1070-145.

• Rayan GM. Lower trunk brachial plexus compression neuropathy due to cervical rib in

young athletes. Am J Sports Med. 1988 Jan-Feb. 16(1):77-9.

• Roos DB. Congenital anomalies associated with thoracic outlet syndrome. Anatomy,

symptoms, diagnosis, and treatment. Am J Surg. 1976 Dec. 132(6):771-8.

10/20/2015

59


• Causes

• Soft tissue factors

• Anomalous fibrous muscular bands near plexus

• Hypertrophic muscles

• Space occupying lesions (tumors, cycts)

• Inflammation in soft tissues

• Roos DB. Congenital anomalies associated with thoracic outlet syndrome. Anatomy,

symptoms, diagnosis, and treatment. Am J Surg. 1976 Dec. 132(6):771-8.

• Esposito MD, Arrington JA, Blackshear MN, Murtagh FR, Silbiger ML. Thoracic outlet

syndrome in a throwing athlete diagnosed with MRI and MRA. J Magn Reson Imaging.

1997 May-Jun. 7(3):598-9.


• Causes

• Other

• Trauma

• Combination (trauma and anatomy)

• Post-trauma

– Hematoma

– MO

– Scar formation

– Weakness and poor posturing

– Clavicle fracture

• Fujita K, Matsuda K, Sakai Y, Sakai H, Mizuno K. Late thoracic outlet syndrome secondary to

malunion of the fractured clavicle: case report and review of the literature. J Trauma. 2001 Feb.

50(2):332-5.

• Al-Shekhlee A, Katirji B. Spinal accessory neuropathy, droopy shoulder, and thoracic outlet

syndrome. Muscle Nerve. 2003 Sep. 28(3):383-5.

10/20/2015

60


• Vascular TOS Diagnosing

• Venous TOS

• Venography

• Swelling in the arm

• Prominent veins at sight of oclusion

• Artierial TOS

• Pulse volume recordings or arteriography

• Deminished pulse

• Pale color changes


• Neurogenic TOS Clinical Diagnosing

• Clinical Prediction Rule:

• 3 of 4 of the following symptoms:

• Aggravation with arm in elevated position.

• Paraesthesia originating from C8/T1.

• Supraclavicular tenderness over brachial plexus.

• Positive EAST/Roos test.

• Lindgren KA. Conservative treatment of thoracic outlet syndrome: a 2-year follow-up.

Archives of physical medicine and rehabilitation, (1997). 78(4), 373-378.

10/20/2015

61


• Neurogenic TOS Clinical Diagnosis

• History & Physical exam

• Positive provocation testing of 2 of 3 tests

• Elevated arm stress test (EAST/ROOS)

• Cyriax Release Test

• Palpation of supraclavicular fossa

Mobility Tests

• First rip spring test

• Cervical rotation lateral flexion (CRLF)/Lindgren

• Rayan GM. Thoracic outlet syndrome. J Shoulder Elbow Surg. 1998 Jul-Aug;7(4):440-51.


• Neurogenic TOS Clinical Diagnosis• Patients should have at least three of the following

four symptoms or signs:• History of aggravation of symptoms with the arm in an

elevated position

• History of parasthesia originating from the spinal segments C8/T1

• Supraclavicular tenderness over the brachial plexus

• Positive hands up abduction/external rotation or stress test (EAST/ROOS)

• LA Watson, Manual Therapy 14 December 2009: 586-595

10/20/2015

62



• Neurogenic

• Testing

– X-Ray & MRI for anomalies - EMG

– Anterior scalene block - NCV

– Pressure over scalene and supraclavicular fossa

• Le Forestier N, Moulonguet A, Maisonobe T, Léger JM, Bouche P. True neurogenic thoracic outlet

syndrome: electrophysiological diagnosis in six cases. Muscle Nerve. 1998 Sep;21(9):1129-34.

• Sanders RJ, Hammond S.L., Rao NM, Thoracic OutletSyndrome. A Review. The Neurologist,

2008. 14(6): p. 365–373.

• Torriani, M., R. Gupta, and D.M. Donahue, Sonographically guided anesthetic injection of anterior

scalene muscle for investigation of neurogenic thoracic outlet syndrome. SkeletalRadiol, 2009.

38(11): p. 1083–7.

• Jordan SE, Machleder HI., Diagnosis of thoracic outlet syndrome using electrophysiologically

guided anterior scalene blocks. Ann Vasc Surg, 1998. 12: p. 260–4.


• Neurogenic TOS Clinical Diagnosing• Variability of the structures involved

• Multiple provocative maneuvers aid in diagnosis • Adson maneuver

• Wright test

• Roos stress test

• High rates of false-positive and false-negative results.

• Diagnosis of exclusion • Emery VB, Rastogi R, Driskill MR, Thompson RW. Diagnosis of neurogenic thoracic outlet

syndrome. In: Eskandari MK, Morasch MD, Pearce WH, Yao JST, editors. Vascular surgery: therapeutic strategies. Shelton (CT): People's Medical Publishing House-USA; 2010. p. 129–48

• Safran MR. Nerve injury about the shoulder in athletes. Part 2: long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med. 2004 Jun. 32(4):1063-76.

• Mackinnon SE, Novak CB. Thoracic outlet syndrome. Curr Probl Surg. 2002 Nov. 39(11):1070-

145.

10/20/2015

63



Adson’s Maneuver

• ABD & EXT

• Neck EXT & ROT toward

• Inhalation

• Palpate radial pulse

• + = Pulse diminishes or

parasthesias & no S&S on

contralateral side


• Neurogenic TOS Clinical DiagnosingWright test

• Progressive Hyper-ABD

• Palpate pulse

• + = Pulse diminishes or

parasthesias

• Safran MR. Nerve injury about the shoulder in athletes. Part 2: long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med. 2004 Jun. 32(4):1063-76

10/20/2015

64


• Neurogenic TOS Clinical DiagnosingEAST/ROOS test

• 90 deg. ABD

& 90 deg. ER with

elbows at 90 deg.

• Open & close hands

3 min.

• + = reproduction of

symptoms or a

sensation of heaviness/fatigue• Safran MR. Nerve injury about the shoulder in athletes. Part 2: long thoracic nerve, spinal

accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med. 2004 Jun. 32(4):1063-76


• Neurogenic TOS Clinical Diagnosis

• Multiple points of compression may be present

• TOS

• Cubital tunnel

• Carple tunnel

• “Double rush” or “Multiple crush”

• Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer, PS. Thoracic outlet syndrome: a

controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. J Man Manip

Ther. 2010 Jun; 18(2): 74–83.

• Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973 Aug 18.

2(7825):359-62.

• Urschel HC Jr, Razzuk MA. Neurovascular compression in the thoracic outlet: changing

management over 50 years. Ann Surg. 1998 Oct. 228(4):609-17.

10/20/2015

65


• Differential Diagnosis: • VTOS as a stand-alone issue or in conjunction with

neurological compromise.

• Shoulder Pathology

• Pathologic Lesion (tumor/cyst/infection)

• Cervical Radiculopathy

• Brachial Plexus Neuritis / Injury

• Postural Palsy

• Raynaud Disease

• Ulnar Nerve Compression (at the elbow)

• Overuse

• Peripheral nerve entrapment

• T4 Syndrome


• Treatment • Muscle Relaxants

• Anti-inflammatories

• Adjustments in ergonomics

• Surgery• Scalenectomy

• Brachial plexus neurolysis

• First rib resection

• Physical Therapy

• Caputo FJ, Wittenberg AM, Vemuri C, Emery VB, Thompson RW. Supraclaviculardecompression for neurogenic thoracic outlet syndrome (NTOS) in pediatric and adult populations: differential patient characteristics and clinical outcomes [abstract].

10/20/2015

66


• Treatment

• Goals of Intervention

• Decrease Pain

• Restore ROM

– Joint mobility

– Soft tissue mobility

• Restore Strength

• Improve Posture

• Enhanced / Normalized Breathing

• Improve Body Mechanics

• Avoid Re-injury


10/20/2015

67


• Treatment

• Restore normal function cervical and thoracic spine

• Measures

• Return to work, normalization of motion in C&T spine,

subjective satisfaction with outcome

• 88% satisfied with outcome

• CT spine motion restored in 80%

• 73% return to work

• 88% follow through with HEP post discharge

• 2 year follow up• Lindgren, K.-A. (1997). Conservative treatment of thoracic outlet syndrome: a 2-year follow-up.

Archives of physical medicine and rehabilitation, 78(4), 373-378.


• Anatomy TrainsS

10/20/2015

68

Peripheral Nerve Entrapment

• Median nerve

• Carpal Tunnel

• Ulnar nerve

• Cubital Tunnel

Median Nerve Entrapment

• Carpal tunnel syndrome (CTS)

• Symptoms and signs that occurs following

compression of the median nerve within the carpal

tunnel.

• Numbness, paresthesias, and pain in the median nerve

distribution.

• May not be accompanied by objective changes in sensation

and strength of median-innervated structures in the hand.

Median n. distribution

10/20/2015

69


• Median nerve

• Demyelination followed by axonal degeneration.

• Sensory fibers often are affected first, followed by

motor fibers.

• Autonomic nerve fibers may be affected.


• Cause = debatableS.

• Likely = high pressures in carpal tunnel.

• Ischemia in the nerve

– Obstruction to venous outflow, back pressure, & edema

formation.

10/20/2015

70


• Risk factors• Genetic, medical, social, vocational, avocational, and

demographic.• � Aerobic fitness

• � BMI

• A complex interaction of the above

• Finger ext in relaxed UE = 11% �median nerve

• Arms in from (keyboard) significant

strain on median nerve• TW Wright, F Glowczewskie, D Wheeler, G Miller, D Cowin. Excursion and Strain of the Median

Nerve. J of Bone Joint Surg. 1996; 78A: 1897-1903

• de Krom MC, Kester AD, Knipschild PG, et al. Risk factors for carpal tunnel syndrome. Am J Epidemiol. 1990 Dec. 132(6):1102-10.


• Motor examination

• Wasting and weakness of the median-innervated

hand muscles (LOAF muscles) may be detectable.

• L - First and second lumbricals

• O - Opponens pollicis

• A - Abductor pollicis brevis

• F - Flexor pollicis brevis

10/20/2015

71


• Special Tests

• No great clinical test exists to support the diagnosis of

CTS.

• Hoffmann-Tinel sign

• Gentle tapping over the median nerve in the carpal tunnel

region elicits tingling in the nerve's distribution.

• Low sensitivity and specificity.


• Special Tests

• Phalen sign

• Tingling in the median nerve distribution is induced by full

flexion (or full extension for reverse Phalen) of the wrists for

up to 60 seconds

• This test has 80% specificity but lower sensitivity.

10/20/2015

72


• Special Tests

• The carpal compression test

• Firm pressure directly over the carpal tunnel for up to 30

seconds to reproduce symptoms.

• Sensitivity of up to 89% and a specificity of 96%.


• Special Tests

• Palpatory diagnosis

• Examining the soft tissues directly overlying the median

nerve at the wrist for mechanical restriction.

• Sensitivity of over 90% and a specificity of 75% or greater.

10/20/2015

73


• Special Tests

• The square wrist sign

• The ratio of the wrist thickness to the wrist width is greater

than 0.7.

• Modest sensitivity/specificity of 70%.


• Electrophysiologic studies

• Electromyography (EMG)

• Nerve conductions studies (NCS)

• Abnormalities on electrophysiologic testing, in association

with specific symptoms and signs, are considered the

criterion standard for CTS diagnosis.

10/20/2015

74


• Treatment

• Aerobic conditioning

• Due to relation with � Aerobic fitness & � BMI

• Modalities (in particular therapeutic ultrasound) may

provide short-term relief in some patients.

• Night wrist splints - neutral or slight extension (to be

worn at nighttime for a minimum of 3-4 wk)• Banta CA. A prospective, nonrandomized study of iontophoresis, wrist splinting, and

antiinflammatory medication in the treatment of early-mild carpal tunnel syndrome. J Occup Med.

1994 Feb. 36(2):166-8.

• Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Therapeutic ultrasound for carpal tunnel

syndrome. Cochrane Database Syst Rev. 2012 Jan 18. 1:CD009601.

• O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection)

for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003. CD003219.

• Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane

Database Syst Rev. 2012 Jul 11. 7:CD010003.


• TreatmentS


• Pectoralis major

• Latissimus dorsi

• Medial intermuscular septum

• Flexor group

• Carpal tunnel

10/20/2015

75


• Steroid injection

• long-term benefit and can be tried if more

conservative treatments have failed

• Surgery

• Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome.

Cochrane Database Syst Rev. 2007. (2):CD001554e treatments have failed.

Ulnar Nerve Entrapment

• Ulnar nerve entrapment:

• Second most common entrapment neuropathy in the

upper extremity (after entrapment of the median

nerve)

• Aguiar PH, Bor-Seng-Shu E, Gomes-Pinto F, Almeida- Leme RJ, Freitas AB, Martins RS, et

al. Surgical management of Guyon's canal syndrome, an ulnar nerve entrapment at the

wrist: report of two cases. Arq Neuropsiquiatr. 2001 Mar. 59(1):106-11.

• Spinner M, Spencer PS. Nerve compression lesions of the upper extremity. A clinical and

experimental review. Clin Orthop Relat Res. 1974 Oct. 46-67.

• FEINDEL W, STRATFORD J. The role of the cubital tunnel in tardy ulnar palsy. Can J Surg.

1958 Jul. 1(4):287-300.

10/20/2015

76


• Entrapment sites

• Most common = The elbow region (cubital tunnel or in

the ulnar groove)

• Second most likely = near the wrist (canal of Guyon)

• Forearm between these two regions, below the wrist

within the hand, or above the elbow.

• Campbell WW, Pridgeon RM, Riaz G, Astruc J, Sahni KS. Variations in anatomy of the ulnar nerve

at the cubital tunnel: pitfalls in the diagnosis of ulnar neuropathy at the elbow. Muscle Nerve. 1991

Aug. 14(8):733-8

• Aguiar PH, Bor-Seng-Shu E, Gomes-Pinto F, Almeida- Leme RJ, Freitas AB, Martins RS, et al.

Surgical management of Guyon's canal syndrome, an ulnar nerve entrapment at the wrist: report

of two cases. Arq Neuropsiquiatr. 2001 Mar. 59(1):106-11

• Elhassan B, Steinmann SP. Entrapment neuropathy of the ulnar nerve. J Am Acad Orthop Surg.

2007 Nov. 15(11):672-81


• Entrapment sites

10/20/2015

77


• Possible denervation and paralysis of

muscles

• Numbness and tingling along the little finger and the

ulnar half of the ring finger

• Weakness of grip / ocationally intrinsic wasting


• Treatment

• Nonsurgical therapy helpful in many cases of ulnar

neuropathy.

• If conservative therapy fails, surgical treatment is

warranted, typically involving one of the following

procedures

10/20/2015

78


• Treatment

• Nerve Glides (Brian Catinia)

https://www.youtube.com/watch?v=3LNekkvyVVY

https://www.youtube.com/watch?v=BB2x66cDV8M

Lateral Epicondylitis

• “tennis elbow” - Lateral epicondylitis

• Misnomer[

• microscopic evaluation of the tendons does not show signs of

inflammation

• The tendons are relatively hypovascular proximal to the

tendon insertion. This hypovascularity may predispose the

tendon to hypoxic tendon degeneration and has been

implicated in the etiology of tendinopathies.[2]

• Most typically, extensor carpi radialis brevis (ECRB) tendon• Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and

exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006

Nov 4. 333(7575):939. [Medline]. [Full Text].

• Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different

orthotic devices. Clin Rheumatol. 2008 Aug. 27(8):1015-9. [Medline].

• Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip

strength of patients with lateral epicondylosis. J Orthop Sports Phys Ther. 2009 Jun. 39(6):484-9.

10/20/2015

79


• Presentation

• 40 to 50 yo

• Insidious onset - history of overuse

• Symptom 24-72 hours after activity

• Probably due to microscopic tears in the tendon.

• Pain over the lateral elbow that worsens with activity

and improves with rest.

• May radiate down the posterior aspect of the forearm.

• Pinpoint pain just distal to the origin of the ECRB.

• Pain mild to severe


• Treatment• Watchful waiting

• At 52 weeks, inj worse than PT and watchful waiting

• PT > watchful waiting at 5 weeks, with only slight improvement at 52 weeks

• NSAID’s• May offer short term relief

• Corticosteroid injection• Effective short term, not long term

• Surgery

• Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol. 2006 Jun. 35(6):371-7. [Medline].

• Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE. Comparison of autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study. J Hand Surg Am. 2011 Aug. 36(8):1269-72.

• Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 Nov 4. 333(7575):939.

10/20/2015

80


• Treatment

• ASTYM

• Stretching


• Treatment

• Eccentric Loading

• Dumbbell

• Weighted ball

• FlexBar

10/20/2015

81


• Treatment

• Anatomy Trains

• Superficial Back Arm Line

• Shoulder ER’s

• Posturing

Medial Epicondylitis

• “Golfers Elbow” – Medial Epicondylitis

• Degenerative state instead of a traditional inflammatory

• epicondylosis

• Med. Epi. = Common origin of the forearm flexor and

pronator muscles

• Most common site of pathology is the interface between

the pronator teres and the flexor carpi radialis origins• Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and

findings of histological, immunohistochemical, and electron microscopy studies. J Bone

Joint Surg Am. 1999 Feb. 81(2):259-78.

• Ljung BO, Forsgren S, Fridén J. Substance P and calcitonin gene-related peptide

expression at the extensor carpi radialis brevis muscle origin: implications for the etiology

of tennis elbow. J Orthop Res. 1999 Jul. 17(4):554-9

• Nirschl RP. Prevention and treatment of elbow and shoulder injuries in the tennis player.

Clin Sports Med. 1988 Apr. 7(2):289-308.

• Nirshal RP. Muscle and tendon trauma: tennis elbow. The Elbow and Its Disorders.

Philadelphia, Pa: WB Saunders Co; 1993. 481-96.

10/20/2015

82


• Presentation• Aching pain over the medial elbow.

• Possible grip weakness.• Ulnar nerve symptoms are associated in up to 20% of

athletes with medial epicondylitis.

• Kohn HS. Prevention and treatment of elbow injuries in golf. Clin Sports Med. 1996 Jan. 15(1):65-83.


• Treatment

• NSAID’s

• Controversial

– Decrease inflam vs bleeding[

• RICE

• Bracing

• Counterforce – cock up

• Surgery

• Plancher KD, Halbrecht J, Lourie GM. Medial and lateral Thurston AJ. Conservative and surgical

treatment of tennis elbow: a study of outcome. Aust N Z J Surg. 1998 Aug. 68(8):568-72.

epicondylitis in the athlete. Clin Sports Med. 1996 Apr. 15(2):283-305.

10/20/2015

83


• Treatment

• ASTYM

• Stretching


• Treatment

• Eccentric Loading

• Dumbbell

• Weighted ball

• FlexBar

10/20/2015

84


• Treatment

• Anatomy Trains


• Shoulder ER’s

• Posturing

Thank youS

common dysfunctions within the upper extremity

Documents