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Upper Extremity Repetitive Use Injuries
© Jackson Orthopaedic Foundation www.jacksonortho.org
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Treating Common Injuries of Everyday Athletes at Work & Play A.J. Benham, DNP
www.jacksonortho.org
UE RSI’s
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I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting.
www.jacksonortho.org
Conflict of Interest
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• Identify likely UE RUIs by presentation & history • Perform a focused physical exam • Order & interpret diagnostic tests • Design & implement treatment plans • Generate complete & specific referrals
www.jacksonortho.org
OBJECTIVES
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17 y.o. female competitive swimmer R > L bilateral shoulder pain Athletic appearance No previous trauma or injury No significant co-morbidities Normal ROS
www.jacksonortho.org
Case Study #1
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• Onset • Location • Duration • Character • Aggravates/Alleviates • Radiation • Timing • Severity
• When did it start • Where is it • How long does it last • What does it feel like • ? makes worse/better • Where does it go • When does it happen • Scale of 1-10
www.jacksonortho.org
O.L.D. C.A.R.T.S.
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• Onset • Location • Duration • Character • Aggravates/Alleviates • Radiation • Timing • Severity
• Gradually over 3 mos. • Lateral shoulder • Constant • Dull, aching, burning • Swimming/rest • Trapezius, neck • Worst after practice • 4-7 depending on
activity www.jacksonortho.org
Subjective Complaints
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Shoulder Anatomy Animated Tutorial https://www.youtube.com/watch?v=D3GVKjeY1FM
www.jacksonortho.org
Anatomy Review #1
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A
www.jacksonortho.org
Shoulder Anatomy
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• Inspection • Palpation • Range of Motion • Strength
• Sensation • Circulation
• Swollen tendon insert. • TTP tendon insertions • Pain arc 90-130 • 5/5 w mod pain
flexion and ext. rotate • WNL • WNL
www.jacksonortho.org
Physical Exam
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• Impingement Sign • Jobe’s/Empty Can
• Drop Arm Test
• (+) pain with
passive/resisted flex • (+) Pain with
abd/rotate • (-) Able to maintain
abduction
www.jacksonortho.org
Special Tests
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• Probable
• Possible
• Rule Out
• Unlikely
• Impingement Syndrome
• Bursitis
• Partial thickness RCT
• Full thickness RCT
www.jacksonortho.org
Diagnosis
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• Ice > heat • TENS • Pendulums/ Stretches • NSAIDS, Analgesics • PT ? (Trainer?) • Avoid reaching/lifting
overhead • Coach; family • RTC 2 wks
www.jacksonortho.org
Treatment
• Physical Modalities • DME • IEP • Pharmacologic • Referral • Activity Modification
• Other
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• Subjective:
• Objective:
• Special tests: Imping/Jobes/DA
• Pain somewhat reduced now less constant, 0-5
• Reduced swelling, ++ ttp; ROM still painful 90-130; Resisted strength 5/5
+/+/-
www.jacksonortho.org
Follow Up Eval #1
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• Type of Therapy • Body part • Diagnosis • Frequency • Duration • Objectives
Physical Therapy Right shoulder Prob. Impinge Syndr 2x week 4 weeks Decrease inflammation; teach IEP & postural awareness
www.jacksonortho.org
Referral
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• Subjective:
• Objective:
• Special Tests: Imping/Jobes/DA
• Pain now occasional, intermittent, 0-3
• Reduced swelling, neg ttp; ROM full, pain free; Resisted strength 5/5
-/-/-
www.jacksonortho.org
Follow Up Eval #2
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• Ice > heat • TENS • Continue per PT • NSAIDS, Analgesics • None right now • Resume limitd
training • Coach; family • RTC 4 wks
www.jacksonortho.org
Treatment #2
• Physical Modalities • DME • IEP • Pharmacologic • Referral • Activity Modification • Other
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• Subjective:
• Objective:
• Imping/Jobes/DA*
• Pain 6-7, increased frequency
• Incr. swelling, ttp; ROM guarded w comp 70-130; Resisted strength 4/5
+/+/-*
www.jacksonortho.org
Follow Up Eval #3
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• Ice > heat • TENS • Pendulums/ Stretches • NSAIDS, Analgesics • Imaging • Avoid reaching/lifting
overhead • Injection • RTC 4 wks
www.jacksonortho.org
Treatment #3
• Physical Modalities • DME • IEP • Pharmacologic • Referral • Activity Modification • Other
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•Xray – AP int/ext rot plus Y view •Subacromial Inj
• Downward sloping Type III acromion
Transient relief within 15-20 minutes/ lasts 30 days.
www.jacksonortho.org
Imaging/Diagnostics
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• Subjective:
• Objective:
• Impngmnt/Jobes/DA*
• Pain 7-9, constant; felt something “pop”
• Incr. swelling, ttp; ROM guarded w comp 70-130; Resisted strength 4/5
+/+/-*
www.jacksonortho.org
Follow Up Eval #4
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• Ice > heat • TENS • Hold for now • NSAIDS, Analgesic • Avoid reaching/lifting
overhead • MRI www.jacksonortho.org
Treatment #4
• Physical Modalities • DME • PT • Pharmacological • Activity Modification
• Referrals
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• Type of Consult • Body part • Diagnosis • Duration of Treatment • Treatment provided
to date • Response to
treatment
• MRI Right shoulder rule out rotator cuff tear vs. tendinopathy for pain that has persisted >3 mos cons. care incl NSAIDs, PT, & injections x 3.
www.jacksonortho.org
Referral for MRI
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•Xray – AP int/ext rot plus Y view
•Subacromial Inj
•MRI
• Downward sloping acromion – Type III
Transient relief within
15-20 minutes, lasted 30 days
Mild-mod supraspinatus & infraspinatus tendinosis
www.jacksonortho.org
Imaging/Diagnostics
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• Ice > heat • TENS • 8 sessions • NSAIDS, Analgesic • Avoid reaching/lifting
overhead • Coach/Trainer • Psychologist • Surgery
www.jacksonortho.org
Treatment #5
• Physical Modalities • DME • PT • Pharmacological • Activity Modification
• Referrals
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• Type of Consult • Body part • Diagnosis • Duration of Treatment • Treatment provided
to date • Response to
treatment
• Evaluate & recommend treatment for pain management & possible adjustment disorder r/t shoulder condition that has failed to improve with >3 mos cons. care incl NSAIDs, PT, & injections x 3.
www.jacksonortho.org
Referral to Psychologist
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• Type of Consult • Body part • Diagnosis • Duration of Treatment • Treatment provided
to date • Response to
treatment
• Evaluate & recommend treatment for right shoulder pain that has failed to improve with >3 mos cons. care including NSAIDs,12 sessions PT, & injections x 3.
• MRI shows …..
www.jacksonortho.org
Referral to Orthopedist
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• 56 y.o. right handed male school custodian c/o right elbow pain radiating to lateral forearm, wrist and pinkie finger.
• Three previous episodes over last year resolved spontaneously with weekend rest.
• ROS: Type II Diabetes; HTN; HDL
www.jacksonortho.org
Case Study # 2
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• Onset • Location • Duration • Character • Aggravate/Alleviate • Radiation • Timing • Severity
7 days ago Lateral R elbow to hand Hours - constant Burning, dull, weak Ext/flex elbow/wrist Occ paresthesia pinkie* Floor wax; side reach Variable 2-7 w activity
www.jacksonortho.org
Subjective Complaints
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Elbow Anatomy Tutorial
www.jacksonortho.org
Anatomy Review #2
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A
www.jacksonortho.org
Elbow and Forearm Anatomy
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• Inspection
• Palpation
• Range of Motion • Strength • Sensation • Circulation
• Diffuse elbow edema
• +++TTP lat elbow/FA • + TTP medial elbow • (-)TTP dorsal FA • Guarded ext Elb/ Wrst • WNL, painful R • WNL R=L • WNL
www.jacksonortho.org
Physical Exam
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• Probable
• Possible
• Rule Out
• Unlikely
• Lateral epicondylitis
• Medial epicondylitis
• Cubital tunnel syndrome
• Radial nerve syndrome
www.jacksonortho.org
Diagnosis
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• Resisted wrist ext • Resisted wrist ext and
forearm supination • Resisted 3rd digit ext
• Resisted wrist flex
• Tinel’s at Olecranon
• (+) Painful • (+) Painful
• + Painful
• (-) Not painful • (+) with radiation to
pinkie www.jacksonortho.org
Special Tests
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• Probable
• Possible
• Unlikely
• Unlikely
• Lateral epicondylitis
• Cubital tunnel syndrome
• Radial nerve syndrome
• Medial epicondylitis
www.jacksonortho.org
Diagnosis
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• Ice • Elbow band • Strength/Stretch • NSAIDs, analgesics • Limit extension of
elbow • 6 weeks PT • 2cc 50/50 lido/depo
www.jacksonortho.org
Treatment
• Physical Modalities • DME • IEP • Pharmacologic • Activity
• Referral • Injections • Other
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• Xray
• MRI
• EMG/NCS
• r/o arthritic changes,
calcific tendinitis
• r/o ligament tear/ tendinopathy
• r/o nerve entrapment syndrome
www.jacksonortho.org
Imaging/Diagnostics
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• Xray
• MRI • EMG/NCS
• Mild effusion; arthritic changes, calcium deposits in proximal extensor tendon
• Mod-severe extensor tendinosis
• Moderate ulnar neuropathy w/o signs of polyneuropathy
www.jacksonortho.org
Imaging/Diagnostics
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• Type of Therapy • Body part • Diagnosis • Frequency • Duration • Objectives
• Physical Therapy –evaluate and treat right epicondylitis 2x week x 6 wks. Include ultrasound, massage, phonophoresis to reduce inflammation improve strength and decrease meds.
www.jacksonortho.org
Referral - PT
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• Type of Consult • Body part • Diagnosis • Duration of Treatment • Treatment provided
to date • Response to
treatment
• Evaluate & recommend tx for right elbow pain that has failed to improve with >3 months cons. care including NSAIDs,12 sessions PT, and injections x 3.
• Diagnostic study summaries
www.jacksonortho.org
Referral to Orthopedist
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• 48 y.o. L. handed female self employed medical biller
• Increasing pain L wrist & thumb 2-3 years. • New c/o L long finger “sticking”. • ROS: mod obese, recent dx “pre”
diabetes, managed w diet & exercise, otherwise healthy.
www.jacksonortho.org
Case Study #3
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• Onset • Location • Duration • Character • Aggravates • Alleviates • Radiation • Timing • Severity
• Gradual • L wrist, 1st,2nd, 3rd • 2-3 years/ months • Aching,burning/sharp • *Keyboard & bowling • Rest & heat • None except night • Morning;>2 hrs work • 6-7
www.jacksonortho.org
Subjective Complaints
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• Animated Wrist/Hand Anatomy Review
www.jacksonortho.org
Anatomy Review #3
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A
www.jacksonortho.org
Forearm & Wrist Anatomy
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A
Anatomy of the Wrist
www.jacksonortho.org
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• Inspection • Palpation
• Range of Motion
• Strength • Sensation • Circulation
• Diffuse edema • ++TTP 1st mcp, palm,
distal radius • WNL wrist, digits
Thumb – painful • Decreased grip, ++ • Decreased 1st, 2nd, 3rd • WNL
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Physical Exam - Left
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• Probable
• Possible
• Rule Out
• Unlikely
• Thumb OA • CTS • DeQuervain’s
• 3rd digit tenosynovitis ? Underlying metabolic
contributors Autoimmune/inflammato
ry www.jacksonortho.org
Diagnosis
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• Grind
• Tinel’s, Carpal Compression,
• Finkelsteins
• Triggering
• Positive L>R
• Positive L>R
• Equivocal L, + R
• Negative L, + R
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Special Tests
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• Xray: Wrist, hand &
thumb
• MRI
• Other
Diffuse mod -severe OA,worst at 1st MCP Not required at this time EMG/NCS – mod-severe median neuropathy
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Imaging/Diagnostics
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• Ice/heat • Thumb spica splints • Wrist stretches • NSAIDs, analgesics • Ergonomics, activity
restriction • Anti-inflamm diet • Exercise • PT/Hand Specialist
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Treatment
• Physical Modalities • DME • IEP • Pharmacologic • Other
• Referral
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• ½ cc lido + ½ cc depo • Carpal Tunnel
Release; MCP joint debridement; tendon release
• Post-op PT • Pain management • Activity pacing • Follow up! www.jacksonortho.org
Treatment, continued
• Injection • Surgery
• Referrals • Other
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• Type of Therapy • Body part • Diagnosis • Frequency • Duration • Objectives
• Rx Physical therapy to left upper extremity 2x wk x 4 weeks for treatment of 1st MCP osteoarthritis and CTS with instruction in IEP and self care with goal of improving function and decreasing meds
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Referrals
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•Our Mission: To improve the lives of people with musculoskeletal conditions through education, research & service.
•Our Goal: To raise the profile and priority of non-surgical musculoskeletal health with local hospitals, schools and the general public, while encouraging a collaborative, multi-disciplinary care model in ortho community.
•We call this approach Orthopedic Primary Care.
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About JOF
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Thank You
Jackson Orthopaedic Foundation 3317 Elm Street, Suit 201
Oakland, CA 94609 Phone (510) 238-4851
www.jacksonortho.org