Patrick S. Pabian, DPT, PT, SCS, OCS, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Elbow bursitis
Student’s elbow1
Draftsman’s elbow1
Miner’s elbow
++
++
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation
++
PATIENT PRESENTATION
A 54-year-old male bartender presents with posterior elbow pain that has been present for the past 2 weeks. The patient complains of dull pain with difficulty bending and straightening the elbow for dressing activities and weakness with pushing heavy items at work. He has marked pain when leaning his weight on his elbow when bent, especially on hard surfaces. The patient has focal swelling at the posterior elbow over the olecranon, which he notes varies in size when he leans on his elbow at work. The patient has had plain film x-rays which were negative for fracture.
++
Localized inflammation of the olecranon bursa, which is a subcutaneous bursa at the olecranon process of the elbow
Bursa fills with blood and serous fluid as a response to either acute or repeated microtrauma
Presents as pronounced, local swelling, isolated to the posterior elbow
+++
Essentials of Diagnosis
++
Olecranon bursitis (OB) is a result of single episode of trauma or repeat trauma to the posterior elbow when the elbow is in a flexed position.
Commonly related to occupation or specific activity that causes rubbing or pressure on the posterior elbow from a hard surface.
Swelling is contained to olecranon bursa which results in the visualization of an “egg” appearance at the posterior elbow.
Patients often note focal pain to palpation of swollen bursa, decreased range of motion, or inability to don a long-sleeved shirt.
Laboratory evaluation of the bursal aspirate.1
++
+++
General Considerations
++
Isolated diagnosis related to acute or chronic activity (pressure to the posterior elbow by a hard surface) and focal swelling/pain to the olecranon bursa
Marked tenderness or swelling with acute onset may signal underlying fracture
Exquisite swelling, marked tenderness, and redness or heat may be indicative of infection
++
No reports identifying or limiting demographics. Incidence related to activity
Occurs primarily in adults, but can occur in children and athletes of any age
Chronic cases often associated with occupation (miner) or prolonged activity (student), which places posterior elbow on hard surface
Acute cases often associated with acute blow to the posterior elbow when flexed (athletes) 1
++
SIGNS AND SYMPTOMS
Point tenderness to the posterior elbow
Focal swelling to the posterior elbow
Stiffness of elbow
Pain with rubbing or light pressure to posterior elbow (wearing long-sleeved shirt)
Pain with focal pressure (leaning on desk with bent elbow)
Elbow range of motion can be reduced, either flexion, extension, or both
Pain and swelling can be either insidious or acute
Occasionally, swelling can be spontaneous and without pain
Possible reduction in strength due to pain and inflammation
+++
Functional Limitations
++
Difficulty with dressing, grooming, reaching due to decreased elbow range of motion
Pain with sitting or leaning postures due to contact on the posterior elbow
Pain with movements of the hand and wrist
Difficulties with reaching, grasping, or pushing activities
+++
Possible Contributing Causes
++
Occupations or activities that involve repeated contact of the posterior elbow on hard surface (e.g., bartender, office work, student)
Direct trauma to the posterior elbow with elbow flexed
Sporting activities involving direct blow to posterior elbow (e.g., hockey, basketball, football)
Olecranon bursa infection
+++
Differential Diagnoses
++
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
++
+++
FINDINGS AND INTERPRETATION
++
++
++
++
++
++
REFERRALS/ADMITTANCE
To radiologist for imaging; X-ray
To primary care physician for aspiration and lab studies
To orthopedist for surgical consult for injection or excision
++
++
Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function
Selective tissue tension tests
Circumference
Shine a pen light to see if fluid is clear or how it lights up, that is, blood
++
Acute phase
PRICE: Protection, Rest, Ice Compression, Elevation
Bracing and padding to reduce pressure to posterior elbow
Low-level cold laser
Ice massage
Pulsed ultrasound
Active movement during the day with prevention of direct pressure to area from external hard surfaces
Chronic phase
Gradually increase workload as pain and discomfort diminish
Continue padding/bracing to reduce contact to area
Addressing pain
Addressing swelling
Addressing weakness; joint instability
As symptoms improve, gradually resume activities
Establish full, pain-free elbow range of motion
Incorporate stretching and progressive strengthening exercises as warranted to restore full mobility and strength
++
Patient will be able to
Press up from seated position with use of upper extremities without pain.
Reach into overhead cabinets in kitchen without pain or restriction.
Lift a gallon milk carton from refrigerator at shoulder level without pain.
Turn steering wheel without pain.
Use garden tools without pain.
Turn a door knob without pain.
++
Good. A prolonged period of healing can last several months.
Slower recovery for those with infection.
Aspiration may hasten recovery, but risk of infection exists.
++
+++
ADDITIONAL REFERENCES
+
Bell
S. Elbow and arm pain. In:Brukner
P, Khan
K Clinical Sports Medicine. 3rd ed. North Ryde, NSW, Australia: McGraw-Hill Book Company Australia; 2006:289–307.
+
Dutton
M. Practice Pattern 4E: impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. In:Dutton
M Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 3rd ed. New York, NY: McGraw-Hill; 2012.
http://www.accessphysiotherapy.com/content/55576376. Accessed March 27, 2013.
+
Dutton
M. The elbow complex. In:Dutton
M Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York, NY: McGraw-Hill; 2008:653–733.
+
Prentice
WE. The elbow. In:Prentice
WE. Principles of Athletic Training: A Competency-Based Approach. New York, NY: McGraw-Hill; 2011:681–701.
Patrick S. Pabian, DPT, PT, SCS, OCS, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Elbow subluxation
Nursemaid’s elbow
++
832 Dislocation of elbow
832.0 Closed dislocation of elbow
832.00 Closed dislocation of elbow, unspecified
832.01 Closed anterior dislocation of elbow
832.02 Closed posterior dislocation of elbow
832.03 Closed medial dislocation of elbow
832.04 Closed lateral dislocation of elbow
832.09 Closed dislocation of elbow, other
832.1 Open dislocation of elbow
832.10 Open dislocation of elbow, unspecified
832.11 Open anterior dislocation of elbow
832.12 Open posterior dislocation of elbow
832.13 Open medial dislocation of elbow
832.14 Open lateral dislocation of elbow
832.19 Open dislocation of elbow, other
832.2 Nursemaid’s elbow
++
S53.016A Anterior dislocation of unspecified radial head, initial encounter
S53.116A Anterior dislocation of unspecified ulnohumeral joint, initial encounter
S53.146A Lateral dislocation of unspecified ulnohumeral joint, initial encounter
S53.136A Medial dislocation of unspecified ulnohumeral joint, initial encounter
S53.033A Nursemaid’s elbow, unspecified elbow, initial encounter
S53.096A Other dislocation of unspecified radial head, initial encounter
S53.196A Other dislocation of unspecified ulnohumeral joint, initial encounter
S53.026A Posterior dislocation of unspecified radial head, initial encounter
S51.009A Unspecified open wound of unspecified elbow, initial encounter
S53.006A Unspecified dislocation of unspecified radial head, initial encounter
S53.106A Unspecified dislocation of unspecified ulnohumeral joint, initial encounter
++
+++
PREFERRED PRACTICE PATTERN
++
4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion (ROM) Associated with Connective Tissue Dysfunction
++
PATIENT PRESENTATION
A 17-year-old male presents with elbow pain, weakness, and lack of mobility. Patient sustained an elbow dislocation 2 weeks ago due to a fall on an extended elbow while playing football. He reports immediate pain and inability to move his elbow, necessitating transport to urgent care for relocation. He reports that pre-and postreduction X-rays did not reveal a fracture. He was placed in a hinged brace with ROM limits as set by the orthopedic physician.
He currently presents with moderate global swelling and bruising into his forearm. The patient has difficulty with writing while at school and dressing, grooming, and eating due to decreased mobility. He also notes weakness with carrying objects due to diminished grip strength. He has negative varus and valgus stress tests. Patient has normal capillary refill and no sensory deficits in hand.
++
Traumatic injury to the elbow
Displacement of the ulna and radius in a posterior, anterior, or lateral direction
Mechanism of injury is a forced hyperextension
Typically from fall on outstretched elbow
Traumatic unidirectional blow to the elbow
Forceful twisting of the elbow while in a flexed position
Nursemaid’s elbow
+++
Essentials of Diagnosis
++
Injury warrants immediate medical referral for imaging studies, relocation (often under anesthesia), and evaluation of neurovascular structures around the elbow.
Traumatic event/mechanism of injury, resulting in obvious deformity, pain, and acute inflammatory response.
Injury commonly observed in contact sport athletics, but also in other situations where traumatic blow or fall occurs.
+++
General Considerations
++
Most common direction is posterior dislocation of ulna and radius.
Comprehensive evaluation of all neurovascular structures around the elbow is necessary after relocation.
Examination of all ulnar and lateral collateral ligament branches is necessary after relocation to assess for possible injury.
Postreduction radiographs and other possible advanced imaging techniques are required to evaluate for associated fractures or additional soft tissue injuries.
Humeroulnar joint is generally stable once reduced but often results in elbow flexion contracture that needs to be managed by rehabilitation provider.
“Dislocation” can also refer to isolated radius dislocation
Injury can be result of similar trauma.
Dislocation of radial head is termed “pulled elbow syndrome,” which results in radial head slipping under the annular ligament due to tractional force through the radius.1
Fibers of interosseous membrane are not aligned to optimally resist distraction force, as they do to compression force.
++
No reports identifying or limiting demographics
Incidence related to traumatic incident
Injury commonly observed in contact sport athletics as well as situations where traumatic blow or fall occurs
++
SIGNS AND SYMPTOMS
Prereduction
Visual deformity
Severe pain
Immediate swelling
Postreduction
Gross effusion
Reduced ROM in all planes of motion
Commonly results in elbow flexion contracture
Reduced elbow strength in all planes of motion
Reduced grip strength
Potential laxity or pain in collateral ligaments
Potential neurovascular symptoms to distal forearm or hand if traumatized in initial injury or if moderate effusion present
++
+++
Functional Limitations
++
Difficulty dressing, grooming, or reaching due to decreased elbow ROM
Difficulty reaching, grasping, or pushing activities
Difficulty, pain, or weakness when grasping and pulling for dressing activities
+++
Possible Contributing Causes
++
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
++
Pre- and postreduction radiographs necessary to evaluate for presence of associated fractures
CT scan possible for further evaluation of suspected fractures
MRI possible for evaluation of ligamentous integrity or other soft tissue injuries
+++
Findings and Interpretation
++
Fracture with displacement of the proximal ulna
Elbow fracture dislocation, Salter–Harris type I epiphyseal fracture
Supracondylar fracture
Lateral view, radial head fracture
Fracture of the tip of the olecranon
Radial head fracture
Oblique view, frank dislocation of the elbow
Avulsion fracture of the medial epicondyle
++
++
++
REFERRALS/ADMITTANCE
Immediate medial referral for evaluation, imaging, and reduction.
To radiologist for imaging, X-ray.
To orthopedist for surgical consult if associated injuries present.
++
++
++
Acute phase
Brace/splint until acute pain subsides
PRICE: protection, rest, ice compression, elevation
Low-level cold laser
Ice massage
Pulsed ultrasound
Active and passive movement allowed, but protect from varus/valgus stresses due to potential associated injury to collateral ligaments
Chronic phase
Gradually increase workload as pain and discomfort diminish
Gradually progress to aggressive stretching/ROM to establish normal mobility. May require dynamic splinting to obtain full ROM.
Addressing pain
Addressing swelling
Addressing weakness and joint instability
As symptoms improve, gradually resume activities
Establish full, pain-free elbow ROM
Incorporate stretching and progressive strengthening exercises as warranted to restore full mobility and strength
Medical intervention
++
++
Patient will be able to reach into overhead cabinets in kitchen without pain or restriction
Patient will be able to lift a gallon milk carton from refrigerator at shoulder level, without pain
Patient will be able to turn steering wheel, without pain
Patient will be able to use garden tools, without pain
Patient will be able to turn a door knob, without pain
++
Good. A prolonged period of healing can last several months, especially in the presence of associated injuries
Humeroulnar joint usually very stable after relocation, but often results in significant limitation of elbow extension and supination ROM
++
1. +
Neumann
D. Elbow and Forearm. In:Neumann
D Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd ed. St. Louis, MO: Mosby; 2010:173–215.
+++
ADDITIONAL REFERENCES
+
Hay
WW, Levin
MJ, Sondheimer
JM, Deterding
RR. Trauma. In:Hay
WW, Levin
MJ, Sondheimer
JM, Deterding
RR CURRENT Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/content/6585929. Accessed February 23, 2013.
+
Pattern 4D: impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria,
VA: American Physical Therapy Association; 2001. Revised 2003.
+
Prentice
WE. The Elbow. In:Prentice
WE Arnheim’s Principles of Athletic Training: A Competency-Based Approach. New York, NY: McGraw-Hill; 2011:681–701.
+
Ryan
J, Salvo
J. Elbow injuries. In:Starkey
C, Johnson
G Athletic Training and Sports Medicine. 4th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:337–385.
Jennifer Cabrera, DPT, GCS, Eric Shamus, PhD, DPT, PT, CSCS
++
++
813.05 Fracture of head of radius closed
813.06 Fracture of neck of radius closed
813.15 Fracture of head of radius open
813.16 Fracture of neck of radius open
++
S52.123A Displaced fracture of head of unspecified radius, initial encounter for closed fracture
S52.126A Nondisplaced fracture of head of unspecified radius, initial encounter for closed fracture
S52.133A Displaced fracture of neck of unspecified radius, initial encounter for closed fracture
S52.136A Nondisplaced fracture of neck of unspecified radius, initial encounter for closed fracture
S52.123B Displaced fracture of head of unspecified radius, initial encounter for open fracture type I or II
S52.123C Displaced fracture of head of unspecified radius, initial encounter for open fracture type IIIA, IIIB, or IIIC
S52.126B Nondisplaced fracture of head of unspecified radius, initial encounter for open fracture type I or II
S52.126C Nondisplaced fracture of head of unspecified radius, initial encounter for open fracture type IIIA, IIIB, or IIIC
S52.133B Displaced fracture of neck of unspecified radius, initial encounter for open fracture type I or II
S52.133C Displaced fracture of neck of unspecified radius, initial encounter for open fracture type IIIA, IIIB, or IIIC
S52.136B Nondisplaced fracture of neck of unspecified radius, initial encounter for open fracture type I or II
S52.136C Nondisplaced fracture of neck of unspecified radius, initial encounter for open fracture type IIIA, IIIB, or IIIC
+++
PREFERRED PRACTICE PATTERN
++
++
PATIENT PRESENTATION
A 38-year-old woman arrives to the emergency room complaining of 10/10 elbow pain. She reports she was running in the street, did not see a hole in the road and experienced a “hard” fall against the concrete. She continued to report putting out her arm to attempt to dampen the fall, but felt immediate sharp pain in her elbow upon impact. The woman demonstrated increased upper extremity (UE) guarding with any attempted elbow movements and visible deformity at the distal elbow with edema. Upon palpation, patient demonstrated tenderness directly over radial head. Crepitus was noted with forearm supination. X-rays were performed and patient was found to have a displaced proximal radial head fracture.
++
++
++
Fracture
Any defect in continuity of the radial head or neck
Displaced (radial head/neck is moved on either side of the fracture) or nondisplaced (radial head/neck has not moved)
Closed (skin is intact) or open (skin is breached)
+++
Essentials of Diagnosis
++
Diagnosis is usually made by clinical examination.
May not be a fracture but a proximal radioulnar subluxation/dislocation, humeroradial subluxation/dislocation, radial collateral ligament sprain.
+++
General Considerations
++
++
++
SIGNS AND SYMPTOMS
Pain on the outside of the elbow
Point tenderness
Edema
Ecchymosis
Loss of general function
Loss of active elbow movement
Loss of active forearm movement (supination/pronation)
Muscle guarding with passive movement
Crepitus
+++
Functional Implications
++
Pain with weight-bearing activities on involved UE
Pain with vertical positioning of arm at side
Pain with all elbow and forearm movements (passive or active)
+++
Possible Contributing Causes
++
+++
Differential Diagnosis
++
Proximal radioulnar subluxation/dislocation
Humeroradial subluxation/dislocation
Radial collateral ligament sprain
+++
MEANS OF CONFIRMATION
++
++
+++
FINDINGS AND INTERPRETATION
++
Pain and crepitus with passive/active ROM of the elbow and forearm.
UE held in protective positioning in order to avoid gravity’s distraction of the joint.
Muscle guarding with all movements.
Inability to actively perform elbow movements or forearm pronation/supination secondary to pain.
If vascular structures are involved, the involved forearm and hand will appear cool and pale with diminished palpable pulses.
If neurologic structures are involved, the individual will report numbness and decreased ability to move the involved forearm and hand.
If patient reports severe pain, the individual may be suffering from compartment syndrome.
++
++
++
++
Inability to perform ADLs with involved UE
Inability to bear weight on involved forearm and hand
Inability to use involved hand to write (especially if it is the patient’s dominant hand)
Inability to grab a cup secondary to pain and muscle weakness
++
++
Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function
Upper limb tension test (ULTT), radial nerve dominant
Sensory loss may include diminished two-point discrimination, decreased vibration sense, increased threshold in Semmes–Weinstein monofilament test
++
Address swelling
Ice/Cryotherapy
Compression
Elevation
Electrical stimulation
Address pain
Ice/Cryotherapy
Massage
Electrical stimulation
Address lack of flexibility via stretching
Wrist flexors
Wrist extensors
Elbow flexors
Address mobilization upon healing of fracture site (6 weeks postoperative)
Humeroulnar distraction for pain management
Humeroulnar distal glide to increase elbow flexion
Humeroradial dorsal glide for elbow extension
Humeroradial volar glide for elbow flexion
Proximal radioulnar joint dorsal glide for pronation
Proximal radioulnar joint volar glide for supination
Distal radioulnar joint dorsal glide for supination
Distal radioulnar joint volar glide for pronation
Address weakness via strengthening activities
Closed chain weight-bearing activities
Isometric exercises (initially submaximal)
Open chain via use of free weights and resistance bands
Grip strengthening
Address scar mobility
++
Patient will:
Increase grip strength to 30 kg in order to facilitate opening jars.
Increase forearm supination to 55 degrees in order to facilitate eating with a fork.
Increase arm curl test of the involved UE to 24 repetitions in order to facilitate carrying groceries.
Increase proximal radioulnar joint mobility to three in order to allow the individual to turn the knob of a door.
++
Good, if there is mechanical stability with reduction and stable internal fixation.
Some residual loss of elbow extension is expected.
++
++
3. +
Pattern 4G: impaired joint mobility, muscle performance, and range of motion associated with fracture. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria,
VA: American Physical Therapy Association; 2001. Revised 2003.
+++
ADDITIONAL REFERENCES
+
Goodman
CC, Fuller
KS. Pathology Implications for the Physical Therapist. 3rd ed. St. Louis, MO: Saunders Elsevier; 2009.
+
Kisner
C, Colby
LA. Therapeutic Exercise: Foundations and Techniques. 5th ed. Philadelphia, PA: F.A. Davis Company; 2007.
+
Magee
DJ. Orthopedic Physical Assessment. 5th ed. St. Louis, MO: Saunders Elsevier; 2008.
Kenneth Lee, DPT, PT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation1
++
++
PATIENT PRESENTATION
A 42-year-old female has come to the physical therapy out-patient clinic for an evaluation of her right upper extremity. As a part of her initial history, the patient states that she is a police officer and an amateur bodybuilder. The patient states that the pain in her arm started suddenly and was noticeable when turning the ignition key of her police cruiser. She points to pain along the lateral aspect of her right elbow. She has point tenderness with palpation of area with increased pain in elbow with wrist and elbow extension. Imaging radiographs are normal. Physical inspection reveals that rubor and warmth are present in the muscle bellies of extensor digitorum and extensor carpi radialis longus.
++
Tendinosis of wrist extensor tendons that attach at the lateral humeral epicondyle.2
Normal collagen response is disrupted by fibroblastic, immature vascular response and an incomplete reparative phase.
Early stages may display inflammatory or synovitic characteristics.
Later stages may demonstrate microtearing, tendon degeneration with or without calcification, or incomplete vascular response.
Pain in lateral elbow with resisted wrist extension and radial deviation with elbow extended.
+++
Essentials of Diagnosis
++
Tendonitis of the elbow is rarely caused by acute trauma except in sports-related events, such as tennis.3
Usually affects middle-aged clients; aging process leads to decreased mucopolysaccharide chondroitin sulfate within tissues, making tendons less extensible.
Age-related tissue changes for tennis elbow appear in patients aged 35 years and older.
+++
General Considerations
++
Tendinosis affecting the elbow is rarely acute unless by direct trauma (then considered tendonitis).
Pain usually is associated with activity, more so afterward.
Onset of pain is associated with wrist extension, elbow extension, and forearm pronation activities.
Direct blows to lateral epicondyle can initiate symptoms.2
++
People aged 40 to 50 years4
Accounts for 7% of all sports injuries4
Males and females equally affected4
75% of patients are symptomatic in their dominant arm4
++
SIGNS AND SYMPTOMS
Pain of insidious onset
Active movement may reproduce pain
Passive movement of full wrist flexion with pronation and elbow extension reproduces pain at the lateral epicondyle
Resistive isometric: Resisted wrist extension and elbow extension reproduces pain at lateral epicondyle
Elbow-joint movements should be full and painless
Palpation tenderness at lateral epicondyle within musculature of extensor digitorum and extensor carpi radialis longus; rarely involves extensor carpi ulnaris or extensor carpi radialis brevis (ECRB)
Rubor and warmth may be present over lateral epicondyle or associated muscle belly
Pain and tenderness over the lateral epicondyle
Pain response varies between dull ache, no pain at rest, sharp pain with activities
++
++
++
+++
Functional limitations
++
Pain with pinching, squeezing, holding heavy objects, wringing
Pain with movements of the hand and wrist
Loss of strength
Difficulty with grasping activities
+++
Possible Contributing Causes
++
Occupations requiring repetitive use of hands for excessive periods of time
Direct trauma to tendon or wrist
Sports or occupational activities
Tennis, golf, bowling, football, archery, weightlifting
Carpentry, plumbing, mechanic
Most commonly results from repetitive forearm, wrist, hand motions
+++
Differential Diagnosis
++
Radial nerve entrapment
Bicipital tendonitis
Rheumatoid arthritis
Radiocapitellar arthritis
Posterior interosseous nerve compression (radial tunnel syndrome)
Osteochondritis dissecans of the capitellum
Carpal tunnel syndrome
Triceps tendonitis
Pronator syndrome
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
++
+++
FINDINGS AND INTERPRETATION
++
++
Anti-inflammatory
Corticosteroid injection
NSAIDs6
++
++
REFERRALS/ADMITTANCE
To radiologist for imaging, X-ray
To orthopedist for surgical consult, injection
++
Hand weakness with grasping, squeezing, pinching
Restricted ROM in elbow and wrist
++
++
Acute phase
Rest
Immobilization
Taping, bracing: Inhibit painful muscles or facilitate muscle activity
Low-level cold laser7
Active movement during day with prevention of high-strain loading of tissue
Address swelling
Ice8
Elevation
Iontophoresis9
Chronic phase
Gradually increase workload as pain and discomfort diminish
Elbow and wrist brace to limit motion
Counterforce brace to reduce acceleration force
Address pain
Address weakness, joint instability12
Gradually resume normal activity as symptoms improve
Establish full, pain-free wrist and elbow ROM
Incorporate stretching and progressive isometric exercise
Painful eccentric exercises
Progress to concentric and eccentric resistive exercise as flexibility and strength returns
Grip exercises and progressive strengthening of extensor and flexors using high-repetition/low-weight ratio
Concentrate on ECRB, extensor digitorum, and extensor carpi radialis longus
Address mobilization, radial head mobility
++
Patient will be able to
Turn a door knob without pain.
Turn on faucet without pain.
Lift a gallon carton of milk from refrigerator at shoulder level without pain.
Grip steering wheel without pain.
Use a screw driver without pain.
Use garden tools without pain.
++
+++
ADDITIONAL INFORMATION
++
For additional information, please see the Case Study in Chapter 15 of Orthopaedic Examination, Evaluation, and Intervention on www.accessphysiotherapy.com 5
++
1. +
The American Physical Therapy Association. Pattern 4E: impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. doi: 10.2522/ptguide.3.1_5.
http://guidetoptpractice.apta.org/content/1/SEC12.extract. Accessed May 26, 2014.
4. +
Hertling
D, Kessler
R M. The elbow and forearm. In: Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. 4th ed. New York, NY: Lippincott Williams & Wilkins; 2006:Chapter 12.
10. +
Draper
DO, Prentice
WE. Therapeutic ultrasound. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011: Chapter 10.
http://www.accessphysiotherapy.com/abstract/8138751. Accessed March 9, 2013.
+++
ADDITIONAL REFERENCES
+
Brulhart
L, Gabay
C. The differential diagnosis of tenosynovitis. Rev Med Suisse. 2011;7(286):587–588, 590, 592–593.
[PubMed: 21510342]
Kenneth Lee, DPT, PT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Medial tendon injury
Medial tendonitis
Golfer’s elbow
Bowler’s elbow
Little leaguer’s elbow
++
++
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation1
++
PATIENT PRESENTATION
A 37-year-old male has come to the physical therapy out-patient clinic for an evaluation of his left upper extremity. As a part of his initial history, the patient states that he is a carpenter and enjoys recreational golf with friends on most weekends. The patient states that he has a high pain tolerance, but his current pain became more evident after a vigorous round of golf this weekend. He points to pain along the medial aspect of his left elbow. He has point tenderness with palpation of area with increased pain in elbow with wrist flexion and pronation of forearm. Imaging reveals calcification of medical collateral ligament of elbow. Rubor and warmth are present in the muscle bellies of flexor carpi ulnaris, pronator teres, palmaris longus, flexor digitorum superficialis, and flexor carpi radialis.
++
Tendinosis of wrist flexor tendons that attach at medial humeral epicondyle2
Involvement of common flexor origin, flexor carpi radialis, and humeral head of the pronator teres
Normal collagen response is disrupted by fibroblastic, immature vascular response and incomplete reparative phase
Early stages may display inflammatory or synovitic characteristics
Later stages may demonstrate microtearing, tendon degeneration with or without calcification, or incomplete vascular response
Pain in medial elbow with resisted wrist flexion2
++
+++
Essentials of Diagnosis
++
Caused by medial tension overload of the elbow associated with repetitive microtrauma of flexor–pronator musculature at its origin on medial epicondyle2
Usually affects middle-aged clients; aging process leads to decreased mucopolysaccharide chondroitin sulfate within tissues, making tendons less extensible
+++
General Considerations
++
Tendinosis affecting the elbow is rarely acute unless by direct trauma (then characterized as tendonitis.)3
Pain is usually associated with activity, more so afterward.
Onset of pain is associated with wrist flexion.
Direct blows to the medial epicondyle can initiate symptoms.
++
++
++
++
++
People aged 12 to 80 years4
More common during fourth and fifth decade of life4
Males and females equally affected4
75% of patients are symptomatic in their dominant arm4
++
SIGNS AND SYMPTOMS
Pain of insidious onset
Pain and tenderness over medial epicondyle
Pain may be related to wrist flexion and pronation
Pain response varies between dull ache, no pain at rest, and sharp pain with activities
Active movement may reproduce pain
Passive movement of full wrist extension with supination and elbow extension reproduces pain at medial epicondyle
Resistive isometric: resisted wrist flexion and resisted wrist pronation reproduces pain at medical epicondyle
Elbow-joint movements should be full and painless
Palpation tenderness at medial epicondyle within the musculature of flexor carpi ulnaris, pronator teres, palmaris longus, flexor digitorum superficialis, and flexor carpi radialis
Rubor and warmth may be present over medial epicondyle or proximal 5 to 10 mm of associated muscle belly
+++
Functional limitations
++
Pain with pinching, squeezing, holding heavy objects, wringing
Pain with movements of the hand and wrist
Loss of strength
Difficulty with grasping activities
+++
Possible Contributing Causes
++
Occupations requiring repetitive use of hands for excessive periods of time
Direct trauma to tendon or wrist
Sports or occupational activities
Tennis, golf, bowling, football, archery, weightlifting
Carpentry, plumbing, mechanic
Most commonly results from repetitive forearm, wrist, hand motions
+++
Differential Diagnosis
++
Medial ulnar collateral ligamentous instability
Ulnar neuritis
Compression or entrapment of ulnar nerve
Rheumatoid arthritis
Medial elbow intra-articular pathology
Carpal tunnel syndrome
Pronator syndrome
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
++
Radiographs and electromyography (EMG) for patients with neurologic alterations5
MRI for throwing athletes to evaluate ulnar collateral ligament
MRI may show inflammation/edema or microtearing
++
+++
FINDINGS AND INTERPRETATION
++
Radiographs usually normal, used to rule out arthritis or osteochondral loose bodies
Throwing athletes may have ulnar traction spurs and medial collateral calcification
++
Anti-inflammatory
Corticosteroid injection
NSAIDs6
++
REFERRALS/ADMITTANCE
To radiologist for imaging, X-ray
To orthopedist for surgical consult, injection
++
Hand weakness with grasping, squeezing, pinching
Restricted ROM in elbow and wrist
++
++
Acute phase
Rest
Immobilization
Taping, bracing to inhibit painful muscles or facilitate muscle activity
Low-level cold laser7
Active movement during the day with prevention of high-strain loading of tissue
Address swelling
Ice8
Elevation
Iontophoresis9
Chronic phase
Gradually increase workload as pain and discomfort diminish
Elbow and wrist brace to limit motion
Counterforce brace to reduce acceleration force
Address pain
Address weakness, joint instability
Gradually resume normal activity as symptoms improve; establish full, pain-free wrist and elbow ROM
Incorporate stretching and progressive isometric exercise
Painful eccentric exercises
Progress to concentric and eccentric resistive exercise as flexibility and strength returns
Grip exercises and progressive strengthening of extensor and flexors using high-repetition/low-weight ratio
Concentrate on flexor carpi ulnaris and flexor digitorum superficialis
Address mobilization
++
Patient will be able to
Turn a door knob without pain.
Turn on faucet without pain.
Lift a gallon carton of milk from refrigerator at shoulder level without pain.
Grip steering wheel without pain.
Use a screw driver without pain.
Use garden tools without pain.
++
++
1. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. doi: 10.2522/ptguide.3.1_5. Accessed June 16, 2013.
2. +
Wolf
JM, Mountcastle
S, Burks
R, Sturdivant
RX, Owens
BD. Epidemoiology of Lateral and Medial Epicondylitis in a Military Population. Mil Med. 2010;175(5):336–339.
[PubMed: 20486505]
CrossRef 4. +
Ciccotti
MC, Schwartz
MA, Ciccotti
MG. Diagnosis and treatment of Medial Epicondylitis of the elbow. Clinics in Sports Medicine. Elsevier Saunders; 693–705:2004.
10. +
Draper
DO, Prentice
WE. Therapeutic ultrasound. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011:Chapter 10.
http://www.accessphysiotherapy.com/abstract/8138751. Accessed June 16, 2013.
+++
ADDITIONAL REFERENCES
+
Hertling
D, Kessler
RM. The Elbow and Forearm. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. 4th ed. New York, NY: Lippincott Williams & Wilkins; 2006:Chapter 12.
Steven B. Ambler, DPT, PT, OCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
S43.006 Unspecified dislocation of unspecified shoulder joint
M25.311 Other instability, right shoulder
+++
PREFERRED PRACTICE PATTERN
++
4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction2
++
PATIENT PRESENTATION
A 19-year-old patient is being seen in the clinic with a chief complaint of right anterior shoulder pain that began after a shoulder dislocation 1 week ago. He states that he injured the shoulder while sustaining a direct blow to the arm playing semipro football and that the dislocation did require relocation in the emergency room. Patient has been wearing a sling since the injury and was given a shoulder stabilizer brace to wear during football. The patient is taking Naproxen and has no pain at rest at this time. He does have 4–5/10 pain when he wakes in the morning and when he has to reach overhead. He denies numbness and tingling and has no other complaints at this time. The patient is currently not practicing and is keeping the arm in the sling. He is left handed and would like to be able to return to his team this season where he plays quarterback.
++
Excessive and symptomatic translation of the humeral head in one or more directions
Instability may be associated with dislocation or subluxation associated with trauma
Glenohumeral instability may be secondary to atraumatic factors associated with structural, postural, or movement dysfunction or from recurrent minor injury to the structures of the glenohumeral joint3,4
Symptomatology and management vary based on onset, degree, frequency, direction, associated pathology, neuromuscular control, and premorbid activity level4
++
+++
Essentials of Diagnosis
++
Diagnosis made primarily by clinical examination, though imaging often necessary to rule in or out associated pathology
Anterior instability is most common, followed by multidirectional, then posterior instability
+++
General Considerations
++
Onset, degree, frequency, direction, associated pathology, neuromuscular control, and premorbid activity level dictate the diagnosis and management4
Interaction between glenohumeral, scapulothoracic, acromioclavicular, and sternoclavicular joints must be examined to determine optimal treatment plan8,9
++
Young athletes most commonly affected7
Males more often affected than females by traumatic instability; inconclusive evidence for atraumatic or multidirectional
Multidirectional instability may be associated with gymnastics, swimming, weightlifting, and the individual may have increased joint laxity throughout the body7
++
SIGNS AND SYMPTOMS
Specific signs and symptoms depend on onset, degree, frequency, direction, and associated pathology of the injury
Pain in shoulder; location often depend on the primary direction of instability
Direction-dependent feelings of instability and apprehension toward the primary direction of instability
Direction-specific hypermobility of the glenohumeral joint toward the primary direction of instability3
Clicking and popping in the shoulder with movement
Decreased upward rotation, increased internal rotation and protraction of the scapula
Special tests for instability specific to the primary direction of instability
In multidirectional instability, patient may have higher scores on the Beighton scale for assessing generalized joint hypermobility
++
+++
Functional Implications
++
Difficulty with overhead activities
Pain with end-range motions of the shoulder
Pain and difficulty with pushing/pulling activities
Pain and difficulty with weight-bearing on the arm
Pain with sleeping on affected side
+++
Possible Contributing Causes
++
Poor posture: Forward-shoulder and downwardly rotated, internally rotated, or protracted scapula
Athletes: Swimmers, gymnasts, and overhead athletes4,7
Increased joint laxity elsewhere in the body (high Beighton scale scores)
Atraumatic instability may be increased by prior traumatic instability injury or history of other shoulder injury4
++
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
Diagnostic Procedures
++
+++
FINDINGS AND INTERPRETATION
++
Imaging to diagnose additional pathology
Hypermobility of the glenohumeral joint, may be direction-specific3
Decreased upward rotation of the scapula or increased medial winging (internal rotation) of the scapula with humeral elevation
Increased scapulohumeral rhythm10
Direction-specific positive special tests
Increased joint laxity throughout the body may be present
Sample case study10
++
++
Surgery
Bankart repair
Thermocapsular shift
++
REFERRALS/ADMITTANCE
To hospital for diagnostic imaging: MRI, CT, or radiograph as indicated
To orthopedic surgeon for surgical consult if conservative treatment fails or associated pathology suspected
++
Hypermobility of the glenohumeral joint, may be direction-specific3
Excessive, direction-specific accessory motions of the humeral head with physiologic shoulder movements
Decreased upward rotation of the scapula or increased medial winging (internal rotation) of the scapula with humeral elevation
Muscle performance impairment: Stiffness, shortness, dominance of the pectoralis minor, levator scapulae, rhomboid major and minor
Muscle performance impairment: Weakness, excessive length, or decreased neuromuscular control of the supraspinatus, infraspinatus, teres minor, subscapularis, upper trapezius, middle trapezius, lower trapezius, and serratus anterior
Structural impairments of the humerus or glenoid, such as flattening of the glenoid, may be present
Pain with direction-specific shoulder motions; range of motion may be excessive initially, but limited by pain once symptomatic
++
Anterior instability15,16
Posterior instability15,16
Multidirectional instability15,16
Crossover impingement/horizontal adduction test
Pain provocation test
Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function
Shoulder Pain and Disability Index
++
Intervention based on type (traumatic or atraumatic), onset, degree, frequency, direction, and potential associated pathology4,17
Traumatic
Acute
Immobilization may be used with the arm in 30 degrees of abduction and 30 degrees of external rotation18
PROM and AROM within pain-free ranges
External rotation may be limited to 65 to 70 degrees to prevent overstressing the anterior structures for anterior instability
Internal rotation may be limited to prevent overstressing the anterior structures for posterior instability
Isometric, pain-free strengthening
Gentle, pain-free weight-bearing on the arm
Pain-free dynamic stabilization with the arm in 30 degrees of abduction, neutral rotation, and 30 degrees into the scapular plane
Modalities as needed to control pain, inflammation, and muscle guarding
Intermediate
Progression of items from the acute stage
Isotonic strengthening may be initiated with emphasis on rotator cuff musculature to promote stability
Progression of weight-bearing exercise, such as modified push-ups, may be initiated to promote stability with emphasis on maintaining correct scapular alignment
Trunk-stabilization exercise may be initiated to enhance correct movement patterns and reduce abnormal stress to the glenohumeral joint
Neuromuscular electrical stimulation (NMES) to muscles of the rotator cuff during exercise to improve muscle fiber recruitment
Advanced
Progression of all items from intermediate stage
Unilateral weight-bearing stability exercise, such as wall stabilization drills with medicine or stability balls
Proper alignment of the scapula should be maintained during all stabilization exercise
Plyometric exercise, progressing to overhead then unilateral, may be indicated if the patient is returning to sports17
Atraumatic
Intervention similar to that used for traumatic instability
Progression may be slower than with traumatic
Care should be taken to prevent stretching of capsular tissues
Exercise that emphasizes co-contraction and proprioception is indicated
Exercise with emphasis on muscle balance around the shoulder girdle with correct positioning and movement of the scapula
Trunk-stability exercise to improve stability during functional tasks should be initiated once patient is able to stabilize the glenohumeral joint
++
Note: Duration of the goals will depend on the onset, degree, frequency, direction, associated pathology, neuromuscular control, and premorbid activity level.4
++
Patient will be able to
Dress without pain or instability 100% of the time
Perform all self-care activities without pain or instability 100% of the time.
Sleep through the night without waking from pain 100% of the time.
Bear full weight through the arms without pain or instability 100% of the time.
Lift 10 pounds overhead without pain or instability 100% of the time.
Perform all daily activities without pain or instability 100% of the time.
Resume recreational tasks without pain or instability 100% of the time.
++
Return to full function may be anywhere from 2 weeks to 6 months; rehabilitation visits may range from 3 to 36 visits depending on onset, degree, frequency, direction, associated pathology, neuromuscular control, and premorbid activity level.4,19
Recurrence is common in younger populations, while additional pathology often seen in individuals over 40 years of age.20
++
2. +
The American Physical Therapy Association. Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_4. Accessed March 1, 2013.
3. +
Cameron
KL, Duffey
ML, DeBerardino
TM
et al. Association of generalized joint hypermobility with a history of glenohumeral joint instability. J Athl Train. 2010;45(3):253–258.
[PubMed: 20446838]
CrossRef 4. +
Owens
BD, Duffey
ML, Nelson
BJ
et al. The incidence and characteristics of shoulder instability at the United States Military Academy. Am J Sports Med. 2007;35(7):1168–1173.
[PubMed: 17581976]
CrossRef 5. +
Wilk
KE, Macrina
LC, Reinold
MM. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. N Am J Sports Phys Ther. 2006;1(1):16–31.
[PubMed: 21522197]
6. +
Pope
EJ, Ward
JP, Rokito
AS. Anterior shoulder instability—a history of arthroscopic treatment. Bull NYU Hosp Jt Dis. 2011;69(1):44–49.
[PubMed: 21332438]
7. +
Hottya
GA, Tirman
PF, Bost
FW
et al. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. AJR Am J Roentgenol. 1998;171(3):763–768.
[PubMed: 9725313]
CrossRef 8. +
Cordasco
FA. Understanding multidirectional instability of the shoulder. J Athl Train. 2000;35(3):278–285.
[PubMed: 16558641]
9. +
Kikuchi
K, Itoi
E, Yamamoto
N
et al. Scapular inclination and glenohumeral joint stability: a cadaveric study. J Orthop Sci. 2008;13(1):72–77.
[PubMed: 18274859]
CrossRef 10. +
Ludewig
PM, Reynolds
JF. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther. 2009;39(2):90–104.
[PubMed: 19194022]
CrossRef 13. +
Jana
M, Gamanagatti
S. Magnetic resonance imaging in glenohumeral instability. World J Radiol. 2011;3(9):224–232.
[PubMed: 22007285]
CrossRef 14. +
Waldt
S, Rummeny
EJ. Magnetic resonance imaging of glenohumeral instability. Rofo. 2006;178(6):590–599.
[PubMed: 16703494]
CrossRef 16. +
Cook
C, Hegedus
EJ. Orthopedic physical examination tests: an evidence-based approach. Upper Saddle River, NJ: Pearson Prentice Hall; 2008.
17. +
Magee
DJ. Orthopedic physical assessment. 5th ed. St. Louis, MO: Saunders Elsevier; 2008.
19. +
Itoi
E, Hatakeyama
Y, Kido
T
et al. A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg. 2003;12(5):413–415.
[PubMed: 14564258]
CrossRef 20. +
American Physical Therapy Association. Guide to Physical Therapists Practice. 2nd ed. Phys Ther. 2002;81:9–744.
+
Sonnabend
DH. Treatment of primary anterior shoulder dislocation in patients older than 40 years of age. Conservative versus operative. Clin Orthop Relat Res. 1994;(304):74–77.
Eric Shamus, PhD, DPT, PT, CSCS, Reuben Escorpizo, DPT, MSc, PT
++
+++
CONDITION/DISORDER SYNONYM
++
++
715 Osteoarthrosis and allied disorders
715.11 Osteoarthrosis localized primary involving shoulder region
715.21 Osteoarthrosis localized secondary involving shoulder region
715.9 Osteoarthrosis unspecified whether generalized or localized
++
M19.019 Primary osteoarthritis, unspecified shoulder
M19.219 Secondary osteoarthritis, unspecified shoulder
+++
PREFERRED PRACTICE PATTERNS
++
4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction1
4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders2
4H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Joint Arthroplasty3
4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Bony or Soft Tissue Surgery4
++
PATIENT PRESENTATION
A 48-year-old man who formerly played high school and collegiate football presents with chronic right shoulder pain with progressive loss of function. The patient describes the pain as a deep ache. The patient has all shoulder motions limited. He is slightly weaker on the right side. He denies any neck pain and has full cervical spine range of motion (ROM). The patient had an X-ray that showed decreased joint space at the glenohumeral joint.
++
Most common form of arthritis
Degenerative joint disease
Commonly affects weight-bearing joints
Associated with increased age, obesity, previous trauma, previous surgery
Associated with abnormal loading of joints
Characterized by joint pain
Arthrosis
Osteoarthrosis
Polyarthrosis
++
+++
Essentials of Diagnosis
++
Radiography is standard method for diagnosis
Kellgren and Lawrence (KL) grade ≥2 (definite radiographic OA)5
Osteophytes, joint-space narrowing, sclerosis
Cartilage lesions, bone marrow lesions, synovitis, effusion, and subchondral bone attrition/sclerosis
Erosion of articular cartilage
Synovial hyperplasia
Fibrosis
Inflammatory cell infiltration
Conventional radiograph is most commonly used tool in OA6
Diagnosis is based on a careful history, physical examination, imaging studies, laboratory examination, and exclusion of other possible diseases
+++
General Considerations
++
Low bone-mineral density (BMD)
Repetitive joint use or loading
Joint alignment
Bone or joint morphology
Calcification of the biceps tendon
Bone formation, cyst formation
Thickening of subchondral bone plate, osteosclerosis
Overall joint dysfunction
Joint swelling and inflammation (in certain, severe cases)
Joint pain
Morning stiffness
Long-term disease
Secondary problems
++
More common in middle- to older-aged populations
Women more commonly affected than men
More common in African Americans than other ethnic groups
May affect approximately 12% of the population in the United States and other developed countries7
++
+++
Functional Implications
++
+++
Possible Contributing Causes
++
Chronic factors affecting the joint (obesity, BMD, LLD)
Aging
Chronic and vigorous joint-loading
Previous chronic joint injury (e.g., accident, trauma); secondary OA
++
+++
Differential Diagnosis
++
Rheumatoid arthritis
Gout
Cervical radiculopathy
Rotator cuff tear
Bursitis
Biceps tendinitis
Adhesive capsulitis
Fibromyalgia syndrome
Spondyloarthropathy
+++
MEANS OF CONFIRMATION
++
Synovial fluid examination (optional, not required)
Other laboratory tests can be done to rule out other conditions
++
+++
FINDINGS AND INTERPRETATION
++
OA is a clinical diagnosis, which can be based on
Imaging studies (e.g., radiograph):
Osteophytes, joint-space narrowing, sclerosis
Cartilage lesions, bone marrow lesions, synovitis, effusion, subchondral bone attrition/sclerosis
Erosion of articular cartilage
++
++
REFERRALS/ADMITTANCE
To rheumatologist for assessment of underlying complications
To internal medicine specialist
To orthopedic specialist
To surgeon for surgical consult
To dietician/nutritionist for dietary counseling
++
Mobility
Self-care
Overhead reaching
Sleeping on affected side
Role at home and in community
School and work
Recreation, leisure, sports
++
Pain provocation test
Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function
Shoulder Pain and Disability Index
++
Exercises (resistance, endurance, flexibility)
Training on ADLs
Use of assistive or adaptive devices
Heat therapy
Weight management
Rest
Orthoses, shoulder sling
Ice9
Diet
Acupuncture
Pain management
Energy conservation techniques
Joint protection
Ultrasound10
Electric stimulation11
Patient education
++
Patient will have
Improved joint mobility and stability to reach overhead.
Improved muscle strength to lift dishes into cabinet.
Improved muscle and aerobic endurance.
Improved activity and participation at home, at work, and in the community.
Patient will be able to
Resume ADLs pain-free.
Turn a key or doorknob pain-free.
Lift a baby from crib without pain, maintaining neutral wrist posture.
++
No definite cure for OA.
Treatment is for symptom-management, though emerging drugs may modify OA disease mechanism.
Joint damage is irreversible.
Recovery or relief from symptoms may depend on disease duration and timely intervention.
OA is a chronic disease, may mean long-term burden.
Factors affecting prognosis: Demographics, severity and natural history of disease, medical comorbidities, behavioral comorbidities (fear avoidance, catastrophizing, central sensitization).
General endurance, good muscle strength, and mobile joints are good prognosticating factors.
Motivation and compliance with physical therapy intervention (e.g., home exercise program) and support from family and environment could also improve treatment outcomes.
++
1. +
The American Physical Therapy Association. Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_4. Accessed June 20, 2013.
2. +
The American Physical Therapy Association. Pattern 4F: Impaired joint mobility, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disorders. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_6. Accessed June 20, 2013.
3. +
The American Physical Therapy Association. Pattern 4H: Impaired joint mobility, motor function, muscle performance, and range of motion associated with joint arthroplasty. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_8. Accessed June 20, 2013.
4. +
The American Physical Therapy Association. Pattern 4I: Impaired joint mobility, motor function, muscle performance, and range of motion associated with bony or soft tissue surgery. Interactive Guide to Physical Therapist Practice 2003. DOI: 10.2522/ptguide.3.1_9. Accessed June 20, 2013.
5. +
Kellgren
JH, Lawrence
JS. Atlas of Standard Radiographs. Oxford, UK: Oxford University Press; 1963.
6. +
McKinnis
L. Fundamentals of Musculoskeletal Imaging (Contemporary Perspectives in Rehabilitation). Philadelphia, PA: F.A. Davis; 2005.
7. +
Royal College of Physicians. Osteoarthritis: National Clinical Guideline and Management in Adults. London, UK: Royal College of Physicians; 2008.
10. +
Draper
DO, Prentice
WE. Chapter 10. Therapeutic ultrasound. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/abstract/8138751. Accessed June 20, 2013.
+++
ADDITIONAL REFERENCES
Stacey L. Frazee, DPT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
+++
PREFERRED PRACTICE PATTERN3
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation
++
PATIENT PRESENTATION
A 38-year-old man with a recent supracondylar humerus fracture presents with disproportionate unilateral forearm pain. He is currently experiencing tingling in the area. His radial pulse is absent. Distal phalanges are blanched tint and are cool to the touch. His wrist and fingers are in a flexed position and he has diminished sensation on the volar side of his hand.
++
Flexion contracture of the wrist, resulting in claw-like deformity
Obstruction of brachial artery near the elbow
Three levels of severity
Mild: Contracture of two or three fingers only, only limited sensation deficit
Moderate: All fingers (including thumb) contracted in flexed position; wrist may be in flexion and slight sensation loss
Severe: All muscles in the forearm affected (flexors and extensors)
Arteriolar compression occurs and causes muscle and nerve ischemia
Acute, sensory changes develop after 30 minutes of ischemia
Acute, irreversible nerve damage in 12 to 24 hours
Acute, irreversible muscle changes (i.e., necrosis) in 3 to8 hours
++
+++
Essentials of Diagnosis
++
Diagnosis is typically made by clinical examination and compartment pressure measurement
Severe pain that is not alleviated by elevation or pain medication
Distal pulses are diminished/absent
Strength and sensation are diminished
Edema in affected limb
+++
General Considerations
++
++
Younger age, high-energy/high-velocity trauma, and systemic hypotension associated with an increased risk of traumatic accident
More common in children
High-risk patients include:
Individuals using circumferential wraps, restrictive dressings, casts, or immobilizer are at an increased risk
++
SIGNS AND SYMPTOMS
Swollen and tense tender compartment
Severe pain that does not go away with pain medicine or raising the affected area
Passive extension of fingers is limited and painful
First signs
Paresis
Decreased palpable pulses (radial pulse is absent)
Pallor of skin overlying compartment, paleness of skin
Motor weakness or paralysis
Pain when the area is squeezed
Extreme pain when moving affected area
+++
Functional Implications
++
Flexion contractures in wrist and fingers
Pain out of proportion top that expected from the injury
Decreased strength in affected limb
Loss of sensation and 2-point discrimination deficits
Inability to use upper extremity
Fatigue
+++
Possible Contributing Causes
++
Traumatic compartment syndrome
Car accident
Crush injury
Hematoma
Surgery
Complex fractures
Chronic compartment syndrome
Vascular conditions
Arterial or venous injuries with hemorrhage
Deep vein thrombosis
Constrictive casts or dressings
Tourniquets
Bleeding disorders (i.e., hemophilia)
Soft-tissue injuries
Anabolic steroids
Creatine supplementation5
++
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
Radiographs, bone scans, CT scans, or MRI can be used to rule out fractures and/or muscle tears
Doppler ultrasound used to evaluated arterial flow and rule out DVT
++
++
++
Restoration of blood flow
Subcutaneous fasciotomy to reduce compartmental pressure
Surgery to release fixed tissues and improve function of hand
Hyperbaric oxygen therapy
+++
FINDINGS AND INTERPRETATION
++
++
REFERRALS/ADMITTANCE
For imaging: X-ray, CT, or MRI
For surgery if fasciotomy is required
++
Weakness
Numbness and tingling
Severe pain
++
++
Avoid external pressure
If cast or bandage is causing the problem it should be loosened or removed.
Avoid splints, tight wound dressing.
Rest
Address swelling
Address pain
Wound care
Laser therapy
++
++
Determined by severity and stage of disease at the time treatment was initiated.
Determined by injury leading to the syndrome.
Permanent injury can occur to nerves or muscles if diagnosis is delayed.
Complete recovery if there is good collateral circulation.5
++
3. +
The American Physical Therapy Association. Guide to Physical Therapist Practice. Alexandria,
VA: The American Physical Therapy Association; 2003.
http://guidetoptpractice.apta.org./ Accessed July 4, 2013.
4. +
Hile
AM, Anderson
JM, Fiala
KA
et al.. Creatine supplementation and anterior compartment pressure during exercise in the heat in dehydrated men. J Athl Train. 2006;41(1):30–35.
[PubMed: 16619092]
+++
ADDITIONAL REFERENCES
+
Botte
MJ, Gelberman
RH. Acute compartment syndrome of the forearm. Hand Clin. 1998;14(3):391–403.
[PubMed: 9742419]
+
France
RC. Introduction to Sports Medicine & Athletic Training. 2nd ed. Independence, KY: Cengage Learning. 2011. ISBN 1435464362.
+
Geiderman
JM, Katz
D. General principles of orthopedic injuries. In:Marx
J Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby Elsevier; 2009: Chapter 46.
+
Goodman
CC, Fuller
KS. Pathology Implications for the Physical Therapist. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2009.
+
Gourgiotis
S, Villias
C, Germanos
S, Foukas
A, Ridolfini
MP. Acute limb compartment syndrome: a review. J Surg Educ. 2007;64(3):178–186.
[PubMed: 17574182]
CrossRef +
Hensinger
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