SECTION E: ELBOW AND FOREARM DISORDERS

CONDITION/DISORDER SYNONYMS

• Elbow bursitis

• Student’s elbow¹

• Draftsman’s elbow¹

• Miner’s elbow

ICD-9-CM CODE

• 726.33 Olecranon bursitis

ICD-10-CM CODE

• M70.20 Olecranon bursitis, unspecified elbow

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation

KEY FEATURES

Description

• 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

Demographics

• 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

CLINICAL FINDINGS

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

• Acute olecranon fracture

• Gout

• Olecranon apophysitis/avulsion fracture

• Olecranon bursa infection

• Rheumatoid arthritis

• Triceps tendinitis

MEANS OF CONFIRMATION OR DIAGNOSIS

Laboratory Tests

• Aspirated fluid can be cultured and evaluated for crystals to rule out gout and septic bursitis

• Laboratory studies for suspected rheumatoid disorders

Imaging

• Radiographs usually taken to rule out olecranon fracture

• MRI

FINDINGS AND INTERPRETATION

• MRI will show increased fluid/edema isolated within the olecranon bursa

• T2-weighted MRI would best visualize and result in increased signal intensity within olecranon bursa

TREATMENT

Medication

• NSAIDs

• Corticosteroid injection

• Antibiotics, if infection confirmed

MEDICAL PROCEDURES

• Aspiration may assist in recovery

• Surgical excision

IMPAIRMENTS

• Restricted range of motion in elbow for reaching activities

• Decreased strength for pushing activities

TESTS AND MEASURES

• 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

INTERVENTION

• 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

    • Ice

    • High-Voltage Pulsed Stimulation (HVPS)

    • Iontophoresis

    • Ultrasound

    • Extracorporeal Shock Wave Therapy (ESWT)

  • Addressing swelling

    • Ice

    • Elevation

    • Iontophoresis

    • Increased focus on compression

  • 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

FUNCTIONAL GOALS

• 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.

PROGNOSIS

• 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.

REFERENCE

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Elbow subluxation

• Nursemaid’s elbow

ICD-9-CM CODES

• 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

ICD-10-CM CODES

• 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

KEY FEATURES

Description

• 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

  • Subluxation of the radial head

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.

Demographics

• 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

CLINICAL FINDINGS

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

• Ligamentous laxity

• Participation in contact or high-velocity sports

Differential Diagnosis

• Elbow or distal humerus fractures

• Brachial plexus injury

• Muscle rupture

MEANS OF CONFIRMATION OR DIAGNOSIS

Laboratory Tests

• No special tests noted

• Tuning fork for vibration irritation

• Suspicion of neurologic or vascular compromise warrants immediate medical referral

Imaging

• Pre- and postreduction radiographs necessary to evaluate for presence of associated fractures

• CT scan possible for further evaluation of suspected fractures

  • Axial CT, ORIF

• 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

TREATMENT

Medication

• Nonsteroidal anti-inflammatory drugs (NSAIDs) as prescribed by physician

• Pain medication as prescribed by physician

MEDICAL PROCEDURES

• Surgical intervention possible for fracture presence or with associated soft tissue injury (collateral ligament tear)

• Bracing for protection of soft tissues

IMPAIRMENTS

• Restricted ROM in elbow for reaching activities

• Decreased strength for pushing activities

TESTS AND MEASURES

• Neurologic examination

• ROM

• Strength assessment

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

INTERVENTION

• 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

    • Ice

    • High-voltage pulsed stimulation

    • Ultrasound

    • Extracorporeal shockwave therapy

  • Addressing swelling

    • Ice

    • Elevation

  • 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

    • May be necessary if associated neurovascular or soft tissue injury is present

FUNCTIONAL GOALS

• 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

PROGNOSIS

• 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

REFERENCE

ADDITIONAL REFERENCES

ICD-9-CM CODES¹

• 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

ICD-10-CM CODES²

• 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

• 4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Fracture³

KEY FEATURES

Description

• 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

• Radius is the most commonly broken bone in the arm.

• Occurs in about 20% of all acute elbow injuries.

Demographics

• More frequent in women than in men

• Occurs most often between 30 and 40 years of age

CLINICAL FINDINGS

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

• Mechanism of injury

• Fall on outstretched hand

• Blunt or penetrating trauma is a rare cause

Differential Diagnosis

• Proximal radioulnar subluxation/dislocation

• Humeroradial subluxation/dislocation

• Radial collateral ligament sprain

MEANS OF CONFIRMATION

Imaging

• X-ray for fracture, often limited view

• CT scan for detailed imaging

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.

IMPAIRMENTS

• 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

TESTS AND MEASURES

• 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

INTERVENTION

• 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

  • Scar tissue mobilization progressing from parallel to perpendicular upon wound closure

FUNCTIONAL GOALS

• 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.

PROGNOSIS

• Good, if there is mechanical stability with reduction and stable internal fixation.

• Some residual loss of elbow extension is expected.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Lateral tendon injury

• Lateral tendonitis

• Lateral humeral epicondylitis

• Tennis elbow

• Lateral tennis elbow

ICD-9-CM CODE

• 726.32 Lateral epicondylitis

ICD-10-CM CODE

• M77.10 Lateral epicondylitis, unspecified elbow

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation¹

KEY FEATURES

Description

• 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

Demographics

• 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

CLINICAL FINDINGS

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

Laboratory Tests

• Laboratory studies for suspected rheumatoid disorders

Imaging

• Radiographs

• Electromyography (EMG) for patients with neurologic alterations⁵

• MRI can show inflammation/edema and microtearing

FINDINGS AND INTERPRETATION

• Radiographs

  • Usually normal

  • Can show calcification of ECRB: Anteroposterior and lateral views

TREATMENT

Medication

• Anti-inflammatory

• Corticosteroid injection

• NSAIDs⁶

IMPAIRMENTS

• Hand weakness with grasping, squeezing, pinching

• Restricted ROM in elbow and wrist

TESTS AND MEASURES

• Cozen test

• Mill test

• Tinel sign at elbow

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Froment sign

INTERVENTION

• 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

    • Ice⁸

    • High-voltage pulsed stimulation

    • Iontophoresis

    • Ultrasound¹⁰

    • Extracorporeal shockwave therapy¹¹

  • 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

FUNCTIONAL GOALS

• 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.

PROGNOSIS

• Good; prolonged period of healing can last up to 1 year.

• Recalcitrant cases and individuals with prolonged pain not resolved after 1 year may require surgical intervention.

ADDITIONAL INFORMATION

For additional information, please see the Case Study in Chapter 15 of Orthopaedic Examination, Evaluation, and Intervention on www.accessphysiotherapy.com ⁵

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Medial tendon injury

• Medial tendonitis

• Golfer’s elbow

• Bowler’s elbow

• Little leaguer’s elbow

ICD-9-CM CODE

• 726.31 Medial epicondylitis

ICD-10-CM CODE

• M77.00 Medial epicondylitis, unspecified elbow

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation¹

KEY FEATURES

Description

• 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.

Demographics

• 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

CLINICAL FINDINGS

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

Laboratory Tests

• Laboratory studies for suspected rheumatoid disorders

Imaging

• 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

TREATMENT

Medication

• Anti-inflammatory

• Corticosteroid injection

• NSAIDs⁶

IMPAIRMENTS

• Hand weakness with grasping, squeezing, pinching

• Restricted ROM in elbow and wrist

TESTS AND MEASURES

• Cozen test

• Mill test

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Tinel sign at elbow

• Froment sign

INTERVENTION

• 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

    • Ice⁸

    • High-voltage pulsed stimulation

    • Iontophoresis

    • Ultrasound¹⁰

    • Extracorporeal shockwave therapy¹¹

  • 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

    • Lateral tilt of the humeroulnar joint

FUNCTIONAL GOALS

• 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.

PROGNOSIS

• Good; prolonged period of healing can last up to 1 year.

• Recalcitrant cases and individuals with prolonged pain not resolved after 1 year may require surgical intervention.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• GH instability

• Anterior or anterior-inferior GH instability

• Posterior GH instability

• Multidirectional GH instability

ICD-9-CM CODE¹

• 831.00 Closed dislocation of shoulder

ICD-10-CM CODES

• 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

KEY FEATURES

Description

• 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 joint^3,4

• Symptomatology and management vary based on onset, degree, frequency, direction, associated pathology, neuromuscular control, and premorbid activity level⁴

  • Anterior or anterior-inferior instability

    • Mechanism

      • 95% of traumatic shoulder instabilities⁴

      • May result in dislocation or subluxation

      • The humerus is forced into extreme abduction and external rotation, or horizontal abduction

      • Associated pathology includes Bankart lesion (anterior), humeral avulsion of glenohumeral ligaments (HAGL), and Hill–Sachs lesion⁵

    • Symptoms

      • Anterior and inferior shoulder pain

      • Instability and apprehension to abduction, external rotation, horizontal abduction motions

  • Posterior instability

    • Mechanism

      • 5% of traumatic shoulder instabilities⁴

      • May result in dislocation or subluxation

      • Fall on an outstretched arm, movements of extreme horizontal adduction or internal rotation

      • Associated pathology includes disruption of the posterior capsule, tearing of the teres minor, reverse Hill–Sachs lesion⁶

    • Symptoms

      • Posterior shoulder pain

      • Instability and apprehension to flexion, horizontal adduction, internal rotation

  • Multidirectional instability

    • Mechanism

      • May occur without episode of trauma, though patient may have a history of traumatic dislocation⁷

      • May result in dislocation or subluxation

      • Instability and apprehension present in multiple directions, though one direction may be the primary direction of instability

      • Associated pathology depends on primary direction of instability, duration of instability, history of trauma^4,7

    • Symptoms

      • Pain and instability are often determined by the direction of primary instability and can vary based on activity

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 plan^8,9

Demographics

• 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

CLINICAL FINDINGS

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 athletes^4,7

• 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

• Differential diagnosis may be direction-specific

  • Bankart lesion (anterior)¹⁰

  • Humeral avulsion of glenohumeral ligaments (HAGLs), anterior

  • Hill–Sachs lesion (anterior)¹⁰

  • Reverse Hill–Sachs lesion (posterior)¹¹

  • Tearing of posterior capsule (posterior)

  • Tearing of teres minor (posterior)

  • Marfan syndrome

  • Osteogenesis imperfecta

  • Ehlers–Danlos syndrome

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• MRI and MR arthrography¹⁰ are images of choice for instability^12,13

  • Conventional-traumatic

  • Arthrography-chronic

• CT¹⁴

• Conventional radiograph¹⁰

Diagnostic Procedures

• Arthroscopy

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

TREATMENT

Medication

• Anti-inflammatory

MEDICAL PROCEDURES

• Surgery

• Bankart repair

• Thermocapsular shift

IMPAIRMENTS

• 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

TESTS AND MEASURES

• Anterior instability^15,16

  • Apprehension test

  • Apprehension-relocation test

  • Sulcus sign¹⁰

  • Anterior slide (drawer) test¹⁰

  • Load and shift test¹⁰

  • Crank test¹⁰

• Posterior instability^15,16

  • Posterior apprehension test

  • Posterior drawer

  • Load and shift test

  • Sulcus sign

• Multidirectional instability^15,16

  • Sulcus sign

  • All tests for anterior and posterior instability are appropriate and may be indicated

• 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

• Intervention based on type (traumatic or atraumatic), onset, degree, frequency, direction, and potential associated pathology^4,17

• 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

FUNCTIONAL GOALS

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.

PROGNOSIS

• 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

REFERENCES

ADDITIONAL REFERENCE

CONDITION/DISORDER SYNONYM

• Glenohumeral joint osteoarthritis (OA)

ICD-9-CM CODES

• 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

ICD-10-CM CODES

• 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

KEY FEATURES

Description

• 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

  • Muscle atrophy and weakness

  • Bony protrusion or prominence

  • Joint deformity

  • Difficulty with ADLs

Demographics

• 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

CLINICAL FINDINGS

Functional Implications

• Limited mobility

• Household and work-related activity limitations/restrictions

• Decreased overall activity and participation

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

Laboratory Tests

• Synovial fluid examination (optional, not required)

• Other laboratory tests can be done to rule out other conditions

Imaging

• Conventional radiograph of the joint

• MRI of the joint

• Diagnostic ultrasound of the joint and synovium⁸

FINDINGS AND INTERPRETATION

• OA is a clinical diagnosis, which can be based on

  • Persistent usage-related pain in joint or joints

  • Age ≥45 years⁷

  • Morning stiffness ≤30 minutes⁷

• 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

TREATMENT

• Surgery: Total joint replacement, joint lavage, and debridement

• Medication

  • NSAIDs (including topical NSAIDs, capsaicin)⁸

  • Acetaminophen

  • Opioids

  • Glucosamine and chondroitin sulfate

  • Glucocorticoids or corticosteroids

  • Intra-articular injections (corticosteroids, hyaluronic acid)

  • Emerging drugs: Anti-tumor necrosis factor (anti-TNF), calcitonin, growth factors, nerve growth factor antibodies

IMPAIRMENTS

• Mobility

• Self-care

• Overhead reaching

• Sleeping on affected side

• Role at home and in community

• School and work

• Recreation, leisure, sports

TESTS AND MEASURES

• Pain provocation test

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Shoulder Pain and Disability Index

INTERVENTION

• Exercises (resistance, endurance, flexibility)

  • Aquatic exercises

• 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

FUNCTIONAL GOALS

• 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.

PROGNOSIS

• 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.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Forearm, anterior compartment syndrome

• Volkmann contracture

• Volkmann ischemic contracture

ICD-9-CM CODE¹

• 958.6 Volkmann ischemic contracture

ICD-10-CM CODE²

• T79.6 Traumatic ischemia of muscle

PREFERRED PRACTICE PATTERN³

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation

KEY FEATURES

Description

• Flexion contracture of the wrist, resulting in claw-like deformity

• Obstruction of brachial artery near the elbow

  • Obstruction commonly caused by compartment syndrome or fracture

• 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

  • Pain increases with passive/active range of motion and compression

• Distal pulses are diminished/absent

• Strength and sensation are diminished

• Edema in affected limb

General Considerations

• Occurs in the flexor/volar compartment of the forearm

  • Flexor digitorum profundus becomes fibrotic and shortened

  • Flexor pollicis longus becomes fibrotic and shortened

• Classic P’s

  • Pain

  • Pallor

  • Pulselessness

  • Paresthesias

  • Paralysis

• Complications

  • Infection

  • Contractures

  • Deformity

  • Amputation

  • Acidosis

  • Hyperkalemia

  • Myoglobinuria

  • Acute renal failure and shock

Demographics

• 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:

  • Soft-tissue injury in males aged <35 years with bleeding disorder or receiving anticoagulants

  • Crush injury patients

  • Patients with prolonged limb compression

• Individuals using circumferential wraps, restrictive dressings, casts, or immobilizer are at an increased risk

CLINICAL FINDINGS

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

    • Supracondylar fracture of humerus

    • Radial fracture

• Chronic compartment syndrome

  • Repetitive activities

  • Poor upper extremity biomechanics

• Vascular conditions

  • Arterial or venous injuries with hemorrhage

  • Deep vein thrombosis

  • Constrictive casts or dressings

  • Tourniquets

  • Bleeding disorders (i.e., hemophilia)

• Soft-tissue injuries

  • Burns

  • Crush injury

  • Contusion

  • Snakebite

  • Prolonged limb compression

• Anabolic steroids

• Creatine supplementation⁵

Differential Diagnosis

• Forearm compartment syndrome

• Rhabdomyolysis

• Carpal tunnel syndrome

• Fracture

• Periostitis

• Tumor

• Nerve entrapment

• Muscle tear

• Necrotizing fasciitis

• Cellulitis

• Cnidaria Envenomation

• Gas Gangrene

• Peripheral vascular injuries

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• 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

Diagnostic Procedure

• Intracompartmental pressure measurements

• Pulse oximetry to identify limb hypoperfusion

TREATMENT

Medication

• Non-steriodal anti-inflammatory drugs (NSAIDs)

MEDICAL PROCEDURES

• 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

• Emergency surgery to prevent permanent damage with pressure measurements of ≥30 mm Hg

IMPAIRMENTS

• Weakness

• Numbness and tingling

• Severe pain

TESTS AND MEASURES

• Pain, visual analog scale (VAS)

  • 24-hour pain

  • Worst average pain

  • Best average pain

  • Tenderness on palpation

• Cardiovascular integrity

  • Blood pressure at rest and after activity

  • Palpation of distal pulses

  • Capillary refill

• Skin integrity

  • Associated skin assessment

    • Edema (linear girth measurements, palpation)

    • Color

    • Temperature

• Neurologic examination

  • Sensation

    • Light touch

    • Pin prick Limb sensation

    • 2-point discrimination

  • Upper extremity deep tendon reflexes

  • Proprioception

  • Kinesthetic awareness

  • Coordination

• Limb strength

  • Manual muscle test (MMT)

INTERVENTION

• 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

FUNCTIONAL GOALS

• The patient will be able to:

  • Regain full ROM in upper extremity (UE).

  • Return to activities such as computer use, writing, and driving.

PROGNOSIS

• 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

REFERENCES

ADDITIONAL REFERENCES