dysfunctions of the shoulder, arm and hand

Dysfunctions of the Shoulder, Arm andHand

© Australian Institute of Fitness 1 / 70

POSSIBLE CAUSES OF PAIN AND\ORLIMITATION OF MOVEMENT IN THESHOULDER REGIONThere are several factors that can affect the sensation of pain and the smooth and efficientfunctioning of the shoulder complex. Three typical causes of pain in the shoulder and upper limbinclude visceral referral, neural referral and musculoskeletal pain.


Visceral Referral

An important symptom that must be remembered when evaluating shoulder injuries is referredvisceral pain. Many issues affecting the viscera will cause pain in a part of the body away from aninjured area. For example, acute heart conditions can cause pain in the (L) shoulder and upperlimb. An injured spleen may cause pain in the left shoulder and upper arm or an injury to theliver may refer to pain to the right shoulder.

The most accepted theory of visceral referral suggests that visceral pain fibres synapse withneurons in the spinal cord that receive pain fibres from the skin in the referred area.

Below is a list of the common referral sites for shoulder pain corresponding to the offendingviscera.

Organ Area of body to which pain may be referredDiaphragm Anterior shouldersHeart Base of neck, left jaw, and left shoulder and armLiver Right shoulderSpleen Left shoulder and upper third of arm

Visceral referral patterns


Neural Referral

Spinal nerves supply sensation to the skin in dermatomes related to the level of the spinal nerve.The spinal nerves also supply sensation from structures such as muscles, bones, joint capsules,fascia and vessels in any given area. Typical skin areas that nerves supply sensation to arecalled dermatomes. A compromised nerve could refer pain along any part of the dermatome.

Dermatome patterns in the upper limb


Muscle Referral

Voluntary, or skeletal, muscle is the largest single organ of the human body and accounts fornearly 50% of the body's weight. Myofascial trigger points (TrPs) are extremely common andbecome a painful part of nearly everyone’s life at one time or another. Latent TrPs, which oftencause motor dysfunction (e.g.: stiffness, restricted range of motion) without pain, are far morecommon than active TrPs that cause pain. Active TrPs are found in postural muscles of theshoulder such as the upper trapezius, teres minor and major, deltoids, supraspinatus,subscapularis and the pectorals. The activation of a TrP is usually associated with some degreeof mechanical abuse of the muscle in the form of muscle overload, which may be acute,sustained, and/or repetitive. In addition, leaving the muscle in a shortened position can convert alatent TrP to an active TrP. Clients with active myofascial TrPs usually complain of poorlylocalised, regional, aching pain in subcutaneous tissues, including muscles and joints. Themyofascial pain is often referred away from the TrP in a pattern that is characteristic for eachmuscle.

Myofascial trigger points of the upper trunk


ADHESIVE CAPSULITISAdhesive capsulitis is a chronic shoulder condition that is characterised by limited ROM in allplanes and inflammation of the articular synovial structures, tendons, joint capsules and bursa.

Adhesive capsulitis


Aetiology

Also known as “Frozen Shoulder” this condition primarily affects women in the 40-60 year agegroup. Onset is insidious and increased prevalence in the non-dominant arm is observed.Secondary causes may be rheumatoid arthritis, osteoarthritis, fracture, dislocation or interarticularvascular synovitis.

Clinical Features

Complete inability to abduct the arm over 30 degreesArm often held in medial rotation and adductionTenderness upon digital palpation of the deltoid insertion, bicipital groove, and greatertuberosityGradual progressive restriction of all joint movements ranging from months to yearsSeverely diminished abduction and exquisite pain on external rotationThere is shoulder muscle weakness and soft tissue inflammationPain most frequently radiates to the elbow joint and along the C5 dermatome.

Differential Diagnosis

FractureContusionStrainSubacromial bursitis.

Management

Moist heat followed by NMT to surrounding musculature to reduce abnormal musclecontractionTransverse friction massage at the site of involvement, stroking perpendicular to the fibrealignment to increase fibre mobility without longitudinal stress, thus promoting orientation offibres and induces hyperaemia to hypovascular tissuesMET to shoulder and scapulaNMT to neck and shoulder musculaturePassive ROM exercises (pain free)Strengthen the dynamic shoulder stabilisersAvoid any exercise that increases pain.


Exercises to encourage ROM during the protracted recovery from adhesive capsulitis


SHOULDER IMPINGEMENTShoulder impingement occurs when subacromial structures are squashed between theacromion, coracoacromial arch and AC joint above and the glenohumeral joint below. Theimpingement causes mechanical irritation of the rotator cuff tendons (especially supraspinatus)and/or the subacromial bursa resulting in swelling and tissue damage.

Shoulder impingement may be:

Primary external impingementSecondary impingementInternal impingement


Primary External Impingement

Abnormalities to the superior structures may lead to encroachment into the subacromial spacefrom above. The under surface of the acromion may be beaked, hooked or curved which resultsfrom either a congenital abnormality or osteophyte formation. Other abnormalities that tend tooccur in older age groups include thickening of coracoacromial arch or osteophyte formation onthe inferior surface of the AC joint.

Type I (flat) Type II (curved) Type III (hooked) acromian variations. Type III is implicated inprimary impingement.


Secondary External Impingement

Inadequate stabilisation of the scapula may lead to excessive angulation of the acromion, whichmay also encroach, into the subacromial space. Muscles such as serratus anterior, middletrapezius and rhomboids may become weak or out of balance with one another and fail tocontrol the dynamic position of the scapula with glenohumeral movement.

GH instability results in increased translation of the humeral head in an antero-superior direction,thus narrowing the subacromial space.

This imbalance may lead to the humeral head moving superiorly with deltoid contraction, therebynarrowing the space through which the rotator cuff tendon pass, leading to ischaemia and furtherdamage.

External impingement of the shoulder. Note the proximity of the subacromial bursa andsupraspinatus tendon to the coracoacromial arch.


Internal Impingement

Internal impingement also known as glenoid impingement occurs mainly in overhead athletesduring the late cocking stage of throwing (extension, abduction and external rotation) whenimpingement of the under surface of the rotator cuff occurs against the posterior-superior surfaceof the glenoid. This is normally a physiological occurrence but becomes pathologic in theoverhead athlete due to repetitive microtrauma.

Internal impingement is more common in repetitive overhead activities.


ROTATOR CUFF TENDINOPATHYWhen the rotator cuff tendons become pathological they can be a source of shoulder pain.Tendinopathy can result from overuse, excessive load or faulty biomechanics.

Tendon degeneration in tendinopathy


Clinical Features

HistoryPain – primarily on top and in the front of the shoulder.Pain is usually is worse with any overhead activityMild to moderate weakness, especially with overhead activity.Unable to sleep on shoulder – most clients complain of difficulty sleeping on the shoulder atnight.

Palpation|Tenderness over the supraspinatus tendon proximal to or at its insertion into the greater tubercleof the humerus.

Range of motionActive movement may reveal a painful arm on abduction between approximately 70-180 degreesin abduction (painful arc). Internal rotation is often reduced.


Orthopaedic Examination

Apley’s Scratch TestNeer Impingement TestHawkins-Kennedy Impingement TestPosterior Internal Impingement Test.


Treatment Goals

Promote soft tissue healingRelieve pain and prevent recurrenceIncrease pain free range of motionRestore normal strength and stability to joint structureQuickly change to rehabilitation and restoration of function


Management

Acute phaseIce massage over the involved area for approximately 3 minutes.Manual capsular stretching and NMT.Sub-acute phaseMoist heat followed by NMT to surrounding musculature to reduce abnormal musclecontraction, assess and treat as necessary all muscles that affect the shoulder girdle and theneck. MET to shoulder and scapula.Therapeutic exerciseExercises prescribed include graded exercises for scapular control, closed kinematic chainexercises followed by open kinematic chain exercises.


ROTATOR CUFF TEARRupture of the rotator cuff can result from severe trauma as well as from daily activities. Rotatorcuff rupture can be derived as degenerative thinning and fissuring of the cuff in the hypovascularzone which is exposed to impingement or direct trauma and consequently leading to tearing ofthe cuff fibres. There are many predisposing factors which can lead to rupture of the rotator cuffthese include:

Degenerative changesMechanical traumaGenetic factorsMetabolic factorsDaily activities as added traumaAgeing factors (not clearly delineated).

Rotator cuff tear


Injury Mechanism

Four key mechanism have been put forward for tears to the rotator cuff:

Relatively minor trauma imposed upon a degenerative cuff.Direct fall upon the outstretched arm, transmitting the damaging force of the humeral headagainst the acromial arch.Impingement of the rotator cuff against the acromion and coracoacromial ligamentfrom poorshoulder mechanicsDirect fall upon the arm which remains at the side, but the impact is on the anterior portion ofthe humeral head, causing posterior subluxation as well as direct trauma to the exposedgreater tubercle and tendon insertion.

Rotator cuff tears occur most frequently between the ages of 45 and 65 from trivial trauma, butwhen it occurs at a younger age the trauma is usually more severe and the tear more significant.

Direct impact from a fall onto the shoulder can result in a rotator cuff tear.


Clinical Features

History

Sudden onset with pain primarily on top and in the front of the shoulder.Worse with any overhead activityWeakness – moderate to severe weakness, especially worse with overhead activity.Unable to sleep on affected side

Physical examination

Tenderness in the sub-acromial space.Atrophy may be apparent in the supraspinatus or infraspinatus fossa in clients with full-thickness tears.Passive movement often pain free.Active, and resisted ROM tests elicit significant pain and /or weakness


Management

Acute phase

RICE.

Subacute phase

NMT to surrounding musculature to reduce abnormal muscle contraction.MET to shoulder and scapula.NMT to neck and shoulder musculature.Passive ROM exercises when pain merits.Strengthen and control exercises for the dynamic shoulder stabilisers.

Medical and surgical options

Analgesics – primarily help to reduce pain, minimal effect on ROM.Surgery to repair musculotendinous lesion.


SUBACROMIAL BURSITISA chronic inflammation of the subacromial bursa that sits on top of the supraspinatus tendon.

The subacromial burs sits between the supraspinatus tendon and the coracoacromial arch.


Clinical Features

HistoryPain can vary from an achy pain and stiffness to the local area of the joint, to a burning thatsurrounds the whole joint around the inflamed bursa. With this condition, the pain is usuallyworse during and after activity, and the bursa and surrounding joint area can become stiffer thefollowing day.

Differential diagnosis

Supraspinatus tearSupraspinatus impingement

Physical examinationRestricted active movement into abduction / flexionPositive impingement signMay be weakness in resisted abduction


Management

Acute phaseIce, analgesics and anti-inflammatories.

Subacute phase

Address muscle imbalancesManual techniques to improve specific areas of hypertonicity or restriction


Medical and Surgical Options

Cortisone injections can be helpful if conservative management fails.

Surgery to decompress sub-acromial space of remove bursa may be indicated in recalcitrantcases.

Injection site for subacromial bursitis


BICIPITAL TENDONITISBiceps tendonitis is an inflammatory process of the long head tendon and is a common cause ofshoulder pain due to its position and function. The tendon of the long head of biceps is exposedon the anterior shoulder as it passes through the bicipital groove and inserts on the supra glenoidtubercle. Disorders can result from impingement or as an isolated inflammatory injury. Othercauses are secondary to compensation to rotator cuff disorders, labral tears, and intra-articularpathology.

Bicipital tendonitis


Clinical Features

Anterior shoulder pain that is worse during forward flexion of the shoulder.Local tenderness of the biceps brachii long head tendon either in the bicipital groove close toits attachment to the glenoid or at its musculotendinous junction.Pain may be reproduced by passive stretching of the biceps or resisted active contraction ofthe biceps.


Referred painRotator cuff tendinopathyImpingement syndromeLabral tears

Resisted shoulder flexion (Speed’s test) is often provocative in bicipital tendonitis


Management

Acute phase

Ice massage over the involved area for approximately 3 minutes.Rest from any activity that aggravates symptoms.

Subacute phase

NMT to surrounding neck and shoulder musculature to reduce abnormal muscle tonus.Exercise to address inappropriate biomechanics and muscle synergies.Correction of poor technique if appropriate in throwing sports, racquet sports or weighttraining.


AC SEPARATIONWhen the acromio-clavicular joint is disrupted, it is called a shoulder separation. Another namefor this injury is an acromioclavicular joint separation, or AC separation. A shoulder separation isalmost always the result of a sudden, traumatic event that can be attributed to a specific incidentor action. In collision sports such as rugby, AFL, MMA, cycling and snowboarding AC jointdisruptions are a common shoulder injury.

Because of their increased participation in collision sports, males are 5-10 times more likely tohave an AC joint injury than females.


Injury Mechanism

The two most common descriptions of a shoulder separation are eithera direct blow to the shoulder (often seen in football, rugby, or MMA) ora fall on to an outstretched hand (commonly seen after falling off abicycle or horse).


Anatomy

The clavicle is attached to the acromion through theAC ligament that surrounds the joint, the strongest inthe superior and anterior/posterior regions. Acartilaginous disk occupies the space between theclavicle and acromion and provides cushioning. Twosets of ligaments stabilise the AC joint (i.e., the ACand coracoclavicular (CC) ligaments). The ACligaments support the capsule of the AC jointanteriorly, posteriorly, superiorly, and inferiorly. Thesuperior ligament is considered to be the strongest ofthe AC ligaments, and its fibres join those of thedeltoid and trapezius muscles, both of which areimportant in the dynamic

support to the joint. The CC ligament complex also is important for the stability of the AC joint andis comprised of the conoid ligament and the trapezoid ligament. The CC ligament complex isbelieved to be responsible for the vertical stability of the AC joint, and the AC ligamentscontribute more to horizontal stability.


Clinical Features

Inability to sleep on the injured side.Significant tenderness directly over the superior shoulder.Swelling and prominence over the distal clavicle often is observed.Step deformity if high grade separation injury.Ranges of movement are restricted in all planes. Horizontal flexion is generally restricted andpain limited.Weakness due to pain inhibition, particularly in scapular elevation, shoulder abduction andshoulder flexion.


Clavicle fractureAcromion fractureLigament tearsRotator cuff injuryShoulder dislocationShoulder impingement syndromeSuperior labrum lesions


Management

Sling to restrict movement.Moist heat followed by NMT to surrounding musculature toreduce abnormal muscle contraction.Massage at the site of involvement.MET to shoulder and scapula.NMT to neck and shoulder musculature. Passive ROM exercises when pain merits.Functional strengthening to restore stability, strength andcontrol through range.


ACROMIOCLAVICULAR LIGAMENT SPRAINThe AC joint is commonly injured by either a direct lateral blow to the shoulder or indirect injuriessuch as in all body contact sports, after a fall onto the point of the shoulder. Injuries are dividedinto three grades as follows:

Grade 1Grade 2Grade 3


Clinical Features

Grade 1Tear in some fibres of the AC joint without any joint displacement. Pain swelling tendernessare localised over the joint and no obvious deformity or instability present. Passive shouldermovements, especially horizontal flexion of the arm across the body, usually reproduce theclient’s pain. Grade 2Damage includes a disruption of the joint capsule and the acromioclavicular ligament fibreswhich allows the joint to sublux, so that the clavicle moves slightly upwards. A slight stepdeformity is present. Abduction of the shoulder is painful beyond 80°. Pain is also reproducedon horizontal flexion of the shoulder. Grade 3Also referred to as AC separation. The ligaments that stabilise the AC joint are disrupted sothat the clavicle becomes dislocated upwards on the acromion. The AC ligaments andusually the coracoclavicular ligaments and attachments of the deltoid and trapezius areruptured allowing further elevation of the clavicle. Dislocation is readily observed as the clientstands with arms by the sides may be mad more obvious by holding a weight in the hand onthe affected side. X-rays are essential for confirming diagnosis.


Management

Grade 1Initial rest, ice and analgesics, pain usually settles after the acute inflammation phase whereactive exercises can be commenced. Grade 2Supporting arm in a sling until the strong pain settles over 5-10 days. Mobilisation techniquesare performed by a suitable manual therapist. MET to regain pain free motion.Active exercises would commence as soon as pain free range is established. Grade 3Conservative treatment involves reducing and immobilising the dislocation, this is normallyperformed with the use of strapping, slings, bracing and plaster casts. Conservative treatmentshould be used for at least 6 weeks before assessment of the need for surgery.Conservative management is the same as for shoulder separation


AC JOINT ARTHRITISAC joint osteoarthritis is common. It may result fromprevious trauma or may follow a rupture of the rotatorcuff, which allows the head of the humerus to subluxupwards.

Clinical Features

AC joint arthritis often presents as swelling over the joint.May be asymptomatic and pain usually develops afterexcessive use of the joint in the middle aged client. Painmay occur after playing golf or from movements thatinvolve the repetitive use of the shoulder with the armoverhead. Pain may be reproduced by passivemovement of the joint or horizontal flexion of theshoulder. Accessory movements are restricted andpainful. Crepitus is often palpable over the joint. Thediagnosis can be confirmed from radiography.

Management

Rest from aggravating shoulder movements.Range of motion exercises in pain-free rangeMET and soft tissue techniques to surrounding musculature.Exercises to optimise control and function once pain settles.


SHOULDER INSTABILITYAtraumatic instability is a condition in which the humerus starts to move excessively in the jointwithout having had a significant injury. Atraumatic instability may arise from a variety of causes. Aflat or small socket, weak muscles, stretchy ligaments, periods of disuse, and loss of normalcoordination may contribute to atraumatic instability.

In some cases capsular tightening by surgery may be considered. The postoperativerehabilitation after this surgery is particularly important.


Contributing Factors

A shoulder that has been stable may become unstable after a minor injury or a period of disuse.

Features that make a shoulder more susceptible to atraumatic instability include:

A flat or small glenoid fossa.Thin, excessively compliant capsular tissue surrounding the joint. Weak muscles that provideinsufficient force for the dynamic stabilising mechanism.Poor neuromuscular control may fail to position the scapula to balance the net humeral jointreaction force.


Aetiology

Shoulder instability often begins with some minor event or series of events which lead toprogressive decompensation of the glenohumeral stability mechanisms. An awkward lift,reaching over the back seat of the car, or a sneeze may be all that is necessary to launch thepredisposed, but compensated, shoulder down the path toward instability. The client notices thatthe shoulder has become loose and may feel it slip out and clunk back in with different activities.These episodes almost never require manipulative reduction. The instability may be sufficientlysubtle that the client is unaware of the humerus translating on the glenoid. The client may only beaware of a feeling that the shoulder does something unnatural in certain positions, or that certainfunctions cannot be performed, such as reaching out in front or lifting at the side.

Grades of laxity in the glenohumeral joint.


Management

Surgery is not always an option. The goal of treatment for clients with atraumatic instability is therestoration of shoulder function. Many clients with the shoulder instability have simply becomede-conditioned from their normal state of dynamic glenohumeral stability. They have lost theproper neuromuscular control of humeroscapular positioning and concavity compression hasbecome dysfunctional. An exercise program of control and dynamic stability exercises thataddresses inappropriate joint mechanics is essential.


GLENOHUMERAL DISLOCATIONDislocation of the glenohumeral joint is an extremely common acute injury in which the articularsurfaces of the humerus and the glenoid of the scapular are completely separated. The shoulderis the most commonly dislocated joint in the body, and up to 96% of these dislocations aretraumatic in nature. The direction of dislocation can be anterior, posterior, superior, or inferior;however, approximately 85% are anterior.


Injury Mechanism

The most common mechanism for a shoulder dislocation is a fall where the shoulder is in aposition of abduction and external rotation.


Management

Acute phaseReferral to a medical professional for the joint to be reduced (put back into place).

Subacute phase

Moist heat followed by NMT to surrounding musculature to reduce abnormal musclecontraction.Passive ROM exercises when pain allows.MET to shoulder and scapula musculature.NMT to neck and shoulder musculature.Strengthen the dynamic shoulder stabilisers.A exercise program of control and dynamic stability exercises with particular emphasis onimproving strength and proprioception around the dislocation position.


Surgical Options

Depending upon the damage and level of recurrent instability, procedures to tighten the capsuleof the shoulder may be considered. This can be done with an arthroscope in a procedure called athermal capsular shrinkage. In this surgery, a heated probe shrinks the shoulder capsule totighten the tissue. The more standard method of this procedure is called an open capsular shift.In this surgery, the shoulder joint is opened through a larger incision, and the capsule istightened with sutures. The advantage of the open capsular shift is that the results are morepredictable. The advantage of the arthroscopic procedure is that the recovery is faster and theincision is smaller. If the problem is due to a tearing of the ligaments around the shoulder, or atearing of the glenoid labrum then a surgical repair is indicated.


POSSIBLE CAUSES OF PAIN AND\ORLIMITATION OF MOVEMENT AT THEELBOWPossible causes of pain and\or limitation of movement of the elbow joint include:

Extensor tendinopathy (tennis elbow)Flexor/Pronator tendinopathy (golfer’s elbow)Fracture of the olecranonLigament sprainCubital tunnel syndromeRadial nerve syndromeMuscular strainRupture of the distal attachment of biceps brachiiOlecranon BursitisInstability

Lesions

Extensor tendinopathy (tennis elbow)Flexor/Pronator tendinopathy (golfer’s elbow)Olecranon bursitisCubital tunnel syndromeRadial tunnel syndromeOlecranon fractureBiceps tendon rupture (distal)


EXTENSOR TENDINOPATHYExtensor tendinopathy, also known as lateral epicondylitis or tennis elbow, is a condition wherethe there is degeneration of the extensor carpi radialis brevis (ECRB) tendon in the first 1-2cmdistal to its attachment to the common extensor origin at the lateral epicondyle of the humerus.The area has poor blood supply, which, when combined with excessive use, may lead todegenerative changes in the tendon. This is a degenerative process as opposed to aninflammatory process and therefore should be termed a tendinopathy or a tendinosis as opposedto a tendonitis. An inflammatory component may be present if the lesion is exacerbated.

The extensor carpi radialis brevis tendon is often implicated in extensor tendinopathy of theelbow.


Aetiology

During wrist movements such as wrist extension, considerable shearing stress is placed on theECRB tendon. The ECRB muscle crosses both the elbow and wrist and therefore, contractseccentrically at both ends during certain manoeuvres. Additional stress is applied by the head ofthe radius as it rotates anteriorly, compressing the ECRB tendon during pronation of the forearm.This may compromise the blood supply or excessively stretch the tendon. Extensor tendinopathyprimarily involves the extensor carpi radialis brevis muscle and occasionally extensor digitorum,extensor carpi radialis longus and very rarely the extensor carpi ulnaris.


Clinical Features

History

The client usually describes lateral elbow pain of gradual onsetThe aching pain generally increases with activity.Symptoms occurring during simple activities of daily living (ADL), such as picking up a cup ofcoffee

Examination:

localised tenderness to palpation just distal and anterior to the lateral epicondylePain increases with resisted wrist extension, especially with the elbow in extensionThe client may have a weakened grip on the affected side


Management

No single treatment has been shown to be totally effective in thetreatment of this condition. Combining treatments may well result inthe resolution of the symptoms in most cases. However thiscondition can run a protracted course, with exacerbation andremissions often lasting up to 2 years, before most cases undergonatural remission.

Typical management strategies include:

Massage including the use of Cyriax cross fibre frictions anddeep compression over the tendon itself.Myofascial release and stretching techniques.Eccentric loading exercise protocols.Counterforce bracing to reduce the forces on the extensor tendons.


FLEXOR / PRONATOR TENDINOPATHYFlexor/pronator tendinopathy – also referred toas medial epicondylitis or golfer’s elbow – isnot as commonly seen as its lateral equivalent,lateral epicondylitis.

Pathophysiology

Flexor/pronator tendinopathy is a degenerativecondition that exists in the common flexororigin particularly in the pronator teres tendon.Disorganised and degraded tendon collagenis a hallmark of this condition.

Clinical Features

Localised tenderness just at or below themedial epicondylePain on resisted wrist flexion and resistedforearm pronation, especially whenpassive stretch is placed on the tendon(Mills’ Test)

Management

Like extensor tendinopathy, this condition can run a protracted course, with exacerbation andremissions. Management strategies include:

Massage including the use of Cyriax cross fibre frictions and deep compression over thetendon itself.Myofascial release and stretching techniques.Eccentric loading exercise protocols with an emphasis on combined flexion and supination.


OLECRANON BURSITISThe olecranon bursa is a fluid filled sac locatedposteriorly on the olecranon process of the ulna. Inolecranon bursitis the bursa fills with inflammatoryfluid fills the sac. This can cause pain and noticeableswelling behind the elbow.

Aetiology

Olecranon bursitis may follow a traumatic accident,such as a fall onto the back of the elbow, or it mayseemingly pop up out of nowhere. People who resttheir elbows on hard surfaces may aggravate thecondition and make the swelling more prominent. The condition is also known as “student’selbow”. Clients with systemic inflammatory conditions, such as gout and rheumatoid arthritis, arealso at increased risk of developing this condition.

Clinical Features

Decreased ROM in elbow extension.Palpation and visible inspection of the area around the olecranon will display swelling in theshape of an egg over the olecranon.Painful to pressure.

Treatment

Treatment consists of initially the use of NSAIDs, ice, rest and firm compression. Aspiration of thebursa and injection with corticosteroid and local anaesthetic agents is very effective if the initialtreatment in non-effective. If the bursitis does not respond to aspiration and injection then surgicalexcision of the bursa is indicated.


CUBITAL TUNNEL SYNDROMENerve compression syndromes cause symptoms such as pain andweakness. In the case of cubital tunnel syndrome, one of the nervesof the arm and hand, the ulnar nerve, is compressed as it passesbehind the elbow. This is the same nerve that causes the tinglingsensation of hitting your ‘funny bone’. Hitting your ‘funny bone’ isactually a sensation caused by irritating the ulnar nerve behind theelbow. The ulnar nerve supplies sensation to the medial border ofthe hand, including the little finger and the medial half of the ringfinger.

Clinical Features

In cubital tunnel syndrome, common symptoms include pain in the hand (primarily in the little andring fingers) and weakness of the hypothenar muscles on the little finger side of the hand.

These muscles help with finger movements and grip strength. More severe cases of cubitaltunnel syndrome may also lead to weakness of muscles in the forearm.

Treatment

Local massage therapy to muscles and tissues around the cubital tunnel.Neural mobilisation techniques to improve neural slide along the course of the ulnar nerve.Splinting the elbow, especially at night, and anti-inflammatory medications may reduce thepain.


RADIAL TUNNEL SYNDROMERadial tunnel syndrome, also called resistant tennis elbow, is anentrapment or compression of the radial nerve with the supinatormuscle in the proximal forearm.

Clinical Features

The symptoms of radial tunnel syndrome closely resembles tenniselbow, although the cause is different. Radial tunnel syndrome iscaused when a branch of the radial nerve that operates severalmuscles around the wrist and hand (the posterior interosseous nerve)is compressed, or pinched as it passes the supinator muscle. Thiscauses pain over the elbow where the compression takes place.There is no motor deficit with this condition. Any weakness is normally caused by pain inhibition.

Treatment

Neural mobilisation techniques to improve neural slide and ensure appropriate tension alongthe course of the radial nerve.Splinting the elbow, especially at night, and anti-inflammatory medications may reduce thepain.Avoiding prolonged periods of combined elbow extension with pronation and wrist flexion.


OLECRANON FRACTUREAn olecranon fracture is an injury that affects the distal ulna. The olecranon is the attachment siteof the powerful triceps muscle. Any injury to the olecranon can impair a client's ability to extendthe elbow.

Injury Mechanism

Falling directly on the elbowTriceps muscle pulling off a fragment of bone from the olecranon (avulsion fracture).Stress fractures are also a possible mechanism of injury to the ulna, commonly seen inathletes such as baseball pitchers and wood choppers.

Treatment

Treatment of an olecranon fracture depends on the amount of displacement of the fracturefragments and upon how much the function of the triceps muscle is compromised. If thefracture is non-displaced, or minimally displaced, and the triceps muscle is able to extend theelbow, then surgery may not be necessary. In these cases, protected motion and time willgenerally heal the fracture.If the bone fragments are out of position, or if the triceps muscle is detached, then surgery isusually necessary for treatment of an olecranon fracture. Some combination of pins, wires,and/or screws may be used to secure the bone fragments in the proper position.Total healing time of an olecranon fracture is about 12 weeks.


BICEPS TENDON RUPTURE (DISTAL)Rupture of the distal biceps tendon at the elbow joint accountsfor less than 5% of biceps tendon ruptures. Even though it is lessfrequent than proximal tendon ruptures, a distal bicep tendonrupture has more functional significance due to the impact on theclient’s ability to lift and carry. The significance of a distal bicepstendon rupture is that without surgical repair, clients whoexperience complete rupture of the distal biceps tendon willnotice loss of strength at the elbow.

Clinical Features

This injury is more common in elderly clients.There is usually some degree of tendinosis, or degenerativechanges within the tendon, that predisposes the client torupture of the tendon.After the ruptured tendon retracts, clients may notice a bulgein their arm at the biceps muscle. This is the retracted muscle bunched up in the arm, and issometime referred to as a ‘Popeye muscle’ because it is more pronounced than normal.Usually the client will hear a snap and have pain where the tendon rupture occurs.Swelling and bruising around the elbow are also common symptoms of distal biceps tendonrupture.

Treatment

The majority of clients who rupture the distal biceps tendon will require surgical repair.


POSSIBLE CAUSES OF PAIN AND\ORLIMITATION OF MOVEMENT AT THE WRISTAND HANDPossible causes of pain and\or limitation of movement in the wrist and hand joints are as follows:

Carpal tunnel syndromeDe Quervain's diseaseGanglionTrigger fingerOlecranon fractureArthritisMallet fingerWrist sprainsWrist tendonitis


CARPAL TUNNEL SYNDROMECarpal tunnel syndrome is a common source of hand numbness and pain. It affects up to 10% ofthe population. Carpal tunnel syndrome is caused by increased pressure on the median nerve asit enters the hand through the confined space of the carpal tunnel. The roof of the carpel tunnel isformed by the transverse carpel ligament as it joins the hamate and pisiform bones medially tothe scaphoid and trapezium bones laterally. The remaining carpel bones form the floor of thetunnel.

The median nerve supplies sensation to the palmar aspect of the hand from the thumb to thelateral border of the ring finger. It also supplies the muscles of the thenar eminence of the thumb.The meduian nerve shares the carpel tunnel with blood vessels and also the flexor tendons ofthe fingers.


Clinical Features

Carpal tunnel syndrome is more common in women.Symptoms usually begin gradually without a specific injury.Numbness, tingling and pain in the hand are common.The thumb side of the hand is usually most involved.Symptoms frequently occur with holding a phone, reading or driving.Symptoms at night are common.Moving or shaking the hands often helps decrease symptoms.Initially symptoms come and go, but over time they may become constant.Affects people with conditions such as diabetes, thyroid conditions and rheumatoid arthritismore frequently.The swelling that occurs during pregnancy may cause symptoms, but those will frequently goaway after delivery.


StrainReferred painFibrosis of the median nerve is present Enlargement or swelling of the median nerveNeuromas, ganglion cysts, lipomas and hemangiomas


Treatment

Conservative treatment involves techniques to reduce compression of the median nerve withinthe carpal tunnel. Generally this includes splinting the wrist in neutral, avoiding sustainedpressure on the palm and or sustained grip activities.

Myofascial release by the therapist combined with the client’s self-stretch has been shown toreduce pain and numbness and improved electromyographic results. This manipulativeapproach releases the transverse carpal ligament and ‘opens’ or dilates the canal. The clientstretches the wrist, digits, and thumb, including myofascial components. An aggressive,conservative approach lessens the need for surgery in mild to moderate cases.

Myfascial release to open up carpel tunnel


DE QUERVAINâ€™S TENOSYNOVITISDe Quervain's tenosynovitis is a painfuldisorder affecting the tendons at the base of thethumb. This is one of the most common kinds oftendon lining inflammatory conditions. Sometendons are encased in sheaths, or sleeves,through which the tendons slide. The inner wallof the sheaths contains cells that produce aslippery fluid to lubricate the tendons. Withrepetitive or excessive movements such ashand twisting and forceful gripping, thelubrication system may malfunction. Failure ofthe lubricating system allows friction to developbetween the tendons of the thumb and theircommon sheath. The repetitive frictionaccounts for the abnormal thickening and theconstriction of the sheath which interferes withthe smooth gliding motion of the tendons.

Clinical Features

The pain occurs at the base of the thumb and the radial sideof the distal forearm.Pain when moving the thumb away from the handPain in activities requiring a firm grip and twisting of the hand.

Treatment

Cyriax transverse frictions are commonly recommended as a method for treating tenosynovitis.The theory on the effectiveness of the method is that the pressure and transverse movement onthe tendon will help mobilise the adhesions that may have developed between the tendon and itssheath.

Medical management of De Quervain's disease consists mainly of splinting the thumb and wristto avoid those movements that caused the disorder. The majority of clients with De Quervain'sdisease respond to medical management but in some cases surgical release of the affectedtendons may be necessary.


GANGLIONS (CYSTS)A ganglion can grow out of tissues such as joint capsules, tendon sheaths and ligaments. Insidethe ganglion is a thick, slippery fluid. Usually, the more active you are, the larger the lumpbecomes. The lump decreases in size with rest.

Commonly, ganglion cysts grow on the top of the wrist (dorsal ganglions). They can also befound on the underside of the wrist (between the thumb and your pulse point), at the end joint of afinger or at the base of a finger. No one knows what triggers the formation of a ganglion.

Clinical Features

Women are more likely to be affected than menCommon among gymnasts and weight trainers,who repeatedly apply stress to the wrist.Because the fluid-filled sac puts pressure on thenerves that pass through the joint someganglion cysts may be painful.Palpation and visible inspection of the areaaround the hand will display swelling and thepresence of a lump.As with any lump, you will probably need to referthe client to their doctor to get an X-ray so thatthe doctor can rule out conditions such as arthritis or a bone tumour.

Treatment

Observation – as the ganglion is not cancerous and may disappear in time, the doctor mayrecommend just waiting and watching to make sure that no radical changes occur.Immobilisation – activity often causes the ganglion to increase in size, thus increasing thepressure on nerves and causing pain. Immobilisation with a wrist brace or splint may relievesymptoms and allow the ganglion to decrease in size.Aspiration – if the ganglion causes significant pain or severely limits your activities the doctordrain the fluids.Surgery can remove the ganglion, but is no guarantee that the cyst will not recur.


TRIGGER FINGERAlso known as digital tenovaginitis stenosans, thisdeformity is the result of a thickening of the sheatharound the flexor tendons. Inflammation of theproximal fold of this tendon leads to swelling and theformation of a fibrous nodule. This thickening causessticking of the tendon when the client tries to flextheir finger. When the client tries to flex their fingerthe tendon sticks and the finger releases with asnap. As this condition gets worse the finger will flexbut not ‘let go’ and it will then have to be passivelyextended.

Clinical Features

This condition is usually more likely to occur inmiddle aged women in the 3rd or 4th finger and ismost often associated with rheumatoid arthritis.

Treatment

If the symptoms are mild, simply resting the finger may be enough to relieve the problem. If thefinger is stuck in a bent position, surgery may be recommended to prevent permanent stiffness.Surgery widens the opening of the tunnel so the tendon can slide through more easily.


ARTHRITISArthritis is a problem that causes a wearing away of normal joint surfaces where the jointsarticulate. When the cartilage is worn away, arthritis is the condition that results. As there are 27 bones in each hand there are many joints in the fingers that can develop arthritis and as we arevery dependent on our fingers for many normal activities any problem that affects these joints canlimit many normal activities. There are two types of arthritis that commonly affect the fingers andthumb. These are osteoarthritis and rheumatoid arthritis.


Clinical Features

The most commonly affected joints in the fingers are the knuckles of the mid-finger and fingertip(the PIP and DIP joints), and the joint at the base of the thumb. Clients with osteoarthritis oftendevelop lumps or nodules around the knuckles of the fingers. These lumps are calledHeberden's nodes (when around the more distal knuckle) or Bouchard's nodes (when around themore proximal knuckle), and actually consist of bone spurs, or osteophytes, around the joints.These knuckles often become enlarged, swollen, and stiff.

Clinical Features

Osteoarthritis

The most commonly affected joints in the fingers are theknuckles of the mid-finger and fingertip (the PIP and DIPjoints), and the joint at the base of the thumb. Clients withosteoarthritis often develop lumps or nodules around theknuckles of the fingers. These lumps are calledHeberden's nodes (when around the more distal knuckle)or Bouchard's nodes (when around the more proximalknuckle), and actually consist of bone spurs, orosteophytes, around the joints. These knuckles oftenbecome enlarged, swollen, and stiff.

Rheumatoid Arthritis

The most commonly affected joints in the hand are theknuckles at the base of the fingers (the MCP joints). Clientswith rheumatoid arthritis often have the aforementionedsymptoms, but can also have more complex deformities ofthe hands. These include deformities such as a‘Boutonniere’ or ‘swan neck’ deformity. The fingers maybegin to shift from their normal position, and drift away fromthe thumb.

Symptoms of hand rheumatoid arthritis include:

Joint painSwellingMorning stiffnessLoss of motion.


Treatment

Early treatments of finger and thumb arthritis are focused on managing the symptoms in an effortto avoid surgery. Treatment options include:

Anti-inflammatory medications can help treat the pain of arthritis, and also help decreaseinflammation and swelling around the jointsCortisone injections can help as cortisone is a more powerful anti-inflammatory medicationand can be useful in limited applications in the handHand therapy, usually performed by an occupational therapist, is helpful to maintain motionand prevent stiffening of the jointsJoint stiffness and range of motion can be improved by ice and heat treatments and splintinghelps to relax and rest the joints. Splinting should be done for limited periods of time to allowfor relief without allowing the joint to stiffen


MALLET FINGERA mallet finger is an injury to one of the tendons that helps to straighten out your finger. Normally,the finger tip bends down at your last knuckle only about 45 degrees. It is limited by a tendon onthe back of the finger. When the finger tip is ‘jammed’ or forcefully bent down at this last knuckle,the tendon can be stretched too far. If there is enough force, the tendon will snap and a malletfinger will result.

Mallet fingers are called ‘baseball fingers’ as they can occur by jamming the finger tip with abaseball. Mallet fingers are also common in sports such as netball, basketball, AFL and rugby.

Clinical Features

Swelling and tenderness around the fingertip.Inability to straighten the distal interphalangealjoint

Treatment

Only rarely do mallet fingers need surgery. Theusual treatment is to splint the finger in a specialtype of splint (called a stack splint) for at least sixweeks. This splint holds the finger out straight. Thesplint allows the torn tendon to properly heal backinto position. Once removed, the injured joint is usually stiff, but will regain its flexibility over time.


WRIST SPRAINSWrist injuries are common problems. When you begin to fall, your natural instinct is to put yourhands out to catch or break your fall. In doing so, the wrist is often suddenly and forcefullytwisted. When this type of injury occurs the ligaments of the wrist are stretched beyond theirnormal limits.

Wrist sprains are graded according to the severity of the injury:

Grade I – mild injury, the ligaments are stretched, but no significant tearing has occurredGrade II – moderate injury, the ligaments may be partially tornGrade III – severe wrist sprain, the ligaments are completely torn, and there may be instabilityof the joint

Sports in which wrist sprains commonly occur include football, basketball, gymnastics,snowboarding, skateboarding and mountain biking.

Clinical Features

Pain with movement of the wristSwelling around the wrist jointBruising or discoloration of the skinBurning or tingling sensations around the wrist


Wrist fracture Scaphoid fracture.

Treatment

During the inflammatory stage use RICESplinting and immobilisationRemedial therapy to reduce the hyper tonicity in the areaand improve joint mobility.


WRIST TENDONITISWrist tendonitis, also called tenosynovitis, is a common condition characterised by irritation andinflammation of the tendons around the wrist joint. Many tendons surround the wrist joint. Wristtendonitis usually affect one of the tendons, but it may also involve two or more. Often wristtendonitis occurs at points where the tendons cross each other or pass over a bony prominence.The wrist tendons slide through smooth sheaths as they pass by the wrist joint. These tendonsheaths, called the tenosynovium, allow the tendons to glide smoothly in a low friction manner.When wrist tendonitis becomes a problem, the tendon sheath or tenosynovium, becomesthickened and constricts the gliding motion of the tendons. The inflammation also makesmovements of the tendon painful and difficult.

Tenosynovitis of the wrist affects tendon sheaths

Clinical Features

Pain over the area of inflammation.Swelling of the surrounding soft-tissues is also quite common.Pain in movements where the tendon is more loaded.

Treatment

During the inflammatory stage use RICE, as this subsides use remedial therapy to reduce thehyper tonicity in the area and improve joint mobility.

Surgery

Surgery is only done when these other treatment methods have failed to solve the problem. If thatis the case, the area of tight tendon sheath that cause the painful and difficult tendon movementscan be released. The inflammatory tissue can also be removed in an effort to create more spacefor the tendon to move freely.


BIBLIOGRAPHYBrukner P., Khan K., 2009, Clinical Sports Medicine, 3rd edn, McGraw Hill, Sydney.

Hertling D., Kessler R. M., 2005, Management of Common Musculoskeletal Disorders: PhysicalTherapy Principles and Methods, 4th edn, Lippincott Williams & Wilkins, Baltimore.

Corrigan, P., Maitland G. D., 1994, Musculoskeletal and Sports Injuries, Butterworth-Heinemann,Oxford.

Norris, C. M., 1998, Sports Injuries: Diagnosis and Management, 2nd edn, Butterworth-Heinemann, Oxford.

Cailliet, R., 1996, Soft Tissue Pain and Disability, 3rd, edn, F A Davis, Philadelphia.

Cailliet, R., 1991, Neck and Arm Pain, 3rd, edn, F A Davis, Philadelphia.

Cailliet, R., 1991, Shoulder Pain, 3rd, edn, F A Davis, Philadelphia.

Chaitow L., DeLany D., 2008, Clinical Application of Neuromuscular Techniques, Volume 1, 2ndedn, London.

Simons D. G., Travell J. G. & Simons L. S., 1999, Travell & Simons’ Myofascial Pain andDysfunction: The Trigger Point Manual, Volume 1 – Upper Half of the Body, 2nd edn, Williamsand Wilkins, Pennsylvania.

Magee. D. J, 2007, Orthopedic Physical Assessment, 5th edn, Saunders, Philadelphia.


dysfunctions of the shoulder, arm and hand

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