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Study Guide Questions: 8.

The questions for this week will focus on knowledge of orthopedic tests and SMR
assessment for the following conditions. Complete the table below with the appropriate
tests, clinical picture and SMR examination findings. Hint: (Souza and Magee will be
good texts to refer to answer this question)

Lateral epicondylitis verses Medial Epicondylitis


Elbow Bursitis vs Elbow Tendinitis
Wrist fracture from a fall on an outstretched hand (FOOSH) vs Carpal Tunnel
Syndrome

Lateral Epicondylitis Medial Epicondylitis


Test: • Cozen’s • Reverse Cozens
• Usually associated with any • Inflammation over medial
Clinical activity involving repeated wrist epicondyle can cause entrapment
Picture: extension against resistance. of ulnar nerve = weakness,
SMR • Mostly due to either inflammation numbness or tingling along medial
or degeneration of common aspect of hand
exam extensor attachment to the lateral • Caused by repetitive forceful
Findings: epicondyle (especially portion resisted flexion and pronation
derived from Extensor carpi causing inflammation of anterior
radialis brevis) compartment muscles arising from
common flexor tendon

Elbow Bursitis Elbow Tendinitis

• Swelling is readily seen • Pain on resisted flexion and


Test: • Present after single episode of supination
Clinical trauma – more commonly after • Local pain and tenderness in
Picture: repeated trauma region of bicipital (radial) tuberosity
• Can occur in those who rest • Pain on just resisted flexion
SMR elbow on hard surfaces for indicates rarer brachialis lesion
exam extended periods (pain and tenderness will be
Findings: • Bursa prone to irritation through localised and find behind the
friction or impact biceps tendon)
• Distal biceps and brachialis
musculotendinous units injured in
sports that require repetitive elbow
flexion (gymnastics, bowling,
weightlifting)
Wrist Fracture Carpal Tunnel
(FOOSH) injury Syndrome

Test: • Caused by fall on • A positive Phalen’s


outstretch hand test (median nerve)
Clinical causing a fracture • The main symptom is Intermittent
Picture: numbness of the thumb, index and
• Local pain and long finger and radial half of the
SMR tenderness with ring finger. Pain in carpal tunnel
exam reduced mobility syndrome is primarily numbness
Findings: (requires X-ray to that is so intense that it wakes one
determine type from sleep with the hypothesis that.
and extent of the wrists are held flexed during
fracture sleep
Test INTERPRETATION/WHAT TISSUE STRUCTURE DOES THIS TEST
LOAD? For you to complete

Cozen’s Test
Used to identify lateral epicondylitis or “tennis elbow.” This test is also
called resisted wrist extension test or resistive tennis elbow test

Mill’s Test Test for lateral epicondylitis - extends and pronates patient’s elbow
while flexing the wrist (test stretches the common extensor tendon).

Froment’s Test Wrist examination procedure that identifies the presence of Ulnar
nerve paralysis (Grips paper between thumb and index - pull the
paper, if terminal phalanx of the thumb flexes because of paralysis of
adductor pollicis muscle, indicates a positive test

2 separate phases:

Polk Lift Test Phase 1: diagnosis of lateral epicondylitis – Lifting object in pronation
(pain = positive)
Phase 2: diagnosis of medial epicondylitis – Lifting object in
supination (pain = positive)

Finkelstein’sTest Procedure to determine the presence of de Quervain disease, a


paratenonitis of the thumb. stabilizes the forearm and deviates the
wrist to the ulnar side.

Positive test is indicated by pain over the abductor pollicis longus and
extensor pollicis brevis tendons.

TFCC Test Compression load test to identify trauma to TFCC. Axially loads and
ulnar deviates the wrist while moving it dorsally and palmarly or by
rotating the forearm

A positive test is indicated by pain, clicking or crepitis in the area of


TFCC.

Phalen’s Test Identifies the presence of Carpal Tunnel Syndrome. Flexes the
patient’s wrists maximally and holds this position for 1 minute by
pushing the patient’s wrist together

Positive test is indicated by tingling in the thumb, index finger, and


lateral half of the ring finger

Bunnel Littler’s Procedure to test the structures around the metacarpophalangeal


Test joint. MTP joint is held slightly extended while the examiner moves the
proximal interphalangeal joint into flexion.

Positive if there is an inability to flex the proximal interphalangeal joint


and there is tight intrinsic muscle or contracture of the joint capsule
Elbow:

Presenting complaints
• pain
• loss of movement
• weakness
• clicking
• locking

- Sharply localised pain typically of extra-articular pathology


- Deep joint pain or poorly localised pain of ulnar neuropathy (with or without
typical paraesthesia extending to hand)
- Pain may be felt in elbow from entrapment neuropathy of median nerve in
carpal tunnel
- Acute injury with swelling could mead radial head fracture

Pain
• Usually musculoskeletal disorder
• May be from lesions of CSP or less commonly referred from other areas
• Main cause is olecranon bursitis, triceps tendonitis and posterior
impingement (as well as outstretched arm injuries - Foosh injury)
o Two subgroups
 Associated with excessive activity of wrist flexors (medial
equivalent of extensor tendinopathy)
 Related with throwing activities (produces valgus stress on
elbow – resisted by medial collateral ligament and radio-
capitellar joint)

Pain on resisted:
• flexion at wrist suggests medial epicondylitis
• extension at wrist suggests lateral epicondylitis
• elbow flexion suggests brachialis or biceps, when the forearm is supinated
• elbow extension suggests triceps
• elbow supination suggests biceps or supinator
• elbow pronation suggests pronator teres or pronator quadratus

Functional anatomy
• Ulnohumeral and radiohumeral joint provide 50% of joint stability – rest is
soft tissue
• Compound synovial joint
• Articulations between ulnar notch and trochlea of humerus and between
radial head and humeral capitellum
• Tendon and ligament attachments to elbow common sites of periosteal
trigger points

Note:
Varus forces disrupt lateral soft tissues and compress medial elbow structures
Valgus forces injure ulnar collateral ligament and compress radio-capitellar joint

Patient with swelling, clicking and grinding – intra-articular pathology of synovium,


cartilage or bone suspected

Examination
• Passive movements producing pain indicate intra-articular pathology,
whereas pain on resisted movement alone indicates musculotendinous
pathology associated with that movement.

LOOK
- Hard bony selling when there is radial head pathology (fracture)
- Posterior swelling of subcutaneous olecranon is possible bursa or rheumatoid
arthritis nodules

FEEL
- Palpable tenderness over origin of extensor carpi radialis brevis indicates
tennis elbow (lateral epicondylitis). No inflammation but rather degeneration,
term tendinosis is used
- Tenderness over tip of medial epicondyle extending 1-2 cm along track of flexor
carpi radialis and pronator teres typically medial epicondylitis or golfer's elbow.
Lesion of common flexor tendon at medial epicondyle

MOVE
- ROM
o Flexion 135-165
o Extension 0-5
o Pronation 90 (85-95)
o Supination 90 (85-95)
- In extension - Posterior pain = posterior impingement, Anterior pain = tightness
of anterior capsule (reverse is true for flexion)
- Arthritis mainly effects flexion extension

SPECIAL TESTS
- Elbow extension test

Pain Area: Myofascial Trigger Points:


Lateral Epicondyle • Supinator
• Extensor carpi radialis longus
• Triceps brachii Mobile wad of three
• Supraspinatus 1. brachioradialis
• Anconeus 2. extensor carpi
• Ring finger extensor digitorum radialis longus
Medial Epicondyle • Triceps brachii 3. extensor carpi
• Pectoralis major radialis brevis

Antecubital • Biceps brachii muscle

Olecranon • Triceps brachii.

Carpal Tunnel • Supinator


• Extensor carpi radialis brevis
Wrist:

Pain Area: Myofascial Trigger Points:


Dorsal Wrist and • extensor carpi radialis brevis
hand
Base of thumb and • supinator
radial hand • scalenes
• brachialis
• brachioradialis
• opponens pollicis
• adductor pollicis

Dorsal finger • extensor digitorum


• dorsal interossei
• scalenes
• abductor digiti minimi

Anterior wrist and • flexor carpi radialis


Palm • palmaris longus

Anterior finger • flexor digitorum superficialis


• interossei
• abductor digiti minimi
ROM
For the wrist joint the elbow is flexed at 90 degrees and held into the waist:
• Compare extension and flexion on both sides (normal range is 80-90 degrees)
• Compare ulnar deviation (normal to 45 degrees) and radial deviation (30 degrees)
• Compare pronation and supination (normal to 90 degrees)

Hand screening - range of motion can be used as an initial check:


• Ask the patient to:
– make a fist
– extend and abduct the fingers
– adduct the fingers
– ab- and adduct the thumb
– opposition of the thumb and little finger

A, Standard fist.
B, Hook grasp fist.
C, Straight fist.
D, Pulp-to-pulp pinch.
E, Tip-to-tip pinch.

Tendons commonly affected by tendinitis/tendinosis


• The extensor carpi radialis longus and brevis tendons become palpable when the fist is clenched.
• Ulnar deviation facilitates palpation of the extensor carpi ulnaris tendon
• Flexor carpi radialis and ulnaris

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