Lateral Epicondylitis aka
What is Lateral Epicondylitis thought to begin with?
Tearing of extensor carpi radialis brevis
What lateral epicondylitis extend to?
Extensor digitorum communis or extensor carpi radialis longus
What is the mechanism of injury for Lateral Epicondylitis?
Wrist extension, radial deviation, supination
Types of patients you'll see for lateral epicondylitis?
Carpenters, plumbers, and maids
What would you do to evaluate lateral epicondylitis?
palpatory tenderness, ortho tests, radiographs may demonstrate calcification (25%)
Medial epicondylitis aka?
Golfer's elbow/ little leaguer's elbow
What is the etiology of medial epicondylitis?
Tendinopathy of wrist flexors and pronator teres at origin
What types of patients will you have for medial epicondylitis?
carpenters, plumbers, maids
Upon evaluation of medial epicondylitis, what will you notice?
Palpatory tenderness, ortho tests, radiographs may demonstrate calcification
What also may coexist with medial epicondylitis?
Ulnar neuropathy may co-exist
What is the treatment for Epicondylitis?
Initially, treatment involves reducing symptoms of pain and inflammation through rest and applying ice or cold therapy
What would you do after the initial phase of Epicondylitis?
Gradually increase the load through the elbow through exercises to a point where normal training and completion can be resumed
When should you use Ice and Compression?
In the first 72 hours post injury, you should apply the principles of P.R.I.C.E. (Protection, Rest, Ice, Compression and Elevation)
Apply a cold compression wrap for no more than ________ minutes as the injured tissues are very close to the skin
What type of protection is used in the treatment of epicondylitis?
Wearing a special elbow brace or support can help reduce the strain on the tendon enabling healing to take place
How does wearing an elbow brace work?
By applying compression around the upper arm which puts pressure on the injured tendon, changing the way forces transmitted through it allowing the injured tissues to rest
What is probably the most important part of treatment and is often difficult due to compliance issue?
When should the strengthening exercises be performed?
As soon as pain allows and then continued until and after full fitness has been achieved
What are other conservative therapies for epicondylitis?
ultrasound, EMS, cold laser, OTC's, NSAIDs, Steroid injections
What is the diaphragm referred to?
Phrenic nerve to supraclavicular region
The stomach/pancreas is refers to ?
What is the spine of scapula divided unevenly by?
Spine of scapula
What does the posterior scapula provide attachment for?
Supraspinatus and infraspinatus
The spine of scap expands into ______
THe anterior scapula has what?
Large subscapular fossa
T/F, the the glenuhumeral joint is larger that the head of scap?
What is the clavicle attached to?
1st rib on the underside
What is the AC joint reinforced by?
- synovial membrane
- AC ligament - superior AC lig/inferior AC lig
- Coracoclavicular lig - trapezoid lig/coracoid lig
What is the GH joint?
true synovial line diarthrodial joint
What is special about the GH joint inferiorly?
joint capsule is lax inferiorly to permit full elevation of the arm
What are the reasons for seeking care for shoulder?
RC pathology, C-spine dysfunction, Adhesive capsulitis, OA
What are the 3 types of Grades in the shoulder?
- Grade 1: stretch of fibers
- Grade 2: Tear of fibers
- Grade 3: Avulsion from bone
What is the order of examination?
- Examine related areas
What % of shoulder issues are related to rotator cuff?
Problems of the rotator cuff occur where?
From trauma, attrition, and the anatomical structure of the subacromial space
What is Primary compression of the rotator cuff due to?
Reduction in size to the subacromial space
Primary Tensile Overload occurs when ______ ?
Rotator cuff resists adduction, internal rotation, anterior translation, and other forces during throwing
What occurs when your force exceed strength of tendon?
What are the signs of "sudden occurence" in Rotator cuff Hx?
- intense pain
- snapping sensation
- immediate weakness in upper arm
Long term overuse of the rotator cuff results in what?
- Pain in shoulder on abduction
- Pain when sleep on affected side
- Eventually, OTC's not helpful
Rotator cuff injury =
Pain with use above eye level
Rotator cuff tendon, what are you palpating for?
"cuff tendon defect"
When does pain occur during rotator cuff palpation?
pduring active arc 90 to 120
Find rotator cuff factoids in _______ of 50 and older
_______ of RC factoids are painless?
What is the main cause of pain?
Whats the ortho tests for rotator cuff?
codman, apley, impingement
What should you do for partial tears of Rotator cuff?
- treat inflammation
- refrain from activity
- adjust spine
- adjust shoulder
When should you introduce isometric excercises?
During partial tears of shoulder, begin with isometric exercises progressing to strengthening exercises to ROM exercises
Impingement classic presentation =
Pain with overhead activities
What are the structures that can be impinged at the shoulder?
Biceps tendon, supraspinatus tendon, subacromial bursa
What is impingement of the shoulder due to?
Variant acromion, DJD of acromion, inflammation of subacromial space
subacromial impingement =
pain at anterior/ biceps tendon
supraspinatus impingement =
pain at greater tuberosity or under AC joint
WHat is the way to chiropractically manage impingement syndrome?
Long term goal is to stabilize shoulder with progressive rehab, stretching posterior capsule
- MANIPULATION - S to I may be helpful check cervical spine and scap. continue through subacute and symptom free stage
- TAPING - discontinue during subacute and symptom free stage
- EXERCISE - begin Codman exercise to stretch capsule. Continue through subacute and symptom free stage
If patient doesn't respond after several months of trying to treat impingement syndrome what should be done
MRI is ordered or planning surgical managment
What are open chair exercises for impingment syndrome?
isometrics performed 20 - 30 degrees
- during SYMPTOM FREE stage, perform plyometric exercises if patient is an athlete and uses upper body
CMoIS (chiro managment of impingment syndrome) closed chain exercises -
none in acute stage
CMoIS wall/wobble board?
push ups, press ups, during subacute stage
CMoIS balance ball and wobble board push ups during:
symptom free stage
proprioceptive neuromuscular facilitation (PNF) training
Begin PNF diagonal patterns during -
Incorporate functional patterns specific to sport or occupation during ____
symptom free stage
what % of acute dislocation are anterior?
Talk about inferior dislocations in the shoulder?
Inferior dislocations are rare and are often accompanied by neurovascular injury
How do you fall to create acute dislocation?
Fall with external rotation or abduction force is usual cause
when would you see "cradle arm"?
What are the 3 main bullets in regards to acute dislocation of the shoulder?
- Myospasm sets in quickly making reduction difficult
- Reduction should be performed promptly (often before radiographs are obtained)
- Souza suggests the MILCH MANEUVER IS EASIEST
What is important about bicipital tendinitis?
- Every attempt must be made to identify contributing factors, e.g. , a poorly stabilized scapula, hypomobile C-spine, hypomobile T-spine, or altered muscle recruitment
How would you manage bicipital tendinits?
- mild manipulation
- C - spine manipulation
Name all the types of bicipital tendinits (usually from secondary condition) ***** :
Type A: secondary to impingement syndrome or RC disease
Type B: subluxation of the biceps tendon
Type C: attrition tendinitis
How would you rule out for bicipital tendinitis?
Every attempt must be made to identify contributing factors, a poorly stabilized scapula, hypomobile C-Spine, Hypomobile T-Spine, or altered muscle recruitment
Most common peripheral nerve entrapment is due to:
Dont confuse CTS with _____
pronator teres syndrome or brachial neuritis
What will the patient present with in CTS?
- Pain and parasthesia at median n. distribution
- Pain worse in AM
- Weakness with grip
What is the etiology of CTS?
- Usually Hx of prolonged wrist use in full flexion or extension
- Pts deficient in B vitamins are predisposed
- Obesity increases incidence of CTS
What is the #2 WC injury?
Who is most likely to develop CTS?
Women in 40s and 50s 4 x's more likely to develop
After age 50, men and women's chance of CTS.....
SS of choice for CTS is _____
If CTS condition progresses to -______, surgery is likely
US (for CTS) -
after 7 weeks showed significant improvement
What should be given to CTS patients?
When does DeQuervain's disease occur?
As a result of trauma to synovium or sheath
Dequervain's disease, pt. has pain _____
gripping, ulnar deviation or repetitve use of thumb
Underwater ultrasound is good for what?
DeQuervain's disease (addresses inflammation)
What does a splint for the wrist address?
Inactivity in DeQuervain's disease management
When should you refer out for DeQuervain's disease?
Failure to respond in 3-4 weeks results in referral to ortho surgeon/hand specialist
What is a bulge?
Any abnormality of annular fibers; apparent in 30% of population; 70% have 3 or more ; asymptomatic
What is a protrusion?
Nucleus has slipped through and tears in annulus; there is pressure on thecal sac and/or nerve root; nucleus is contiguous
What is a prolapse?
Nucleus is not contiguous; mother and daughter nucleus; pressure on thecal sac and/or nerve root
What is a sequestation?
Nucleus held in place only by posterior longitudinal ligament; pressure on thecal sac and/or nerve root
When does the cervical spine nucleus dehydrate?
by age 40-45
Patient presents with ______ during cervical disc herniation
Pain and parasthesia in upper extremity
Cervical disc herniation, yu can pinpoint dermatomal pattern, and patient will present with:
Arm above head (Bakody's sign)
Criteria for determining disc herniation:
3 or 4 must be present
- Primary complaint is arm pain (may have neck pain)
- Pain follows a specific dermatomal pattern
- Neural stretch tests are positive
- 2 of 4 neuron positive
Order MRI for cervical if ______
no improvement after 3-4 weeks
Thoracic outlet syndrome affects:
- 1st rib
- pancost tumor
What does the patient present with during TOS (thoracic outlet syndrome)
- Pain and parasthesia at ulnar distribution of hand
- awake at night
- women more common
What is foraminal encroachment?
Degeneration in the spinal column has caused obstruction in the foramina
What is the etiology for foraminal encroachment?
- Herniated discs
- loss of disc height due to DDD
- Loss of vertebral stability due to facet disease
- Bone spurs caused by osteoarthritis
What are the AKA's for foraminal encroachment?
Foraminal stenosis; spinal foraminal stenosis
What are the symptoms of foraminal encroachment?
- radiating pain
- muscle weakness
- local spinal pain
Foraminal Encroachment from Souza:
• Souza - “Manipulation of the neck is the treatment of choice. If unsuccessful, cervical traction may be of benefit. Any myofascial contribution may be addressed with stretch-and –spray techniques, trigger point therapy or myofascial release.
•Because the foramina are relatively isolated within the spinal column, many of the typical conservative treatment methods used for neck and back pain — including exercise, stretching and physical therapy — might not be as effective.
What is the dural sleeve?
When the spinal nerve leaves the vertebral canal via an intervertebral foramen, 2 layers of the spinal meninges, the arachnoid and the dura invaginate the nerve to form a dural sleeve of connective tissue, which is the epineurium
pain emitting away from the source
pain radiating from the nerve root
pathology of the nerve root
inflammation of the nerve root