common dysfunctions within the upper extremity
TRANSCRIPT
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Common Dysfunctions within the
Upper Extremity
Mark Coalson, MSPT, OCS
Outline
• Tensegrity• Continuous Compression - Continuous Tension
• Joint by Joint Approach• Mobile - Stable
• Performance Pyramid• Movement - Performance - Skill
• Movement Patterns• Mucle vs movement
• Shoulder Impingement• Internal Impingement - External Impingement
• Neural Entrapment• TOS - Carpal Tunnel - Cubital Tunnel
• Epicondylitis• Medial - lateral
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The Other Side
I want a clinic
with therapists that think just like me, who
believe the same thing and learn the same way.
everyone has to have their act together
I want a clinic that focuses its efforts
on me. Therapist who don’t measure up
will be looked down on. If you want to
work in this clinic, perfect, nothing will
change
The Other Side
I want a clinic
with therapists that think just like me, who
believe the same thing and learn the same way.
everyone has to have their act together
I want a clinic that focuses its efforts
on me. Therapist who don’t measure up
will be looked down on. If you want to
work in this clinic, perfect, nothing will
change
that isn’t filled
don’t all
I don’t want a place where
because none of us actually do.
on our patients, not focused
will be respected. Nobody
learn and grow, not just
be more rewarding. I will embrace
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Growth and Change
• With growth comes change
Growth and Change
• With growth comes change
• With change comes loss
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Growth and Change
• With growth comes change
• With change comes loss
• With loss comes pain
Growth and Change
• With growth comes change
• With change comes loss
• With loss comes pain
Pain of staying the same > Pain of changing
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Compression & Tension
Compression & Tension
• Seri Wawasan Bridge
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Compression & Tension
• Seri Wawasan Bridge
Compression & Tension
• Cable
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Compression & Tension
• Muscle
Compression & Tension
Compression resistant Tension resistant
beams soft tissues
(fascia)
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Compression & Tension
Compression & Tension
• https://www.youtube.com/watch?v=otHZwjElXwQ
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Compression & Tension
• Bone fracture
Compression & Tension
Muay Thai - Melchor Menor
• https://www.youtube.com/watch?v=O0_mrDbKlns
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Compression & Tension
Basketball - Kevin Ware
• https://www.youtube.com/watch?v=6PSV0AV1BI0
Soccer
• https://www.youtube.com/watch?v=KvrqG5CqoVY
Continuous Compression
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Continuous Tension - Tensegrity
• Buckminster Fuller
• Geodesic dome
• Balanced compression and tension in building
Tensegrity
• Kenneth Snelson
• An American contemporary
sculptor and photographer.
• “Father of Tensegrity”
• Studied with Buckminster Fuller
• His sculptural works are
arranged according to the idea
of 'tensegrity'.
• Snelson prefers the descriptive
term floating compression.
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Tensegrity
Continuous Tension with Discontinuous Compression
Tensegrity
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Tensegrity
https://www.youtube.com/watch?v=8ajowL0T4bM
https://www.youtube.com/watch?v=N_sndY-
Aqvk&list=PL0A8DB4B74B8DAF44
https://www.youtube.com/watch?v=KE0wGpigCBE
Stephen Levin Tom Flemons
Tensegrity
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Tensegrity
• Donald E. Ingber
Tensegrity
• Tensegrity and the human body?
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Tensegrity
• “It is possible that fully triangulated
tensegrity structures may have been
selected through evolution because of their
structural efficiency and their high
mechanical strength using a minimum of
materials.”
The architecture of life. Scientific American 1998; January: 48-57
Anatomy Trains
• Thomas W. Myers – Anatomy Trains
• Myofascial Meridians for Manual and Movement
Therapies
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Anatomy Trains
• Tensegrity and Fascia
• https://www.youtube.com/watch?v=BzgxYpDyO0M
Myers Video on what is fascia
• https://www.youtube.com/watch?v=wL1ZVarr1R8
Myers are you ageing or just drying out
• https://www.youtube.com/watch?v=-uzQMn87Hg0
Myers on the fascial system
Anatomy Trains
• The Arm Lines
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Anatomy Trains
• The Arm Lines
• Scapular positional dysfunction
• Cardinal & Spiral & Deep Front Lines
Anatomy Trains
• Deep Front Arm Line
• Pectoralis minor
• Clavipectoral fascia
• Biceps brachii
• Radial periosteum
• Radial collateral ligaments
• Thenar muscles
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Anatomy Trains
• Superficial Front Arm Line
• Pectoralis major
• Latissimus dorsi
• Medial intermuscular septum
• Flexor group
• Carpal tunnel
Anatomy Trains
• DFAL stretch & SFAL stretchhttps://www.youtube.com/watch?v=eNCCrCSuW24
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Anatomy Trains
• Deep Back Arm Line
• Rhomboids
• Levator scapulae
• Rotator cuff
• Triceps brachii
• Ulnar periosteum
• Ulnar collateral ligaments
• Hypothenar muscles
Anatomy Trains
• Superficial Back Arm Line
• Trapezius
• Deltoid
• Lateral intermuscular septum
• Divides flexors and extensors
• Extensors
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Anatomy Trains
• DBAL stretch & SBAL stretchhttps://www.youtube.com/watch?v=GJdwm3QWrw4
Anatomy Trains• Scapular position and postural balance
Scapular X• Rhoboid – Serattus
• Trapezius – Pec. Minor
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Tensegrity / Anatomy Trains
Muscle vs Movement
vs
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Muscle vs Movement
• Reductionism
• Examining things by breaking them
down into smaller and smaller parts to
examine each parts role
• Aristotle
• Isaac Newton
• Complex system is nothing but the
sum of its parts.
• Goniometric angles
• Force vectors
• This typically creates one perspective
while destroying another
Muscle vs Movement
• Gestaltism
• Kurt Koffka - The whole is other
than the sum of the parts. The
whole has an independent
existence.
• Myers Anatomy Trains: What can
we learn from looking at
synergetic relationships –
stringing our parts together rather
than dissecting them further
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Muscle vs Movement
• Is there such a thing as organic exercise?
• Just as bodies are destroyed by dissection, movement
patterns are destroyed by reductionism.
Muscle vs Movement
• Orchestrated Movement
• The brain thinks in terms of whole
motions not individual muscles”
- Irwin M. Korr
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Joint-by-Joint Approach
• Fingers - Stable
• Wrist - Mobile
• Elbow - Stable
• Glenohumeral / Shoulder - Mobile
• Scapulothoracic - Stable
• Subcranial - Mobile
• Cervical Spine - Stable
• Thoracic Spine - Mobile
• Pelvis/Sacrum/Lumbar Spine - Stable
• Hip - Mobile
• Knee - Stable
• Ankle - Mobile
• Foot - Stable
Gray Cook & Michael Boyle’s joint-by-joint approach
Concept by: Michael Boyle & Gray Cook
Joint-by-Joint Approach
• Fingers - Stable
• Wrist - Mobile
• Elbow - Stable
• Glenohumeral / Shoulder - Mobile
• Scapulothoracic - Stable
• Subcranial - Mobile
• Cervical Spine - Stable
• Thoracic Spine - Mobile
• Pelvis/Sacrum/Lumbar Spine - Stable
• Hip - Mobile
• Knee - Stable
• Ankle - Mobile
• Foot - Stable
Gray Cook & Michael Boyle’s joint-by-joint approach
Concept by: Michael Boyle & Gray Cook
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Joint-by-Joint Approach
• Fingers - Stable
• Wrist - Mobile
• Elbow - Stable
• Glenohumeral / Shoulder - Mobile
• Scapulothoracic - Stable
• Subcranial - Mobile
• Cervical Spine - Stable
• Thoracic Spine - Mobile
• Pelvis/Sacrum/Lumbar Spine - Stable
• Hip - Mobile
• Knee - Stable
• Ankle - Mobile
• Foot - Stable
Gray Cook & Michael Boyle’s joint-by-joint approach
Joint-by-Joint Approach
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The Performance Pyramid
Functional Movement System-Gray Cook
• It is important to understand:
• The distinct difference between stability and strength.
• Need to establish proper movement prior to
conditioning.
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Shoulder Impingement
• Most frequent cause of shoulder pain
• Diagnosis waste basket for the expert
• Voplin G, Stahl S, Stien H. Impingement syndrome following direct injuries of the shoulder joint. Harefuah 1996; 130:244-7;295
• Michner LA, McClure PW, Karduna AW. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clin blomech;18369-79
Shoulder Impingement
• Causes:
• Anatomy
• Acromion Types - Direction & Length - Shape - Thickness -
Defect – Coracoid Slope
• Biomechanical
• Glenohumeral Joint Instability
• Diablo effect
• Scapulothoracic Instability
• Scapular Positioning
• Resting
• Dynamic
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Shoulder Impingement
• Causes:
• Anatomy
• Acromion Types - Direction & Length - Shape - Thickness -
Defect – Coracoid Slope
• Biomechanical
• Glenohumeral Joint Instability
• Diablo effect
• Scapulothoracic Instability
• Scapular Positioning
• Resting
• Dynamic
Shoulder Impingement
• Causes:
• Anatomy
• Acromion Types
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Shoulder Impingement
• Causes:
• Anatomy
• Acromion Direction & Length
• Edelson JG, Taitz C. J Anatomy of the coraco-acromial arch. Relation
to degeneration of the acromion. Bone Joint Surg Br. 1992
Jul;74(4):589-94.
• http://www.sciencedirect.com/science/article/pii/S0002934305000847
Shoulder Impingement
• Causes:
• Anatomy
• Acromion Direction & Length
• Edelson JG, Taitz C. J Anatomy of the coraco-acromial arch. Relation
to degeneration of the acromion. Bone Joint Surg Br. 1992
Jul;74(4):589-94.
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Shoulder Impingement
• Causes:
• Anatomy
• Acromion Direction & Length
• Edelson JG, Taitz C. J Anatomy of the coraco-acromial arch. Relation
to degeneration of the acromion. Bone Joint Surg Br. 1992
Jul;74(4):589-94.
Shoulder Impingement
• Causes:
• Anatomy
• Acromion Shape
• Edelson JG, Taitz C. J Anatomy of the coraco-acromial arch. Relation
to degeneration of the acromion. Bone Joint Surg Br. 1992
Jul;74(4):589-94.
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Shoulder Impingement
• Causes:
• Anatomy
• Acromion Thickness
• Edelson JG, Taitz C. J Anatomy of the coraco-acromial arch. Relation
to degeneration of the acromion. Bone Joint Surg Br. 1992
Jul;74(4):589-94.
Shoulder Impingement
• Causes:
• Anatomy
• Acromion Defect
– (Os Acromiale)
• Fail of fusion
• Fibrocartilaginous
• Degeneration - RCT
• 8% of population
• Blacks / Males• Wright RW et al. Arthroscopic decompression for impingement syndrome secondary to an
unstable os acromiale. J Arth Rel Surg 2000; 16;595-9
• Swain RA, Wilson FD, Harsha DM. The os acromiale: another cause of impingement. Med
Sci Sports Ex 1996;28:1459-62
• Kurtz CA, Humble BJ, Rodosky MW, Sekiya JK. Symptomatic os acromiale. J Acad Orthop
Surg 2006;14(1):12-19
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Shoulder Impingement
• Causes:
• Anatomy
• Acromion Defect
(Os Acromiale)
• X-ray / MRI
• Non-operative 6 mo
• SAD
• Excision (<3cm)
• ORIF - autograft - PT• Mudge MK, Wood YE, Frykman GK. Rotator cufftears associated with Os acromiale. J Bone
Joint Surg [Am] 1984; 66-A :427-9.
• Youm T, Hommen JP, Ong BC, Chen AL, Shin C.Am J Orthop (Belle Mead NJ). 2005
Jun;34(6):277-83. Os acromiale: evaluation and treatment.
• Edelson JG, Taitz C. J Anatomy of the coraco-acromial arch. Relation to degeneration of
the acromion. Bone Joint Surg Br. 1992 Jul;74(4):589-94.
Shoulder Impingement
• Causes:
• Anatomy
• Coracoid Slope
• Edelson JG, Taitz C. J Anatomy of the coraco-acromial arch. Relation
to degeneration of the acromion. Bone Joint Surg Br. 1992
Jul;74(4):589-94.
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Shoulder Impingement
• Causes:
• Anatomy
• Acromion Types - Direction & Length - Shape - Thickness -
Defect – Coracoid Slope
• Biomechanical
• Glenohumeral Joint Instability
• Diablo effect
• Scapulothoracic Instability
• Scapular Positioning
• Resting
• Dynamic
Shoulder Impingement
• Causes:
• Biomechanical
• Glenohumeral Joint Instability
– ���� Acromio-humeral space = ���� pressure
– In many cases, the primary diagnosis is subtle glenohumeral
instability even though impingement and subacromial bursitis
are evident.
• Bigliani LU, Levine WN, Current concepts review subacromial impingement
syndrome. J Bone Joint Surg 1997; 79A:1854-67
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Shoulder Impingement
• Causes:
• Biomechanical
• Diablo effect
– Above 30 degrees elevation
– Posterior capsule tightness prevents
inferior transition
– Change in Acromio-humeral interval
– Superior migration of the humeral head
– ���� Acromio-humeral space = ���� pressure
• Sizer PS, Phelps V, Gilbert K.Diagnosis and Management of the Painful Shoulder. Part 1:
Clinical Anatomy and Pathomechanics. Pain Practice 2003 3(1) 39–57
• Warner JJ. Patterns of flexibility, laxity, and strength in normal shoulders and shoulders
with instability and impingement. Am J Sports Med 1990 8(4): 366-75
• Flatow El, Soslowsky LJ, Ticker JB, Pawluk RJ, Helper M, Ark J, Mow VC, Bigliani LU.
Excursion of the rotator cuff under the acromion. Patterns of subacromial contact. Am J
Sports Med 1994; 22:779-88
Shoulder Impingement
• Causes:• Biomechanical
• ScapulothoracicInstability
– Serratus & Middle trap Dysfunction
– ���� scap upward rot. And ���� scap IR.
– ���� Acromio-humeral space = ���� pressure
• Morais Faria CD, Teixeira-Salmela LF, de Paula Goulart FR, de Souza Moraes GF. Scapular muscular activity with shoulder impingement syndrome during lowering of the arms. Clin J Sport Med. 2008; 18(2):130-6
• Struyf F, Nijs J, Baeyens JP, Mottram S, Meeusen R. Scapular positioning and movement in unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability. Scand J Med Sci Sports. 2011 Jun;21(3):352-8.
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Shoulder Impingement
• Causes:
• Anatomy
• Acromion Types - Direction & Length - Shape - Thickness -
Defect – Coracoid Slope
• Biomechanical
• Glenohumeral Joint Instability
• Diablo effect
• Scapulothoracic Instability
• Scapular Positioning
• Resting
• Dynamic
Shoulder Impingement
• Causes:
• Scapular Positioning
• Resting
• Struyf F, Nijs J, Baeyens JP, Mottram S, Meeusen R. Scapular positioning and movement in
unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability.
Scand J Med Sci Sports. 2011 Jun;21(3):352-8.
Picture: mikereinold.com
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Shoulder Impingement
• Causes:
• Scapular Positioning
• Dynamic
• Struyf F, Nijs J, Baeyens JP, Mottram S, Meeusen R. Scapular positioning and movement
in unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability.
Scand J Med Sci Sports. 2011 Jun;21(3):352-8.
Picture: mikereinold.com
Shoulder Impingement
• Causes
• Static vs Dynamic Scapular Positioning
• Resting position ≠ poor movement patterns
• Unable to identify shoulder injuries
• Alexis AW, Craig AW, Mason F, Lori AM, Eric JH. Diagnostic accuracy of scapular physical examination
tests for shoulder disorders: a systematic review. Br J Sports Med2013;47:886-892 doi:10.1136/bjsports-
2012-091573
• Struyf F, Nijs J, Meeus M, Roussel NA, Mottram S, Truijen S, Meeusen R. Does scapular positioning
predict shoulder pain in recreational overhead athletes? Int J Sports Med. 2014 Jan;35(1):75-82.
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• Causes
• Purpose to compare:
• 3-dimensional scapular kinematics
• Shoulder range of motion
• Shoulder muscle force
• Posture in subjects with and without primary shoulder
impingement syndrome.
• Conclusion: Kinematic differences may represent
compensatory strategies for GH weakness or loss of ROM
• Philip WM, Lori AM, Andrew RK. Shoulder Function and 3-Dimensional Scapular Kinematics in
People With and Without Shoulder Impingement Syndrome. Phys Ther. 2006 Aug;86(8):1075-90.
Shoulder Impingement
Shoulder Impingement
• Causes• Scapular Dyskinesis Test (SDTs)
• Winging or dysrythmia• Med. Inf. border winging
• Lack of smoother mvt. early scap elevation or shrugging during flex.
• Rapid downward rot. with arm lowering from flexion
• Uhl TL, Kibler WB, Gecewich B, et al. Evaluation of clinical assessment methods for scapular dyskinesis. Arthroscopy 2009;25:1240–8.
• Philip M, Angela RT, Stephen K, Dominic I, Erica Z. A Clinical Method for Identifying Scapular Dyskinesis, Part 1: Reliability. J Athl Train. 2009 Mar-Apr; 44(2): 160–164.
• Angela RT, Philip M, Stephen K, Dominic I, Mary FB. A Clinical Method for Identifying Scapular Dyskinesis, Part 2: Validity. J Athl Train. 2009 Mar-Apr; 44(2): 165–173.
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Shoulder Impingement
• Causes
• Scapular Stability
• Clinical Implications of Scapular Dyskinesis in
Shoulder Injury. The 2013 Consensus Statement
From the 'Scapular Summit'
• W Ben Kibler; Paula M Ludewig; Phil W McClure; Lori A
Michener; Klaus Bak; Aaron D Sciascia. Br J Sports Med.
2013;47(14):877-885.
Shoulder Impingement
• Causes
• Scapular Stability
• Clinical Implications of Scapular Dyskinesis in
Shoulder Injury. The 2013 Consensus Statement
From the 'Scapular Summit'
• W Ben Kibler; Paula M Ludewig; Phil W McClure; Lori A
Michener; Klaus Bak; Aaron D Sciascia. Br J Sports Med.
2013;47(14):877-885.
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Shoulder Impingement
• Causes:
• Anatomy
• Acromion Types - Direction & Length - Shape - Thickness -
Defect – Coracoid Slope
• Biomechanical
• Glenohumeral Joint Instability
• Diablo effect
• Scapulothoracic Instability
• Scapular Positioning
• Resting
• Dynamic
Shoulder Impingement
• Classifications/Testing
• External GH impingement
• Subacromial
– SAD Bursa, SSP, ISP, LHB
• Subcoracoid
– SC Bursa, SSC, LHB
• Internal GH impingement– SSP, ISP
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Shoulder Impingement
• Classifications/Testing
• External GH impingement
• Subacromial
– SAD Bursa, SSP, ISP, LHB
• Panni AS, Milano G, Lucania L, Fabbriciani C, Logroscino CA. Histological analysis of the
coracoacromial arch: correlation between age-related changes and rotator cuff tears.
Arthroscopy. 1996 Oct;12(5):531-40.
Shoulder Impingement
• Classifications/Testing
• External GH impingement
• Subacromial
– SAD Bursa, SSP, ISP, LHB
Neer test Hawkins testPassive Elevation 90 ABD with IR
Pictures: mikereinold.com
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Shoulder Impingement
• Classifications/Testing• External GH impingement
• Subcoracoid
– SC Bursa, SSC, LHB
• Gerber C, Terrier F, Ganz R. The role of the coracoid process in the chronic impingement syndrome. J Bone Joint Surg 1985, 67B, 703-8
• Goldthwait JE. An anatomic and mechanical study of the shoulder joint, explaining many of the cases of painful shoulder, many of the recurrent dislocations and many of the cases of brachial neuralgias or neuritis. Am JOrthop Surg l909;6(4):579-606.
Shoulder Impingement
• Classifications/Testing
• External GH impingement
• Subcoracoid
– SC Bursa, SSC, LHB
• Okoro T, Reddy VRM, Ashvin P. Coracoid impingement syndrome: a literature review.
Curr Rev Musculoskelet Med. 2009 Mar; 2(1): 51–55.
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Shoulder Impingement
• Classifications/Testing
• External GH impingement
• Subcoracoid
– SC Bursa, SSC, LHB
Coracoid Impingement Sign
– 90 ABD, Horiz ADD, Max IR
Picture: mikereinold.com
Shoulder Impingement
• Classifications/Testing
• Internal GH impingement– SSP, ISP
• Panni AS, Milano G, Lucania L, Fabbriciani C, Logroscino CA. Histological analysis of the
coracoacromial arch: correlation between age-related changes and rotator cuff tears.
Arthroscopy. 1996 Oct;12(5):531-40.
Picture: mikereinold.com
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Shoulder Impingement
• Classifications/Testing• Internal GH impingement
– SSP, ISP
Internal Resisted Strength Test (IRRST)
• Zaslav KR. Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. J Shoulder Elbow Surg. 2001 Jan-Feb;10(1):23-7.
Shoulder Impingement
• Classifications/Testing
• External GH impingement
• Subacromial
– SAD Bursa, SSP, ISP, LHB
• Subcoracoid
– SC Bursa, SSC, LHB
• Internal GH impingement– SSP, ISP
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Shoulder Impingement
• Presentation
• External GH impingement
• Subacromial
– SAD Bursa, SSP, ISP, LHB
• Subcoracoid
– SC Bursa, SSC, LHB
• Internal GH impingement– SSP, ISP
Shoulder Impingement
• Presentation
• External GH impingement
• Subacromial
– SAD Bursa, SSP, ISP, LHB
– Painful arc 80-130 degrees
– Pain anterior and lateral shoulder
– Limited IR likely
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Shoulder Impingement
• Presentation
• External GH impingement
• Subcoracoid
– SC Bursa, SSC, LHB
– Pain anterior shoulder
– Painful arc of motion
– Pain &limitation with horizontal adduction
– Pain with internal rotation
– Limited IR Possible
Shoulder Impingement
• Presentation
• Internal GH impingement– SSP, ISP
– Pain end ranges of motion
– Pain with ABD and ER
– Limited IR possible
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Shoulder Impingement
• Presentation
• External GH impingement
• Subacromial
– SAD Bursa, SSP, ISP, LHB
• Subcoracoid
– SC Bursa, SSC, LHB
• Internal GH impingement– SSP, ISP
Shoulder Impingement
• Treatment
• Anatomy Trains
https://www.anatomytrains.com/wp-content/uploads/2012/09/bodyreading1.pdf
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Shoulder Impingement
• Treatment
• Scapular X
Shoulder Impingement
• Treatment
• Functional Lines
https://www.anatomytrains.com/wp-content/uploads/2012/09/bodyreading1.pdf
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Shoulder Impingement
• Treatment
• Manual Therapy
• Results: Both groups experienced significant decreases in
pain and increases in function. Significantly more
improvement in the manual therapy group compared to the
exercise group.
• Michael D.B, Gail D.D. Comparison of Supervised Exercise With and Without Manual Physical
Therapy for Patients With Shoulder Impingement Syndrome. Journal of Orthopaedic & Sports
Physical Therapy, 2000; 30: 126-137
Shoulder Impingement
• Treatment
• Manual Therapy
• 21 studies
• Conclusion: Small affect for reduction of pain
• Ariel DC, Jean-SR, Clermont ED, Pierre F, Joy CM, François D. The Efficacy of Manual Therapy
for Rotator Cuff Tendinopathy: A Systematic Review and Meta-analysis. J Orthop Sports Phys
Ther 2015;45(5):330-350.
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Shoulder Impingement
• Treatment
• Manual Therapy
• RESULTS: Both groups 50% improvement Pain & Disability
Index scores maintained through 1 year
• CSI > SIS-related Dr. visits (60% vs. 37%) & required
additional steroid injections (38% vs. 20%), and 19% needed
physical therapy.
• Rhon DI, Boyles RB, Cleland JA. One-year outcome of subacromial corticosteroid
injection compared with manual physical therapy for the management of the unilateral
shoulder impingement syndrome: a pragmatic randomized trial. Ann Intern Med.
2014 Aug 5;161(3):161-9.
Shoulder Impingement
• Treatment
• Posterior capsule stretching
• 60 overhead athletes with GIRD; 30
with pain, 30 without
• Angular or non-angular stretching
groups
• 3x/week x 3 weeks
• Significant improvement in ROM,
pain, and Modified Rowe Scores
• Ann MC, Fredrik RJ, Barbara C, Dirk CC, Erik EW. Stretching the
Posterior Shoulder Structures in Subjects with Internal Rotation
Deficit: Comparison of Two Stretching Techniques. Shoulder &
Elbow January 2012 vol. 4 no. 1 56-63
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Shoulder Impingement
• Treatment
• Significant increase in IR, Horiz Add and AHD
• Annelies M, Valerie VE, Lieselot VD, Aagje V, Ann C. Quantifying Acromiohumeral Distance in
Overhead Athletes With Glenohumeral Internal Rotation Loss and the Influence of a Stretching
Program. Am J Sports Med September 2012 vol. 40 no. 9 2105-2112
Shoulder Impingement
• Treatment
• External Impingement
• Group 1: AROM, Stretching, strengthening cuff, rhomboids,
levator and serratus HEP x 7/week 10-15 min
• Group 2: Joint & STM, ice, stretching and strengthening
exercises and patient education in clinic 3x/week for 4
weeks.
• Both improved, Group 2 > Group 1
• Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual
physical therapy for patients with shoulder impingement syndrome: a prospective, randomized
clinical trial. Knee Surgery, Sports Traumatology, Arthroscopy. July 2007, Volume 15, Issue 7, pp
915-921
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Shoulder Impingement
• Treatment
• Thoracic Manipulation
• Conclusion: Shoulder pain in individuals with SIS
immediately decreased after a TSM. The observed changes
in scapular kinematics following TSM were not considered
clinically important.
• Haik MN, Alburquerque-Sendín F, Silva CZ, Siqueira-Junior AL, Ribeiro IL, Camargo PR. Scapular
Kinematics Pre– and Post–Thoracic Thrust Manipulation in Individuals With and Without Shoulder
Impingement Symptoms: A Randomized Controlled Study
Published: Journal of Orthopaedic & Sports Physical Therapy, 2014, Jul; 44(7): 475-487
Shoulder Impingement
• Treatment
• Thoracic Manipulation
• Conclusion: Overall, patient-reported outcomes improved in
both groups without meaningful changes to thoracic or
scapular motion.
• Kardouni JR, Pidcoe PE, Shaffer SW, Finucane SD, Cheatham SA, Sousa CO, Michener LA.
Thoracic Spine Manipulation in Individuals With Subacromial Impingement Syndrome Does Not
Immediately Alter Thoracic Spine Kinematics, Thoracic Excursion, or Scapular Kinematics: A
Randomized Controlled Trial. J Orthop Sports Phys Ther 2015;45(7):527-538.
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Thoracic Outlet Syndrome
• Defined • TOS represents a spectrum of disorders
encompassing four related syndromes: arterial compression, venous compression, neurogeniccompression, and a poorly defined pain syndrome. (Disputed/Nonspecific Neurogenic)
• TOS may be the most underrated, overlooked, and misdiagnosed, and the most important and difficult to manage peripheral nerve compression in the upper extremity.
• Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurgery Clinics of North America [2001, 12(2):295-309]
Thoracic Outlet Syndrome
• Categories• Vascular
• Difficult to treat conservatively = Surgery
• Venus (5%-10%)
• Arterial (2%-5%)
• Neurogenic TOS• True Neurogenic (3.5%)
• Disputed/Nonspecific Neurogenic (85%-95%)
– Responds to conservative care• Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J.
2012; 39(6): 842–843
• Sanders, RJ, Hammond SL, Rao NM. Thoracic Outlet Syndrome: A Review Neurologist: November 2008 - Volume 14 - Issue 6 - pp 365-373
• Likes K, Rochlin DH, Salditch Q, T Dapash T, Baker Y, DeGuzman R, Selvarajah S, Freischlag JA. Diagnostic Accuracy of Physician and Self-referred Patients for Thoracic Outlet Syndrome Is Excellent. Annals of Vascular Surgery. Volume 28, Issue 5, July 2014, Pages 1100–1105
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Thoracic Outlet Syndrome
• 4 Passages
• Narrow
• Dynamic with movement
• Anterior Triangle
• Posterior Triangle
• Costoclavicular
• Thoraco-coraco-pectoral
Thoracic Outlet Syndrome
• 4 Passages
• Narrow
• Dynamic with movement
• Anterior Triangle
• Posterior Triangle
• Costoclavicular
• Thoraco-coraco-pectoral
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Thoracic Outlet Syndrome
• Ant. Triangle• SCM – Ant. Scalene – 1st Rib
• Post Triangle• Ant. Scalene – Middle Scalene – 1st Rib
• Costo-Clavicular• Dorsal: Scap. & Subscapularis
• Ventral: Clavicle, subclavius mm, fascia
• Caudal: 1st rib, upper seratus
• Cranial: Clavicle
• Thoraco-Coraco-Pectoral• Ventral: Pectoralis minor
• Medial: Thoracic wall
• Cranial / Lateral: Coracoid process
Thoracic Outlet Syndrome
• Vascular TOS• Subclavian artery or vein
• Young athletic
• Vigorous overhead activities
• Mackinnon SE, Novak CB. Thoracic outlet syndrome. Curr Probl Surg. 2002 Nov. 39(11):1070-145.
• Hood DB, Kuehne J, Yellin AE, Weaver FA. Vascular complications of thoracic outlet syndrome. Am Surg. 1997 Oct. 63(10):913-7
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Thoracic Outlet Syndrome
• Vascular TOS• Arterial
• Subclavian artery compression (scalene triangle)
• Pectoralis minor tendon
• Color changes
• Claudication
• Arm & hand pain
• Mild ache & fatigue
• Mackinnon SE, Novak CB. Thoracic outlet syndrome. Curr Probl Surg. 2002 Nov. 39(11):1070-145.
• Duwayri YM, Emery VB, Driskill MR, Earley JA, Wright RW, Paletta GA Jr, Thompson RW. Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete. J Vasc Surg 2011;53(5):1329–40
Thoracic Outlet Syndrome
• Vascular TOS• Veinious
• Subclavian Vein compression
– Clavicle - costoclavicular ligament
– First rib - subclavius muscle
• Swelling
• Venous distention
• Cyanotic discoloration
• Arm and hand pain• Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J.
2012; 39(6): 842–843.
• Thompson RW. Comprehensive management of subclavian vein effort thrombosis. SeminIntervent Radiol 2012;29(1): 44–51.
• Mackinnon SE, Novak CB. Thoracic outlet syndrome. Curr Probl Surg. 2002 Nov. 39(11):1070-145.
• Hood DB, Kuehne J, Yellin AE, Weaver FA. Vascular complications of thoracic outlet syndrome. Am Surg. 1997 Oct. 63(10):913-7
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Thoracic Outlet Syndrome
• Neurogenic TOS
• Young healthy individuals
• Heavy lifting
• Repetitive overhead use of the upper extremities
• Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J.
2012; 39(6): 842–843.
Thoracic Outlet Syndrome
• Neurogenic TOS
• Symptoms (neck, upper back, shoulder, arm, hand)
• Pain
• Numbness
• Paresthesia
• Variable & dynamic
• Positional exacerbation during arm elevation
• Tenderness over the supraclavicular or subcoracoid space
• + Special tests (EAST/ROOS, etc)
• Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J.
2012; 39(6): 842–843.
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Thoracic Outlet Syndrome
• Neurogenic TOS• Characterized by compression and irritation of the
brachial plexus nerve roots (C5 to T1).• Typically within the scalene triangle at the level of the first rib
• Subcoracoid space underneath pec. minor muscle tendon
• Neurogenic TOS
– Congenital variations in anatomy
» Anomalous scalene musculature
» Aberrant fascial bands
» Cervical ribs
– Coupled with injury that has resulted in scalene muscle spasm, fibrosis, or other pathologic changes
• Thompson RW, Driskill M. Thoracic outlet syndrome: neurogenic. In: Cronenwett JL, Johnston KW, editors. Rutherford's vascular surgery. 7th ed. Philadelphia: Elsevier; 2010. p. 1878–98
• Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J. 2012; 39(6): 842–843.
Thoracic Outlet Syndrome
• Neurogenic TOS• True Neurogenic = rare
• Overhead activities
• Intrinsic muscle atrophy in hand
– Gilliatt-Sumner hand
• Weakness in hand
• Pain
• Possible sensory loss Ulnar distribution
• Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery. 2004 Oct. 55(4):897-902; discussion 902-3
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Thoracic Outlet Syndrome
• Neurogenic TOS
• Disputed/Nonspecific Neurogenic = Majority of TOS
• Unexplained pain
• Trauma related
• Weakness
• Decreased sensation
• Difficult to quantify
• Roos DB. Thoracic outlet syndrome is underdiagnosed. Muscle Nerve. 1999 Jan. 22(1):126-9;
discussion 137-8.
• Wilbourn AJ. Thoracic outlet syndrome is overdiagnosed. Muscle Nerve. 1999 Jan. 22(1):130-6;
discussion 136-7.
Thoracic Outlet Syndrome
• Causes
• Bony factors
• Anatomic abnomalaities
– Cervical ribs
– Hypoplastic first thoracic ribs
– Exostoses of the first rib or clavicle
• Mackinnon SE, Novak CB. Thoracic outlet syndrome. Curr Probl Surg. 2002 Nov.
39(11):1070-145.
• Rayan GM. Lower trunk brachial plexus compression neuropathy due to cervical rib in
young athletes. Am J Sports Med. 1988 Jan-Feb. 16(1):77-9.
• Roos DB. Congenital anomalies associated with thoracic outlet syndrome. Anatomy,
symptoms, diagnosis, and treatment. Am J Surg. 1976 Dec. 132(6):771-8.
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Thoracic Outlet Syndrome
• Causes
• Soft tissue factors
• Anomalous fibrous muscular bands near plexus
• Hypertrophic muscles
• Space occupying lesions (tumors, cycts)
• Inflammation in soft tissues
• Roos DB. Congenital anomalies associated with thoracic outlet syndrome. Anatomy,
symptoms, diagnosis, and treatment. Am J Surg. 1976 Dec. 132(6):771-8.
• Esposito MD, Arrington JA, Blackshear MN, Murtagh FR, Silbiger ML. Thoracic outlet
syndrome in a throwing athlete diagnosed with MRI and MRA. J Magn Reson Imaging.
1997 May-Jun. 7(3):598-9.
Thoracic Outlet Syndrome
• Causes
• Other
• Trauma
• Combination (trauma and anatomy)
• Post-trauma
– Hematoma
– MO
– Scar formation
– Weakness and poor posturing
– Clavicle fracture
• Fujita K, Matsuda K, Sakai Y, Sakai H, Mizuno K. Late thoracic outlet syndrome secondary to
malunion of the fractured clavicle: case report and review of the literature. J Trauma. 2001 Feb.
50(2):332-5.
• Al-Shekhlee A, Katirji B. Spinal accessory neuropathy, droopy shoulder, and thoracic outlet
syndrome. Muscle Nerve. 2003 Sep. 28(3):383-5.
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Thoracic Outlet Syndrome
• Vascular TOS Diagnosing
• Venous TOS
• Venography
• Swelling in the arm
• Prominent veins at sight of oclusion
• Artierial TOS
• Pulse volume recordings or arteriography
• Deminished pulse
• Pale color changes
Thoracic Outlet Syndrome
• Neurogenic TOS Clinical Diagnosing
• Clinical Prediction Rule:
• 3 of 4 of the following symptoms:
• Aggravation with arm in elevated position.
• Paraesthesia originating from C8/T1.
• Supraclavicular tenderness over brachial plexus.
• Positive EAST/Roos test.
• Lindgren KA. Conservative treatment of thoracic outlet syndrome: a 2-year follow-up.
Archives of physical medicine and rehabilitation, (1997). 78(4), 373-378.
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Thoracic Outlet Syndrome
• Neurogenic TOS Clinical Diagnosis
• History & Physical exam
• Positive provocation testing of 2 of 3 tests
• Elevated arm stress test (EAST/ROOS)
• Cyriax Release Test
• Palpation of supraclavicular fossa
Mobility Tests
• First rip spring test
• Cervical rotation lateral flexion (CRLF)/Lindgren
• Rayan GM. Thoracic outlet syndrome. J Shoulder Elbow Surg. 1998 Jul-Aug;7(4):440-51.
Thoracic Outlet Syndrome
• Neurogenic TOS Clinical Diagnosis• Patients should have at least three of the following
four symptoms or signs:• History of aggravation of symptoms with the arm in an
elevated position
• History of parasthesia originating from the spinal segments C8/T1
• Supraclavicular tenderness over the brachial plexus
• Positive hands up abduction/external rotation or stress test (EAST/ROOS)
• LA Watson, Manual Therapy 14 December 2009: 586-595
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Thoracic Outlet Syndrome
• Neurogenic TOS Clinical Diagnosing
• Neurogenic
• Testing
– X-Ray & MRI for anomalies - EMG
– Anterior scalene block - NCV
– Pressure over scalene and supraclavicular fossa
• Le Forestier N, Moulonguet A, Maisonobe T, Léger JM, Bouche P. True neurogenic thoracic outlet
syndrome: electrophysiological diagnosis in six cases. Muscle Nerve. 1998 Sep;21(9):1129-34.
• Sanders RJ, Hammond S.L., Rao NM, Thoracic OutletSyndrome. A Review. The Neurologist,
2008. 14(6): p. 365–373.
• Torriani, M., R. Gupta, and D.M. Donahue, Sonographically guided anesthetic injection of anterior
scalene muscle for investigation of neurogenic thoracic outlet syndrome. SkeletalRadiol, 2009.
38(11): p. 1083–7.
• Jordan SE, Machleder HI., Diagnosis of thoracic outlet syndrome using electrophysiologically
guided anterior scalene blocks. Ann Vasc Surg, 1998. 12: p. 260–4.
Thoracic Outlet Syndrome
• Neurogenic TOS Clinical Diagnosing• Variability of the structures involved
• Multiple provocative maneuvers aid in diagnosis • Adson maneuver
• Wright test
• Roos stress test
• High rates of false-positive and false-negative results.
• Diagnosis of exclusion • Emery VB, Rastogi R, Driskill MR, Thompson RW. Diagnosis of neurogenic thoracic outlet
syndrome. In: Eskandari MK, Morasch MD, Pearce WH, Yao JST, editors. Vascular surgery: therapeutic strategies. Shelton (CT): People's Medical Publishing House-USA; 2010. p. 129–48
• Safran MR. Nerve injury about the shoulder in athletes. Part 2: long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med. 2004 Jun. 32(4):1063-76.
• Mackinnon SE, Novak CB. Thoracic outlet syndrome. Curr Probl Surg. 2002 Nov. 39(11):1070-
145.
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Thoracic Outlet Syndrome
• Neurogenic TOS Clinical Diagnosing
Adson’s Maneuver
• ABD & EXT
• Neck EXT & ROT toward
• Inhalation
• Palpate radial pulse
• + = Pulse diminishes or
parasthesias & no S&S on
contralateral side
Thoracic Outlet Syndrome
• Neurogenic TOS Clinical DiagnosingWright test
• Progressive Hyper-ABD
• Palpate pulse
• + = Pulse diminishes or
parasthesias
• Safran MR. Nerve injury about the shoulder in athletes. Part 2: long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med. 2004 Jun. 32(4):1063-76
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Thoracic Outlet Syndrome
• Neurogenic TOS Clinical DiagnosingEAST/ROOS test
• 90 deg. ABD
& 90 deg. ER with
elbows at 90 deg.
• Open & close hands
3 min.
• + = reproduction of
symptoms or a
sensation of heaviness/fatigue• Safran MR. Nerve injury about the shoulder in athletes. Part 2: long thoracic nerve, spinal
accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med. 2004 Jun. 32(4):1063-76
Thoracic Outlet Syndrome
• Neurogenic TOS Clinical Diagnosis
• Multiple points of compression may be present
• TOS
• Cubital tunnel
• Carple tunnel
• “Double rush” or “Multiple crush”
• Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer, PS. Thoracic outlet syndrome: a
controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. J Man Manip
Ther. 2010 Jun; 18(2): 74–83.
• Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973 Aug 18.
2(7825):359-62.
• Urschel HC Jr, Razzuk MA. Neurovascular compression in the thoracic outlet: changing
management over 50 years. Ann Surg. 1998 Oct. 228(4):609-17.
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Thoracic Outlet Syndrome
• Differential Diagnosis: • VTOS as a stand-alone issue or in conjunction with
neurological compromise.
• Shoulder Pathology
• Pathologic Lesion (tumor/cyst/infection)
• Cervical Radiculopathy
• Brachial Plexus Neuritis / Injury
• Postural Palsy
• Raynaud Disease
• Ulnar Nerve Compression (at the elbow)
• Overuse
• Peripheral nerve entrapment
• T4 Syndrome
Thoracic Outlet Syndrome
• Treatment • Muscle Relaxants
• Anti-inflammatories
• Adjustments in ergonomics
• Surgery• Scalenectomy
• Brachial plexus neurolysis
• First rib resection
• Physical Therapy
• Caputo FJ, Wittenberg AM, Vemuri C, Emery VB, Thompson RW. Supraclaviculardecompression for neurogenic thoracic outlet syndrome (NTOS) in pediatric and adult populations: differential patient characteristics and clinical outcomes [abstract].
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Thoracic Outlet Syndrome
• Treatment
• Goals of Intervention
• Decrease Pain
• Restore ROM
– Joint mobility
– Soft tissue mobility
• Restore Strength
• Improve Posture
• Enhanced / Normalized Breathing
• Improve Body Mechanics
• Avoid Re-injury
Thoracic Outlet Syndrome
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Thoracic Outlet Syndrome
• Treatment
• Restore normal function cervical and thoracic spine
• Measures
• Return to work, normalization of motion in C&T spine,
subjective satisfaction with outcome
• 88% satisfied with outcome
• CT spine motion restored in 80%
• 73% return to work
• 88% follow through with HEP post discharge
• 2 year follow up• Lindgren, K.-A. (1997). Conservative treatment of thoracic outlet syndrome: a 2-year follow-up.
Archives of physical medicine and rehabilitation, 78(4), 373-378.
Thoracic Outlet Syndrome
• Anatomy TrainsS
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Peripheral Nerve Entrapment
• Median nerve
• Carpal Tunnel
• Ulnar nerve
• Cubital Tunnel
Median Nerve Entrapment
• Carpal tunnel syndrome (CTS)
• Symptoms and signs that occurs following
compression of the median nerve within the carpal
tunnel.
• Numbness, paresthesias, and pain in the median nerve
distribution.
• May not be accompanied by objective changes in sensation
and strength of median-innervated structures in the hand.
Median n. distribution
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Median Nerve Entrapment
• Median nerve
• Demyelination followed by axonal degeneration.
• Sensory fibers often are affected first, followed by
motor fibers.
• Autonomic nerve fibers may be affected.
Median Nerve Entrapment
• Cause = debatableS.
• Likely = high pressures in carpal tunnel.
• Ischemia in the nerve
– Obstruction to venous outflow, back pressure, & edema
formation.
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Median Nerve Entrapment
• Risk factors• Genetic, medical, social, vocational, avocational, and
demographic.• � Aerobic fitness
• � BMI
• A complex interaction of the above
• Finger ext in relaxed UE = 11% �median nerve
• Arms in from (keyboard) significant
strain on median nerve• TW Wright, F Glowczewskie, D Wheeler, G Miller, D Cowin. Excursion and Strain of the Median
Nerve. J of Bone Joint Surg. 1996; 78A: 1897-1903
• de Krom MC, Kester AD, Knipschild PG, et al. Risk factors for carpal tunnel syndrome. Am J Epidemiol. 1990 Dec. 132(6):1102-10.
Median Nerve Entrapment
• Motor examination
• Wasting and weakness of the median-innervated
hand muscles (LOAF muscles) may be detectable.
• L - First and second lumbricals
• O - Opponens pollicis
• A - Abductor pollicis brevis
• F - Flexor pollicis brevis
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Median Nerve Entrapment
• Special Tests
• No great clinical test exists to support the diagnosis of
CTS.
• Hoffmann-Tinel sign
• Gentle tapping over the median nerve in the carpal tunnel
region elicits tingling in the nerve's distribution.
• Low sensitivity and specificity.
Median Nerve Entrapment
• Special Tests
• Phalen sign
• Tingling in the median nerve distribution is induced by full
flexion (or full extension for reverse Phalen) of the wrists for
up to 60 seconds
• This test has 80% specificity but lower sensitivity.
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Median Nerve Entrapment
• Special Tests
• The carpal compression test
• Firm pressure directly over the carpal tunnel for up to 30
seconds to reproduce symptoms.
• Sensitivity of up to 89% and a specificity of 96%.
Median Nerve Entrapment
• Special Tests
• Palpatory diagnosis
• Examining the soft tissues directly overlying the median
nerve at the wrist for mechanical restriction.
• Sensitivity of over 90% and a specificity of 75% or greater.
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Median Nerve Entrapment
• Special Tests
• The square wrist sign
• The ratio of the wrist thickness to the wrist width is greater
than 0.7.
• Modest sensitivity/specificity of 70%.
Median Nerve Entrapment
• Electrophysiologic studies
• Electromyography (EMG)
• Nerve conductions studies (NCS)
• Abnormalities on electrophysiologic testing, in association
with specific symptoms and signs, are considered the
criterion standard for CTS diagnosis.
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Median Nerve Entrapment
• Treatment
• Aerobic conditioning
• Due to relation with � Aerobic fitness & � BMI
• Modalities (in particular therapeutic ultrasound) may
provide short-term relief in some patients.
• Night wrist splints - neutral or slight extension (to be
worn at nighttime for a minimum of 3-4 wk)• Banta CA. A prospective, nonrandomized study of iontophoresis, wrist splinting, and
antiinflammatory medication in the treatment of early-mild carpal tunnel syndrome. J Occup Med.
1994 Feb. 36(2):166-8.
• Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Therapeutic ultrasound for carpal tunnel
syndrome. Cochrane Database Syst Rev. 2012 Jan 18. 1:CD009601.
• O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection)
for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003. CD003219.
• Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane
Database Syst Rev. 2012 Jul 11. 7:CD010003.
Median Nerve Entrapment
• TreatmentS
• Superficial Front Arm Line
• Pectoralis major
• Latissimus dorsi
• Medial intermuscular septum
• Flexor group
• Carpal tunnel
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Median Nerve Entrapment
• Steroid injection
• long-term benefit and can be tried if more
conservative treatments have failed
• Surgery
• Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome.
Cochrane Database Syst Rev. 2007. (2):CD001554e treatments have failed.
Ulnar Nerve Entrapment
• Ulnar nerve entrapment:
• Second most common entrapment neuropathy in the
upper extremity (after entrapment of the median
nerve)
• Aguiar PH, Bor-Seng-Shu E, Gomes-Pinto F, Almeida- Leme RJ, Freitas AB, Martins RS, et
al. Surgical management of Guyon's canal syndrome, an ulnar nerve entrapment at the
wrist: report of two cases. Arq Neuropsiquiatr. 2001 Mar. 59(1):106-11.
• Spinner M, Spencer PS. Nerve compression lesions of the upper extremity. A clinical and
experimental review. Clin Orthop Relat Res. 1974 Oct. 46-67.
• FEINDEL W, STRATFORD J. The role of the cubital tunnel in tardy ulnar palsy. Can J Surg.
1958 Jul. 1(4):287-300.
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Ulnar Nerve Entrapment
• Entrapment sites
• Most common = The elbow region (cubital tunnel or in
the ulnar groove)
• Second most likely = near the wrist (canal of Guyon)
• Forearm between these two regions, below the wrist
within the hand, or above the elbow.
• Campbell WW, Pridgeon RM, Riaz G, Astruc J, Sahni KS. Variations in anatomy of the ulnar nerve
at the cubital tunnel: pitfalls in the diagnosis of ulnar neuropathy at the elbow. Muscle Nerve. 1991
Aug. 14(8):733-8
• Aguiar PH, Bor-Seng-Shu E, Gomes-Pinto F, Almeida- Leme RJ, Freitas AB, Martins RS, et al.
Surgical management of Guyon's canal syndrome, an ulnar nerve entrapment at the wrist: report
of two cases. Arq Neuropsiquiatr. 2001 Mar. 59(1):106-11
• Elhassan B, Steinmann SP. Entrapment neuropathy of the ulnar nerve. J Am Acad Orthop Surg.
2007 Nov. 15(11):672-81
Ulnar Nerve Entrapment
• Entrapment sites
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Ulnar Nerve Entrapment
• Possible denervation and paralysis of
muscles
• Numbness and tingling along the little finger and the
ulnar half of the ring finger
• Weakness of grip / ocationally intrinsic wasting
Ulnar Nerve Entrapment
• Treatment
• Nonsurgical therapy helpful in many cases of ulnar
neuropathy.
• If conservative therapy fails, surgical treatment is
warranted, typically involving one of the following
procedures
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Ulnar Nerve Entrapment
• Treatment
• Nerve Glides (Brian Catinia)
https://www.youtube.com/watch?v=3LNekkvyVVY
https://www.youtube.com/watch?v=BB2x66cDV8M
Lateral Epicondylitis
• “tennis elbow” - Lateral epicondylitis
• Misnomer[
• microscopic evaluation of the tendons does not show signs of
inflammation
• The tendons are relatively hypovascular proximal to the
tendon insertion. This hypovascularity may predispose the
tendon to hypoxic tendon degeneration and has been
implicated in the etiology of tendinopathies.[2]
• Most typically, extensor carpi radialis brevis (ECRB) tendon• Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and
exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006
Nov 4. 333(7575):939. [Medline]. [Full Text].
• Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different
orthotic devices. Clin Rheumatol. 2008 Aug. 27(8):1015-9. [Medline].
• Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip
strength of patients with lateral epicondylosis. J Orthop Sports Phys Ther. 2009 Jun. 39(6):484-9.
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Lateral Epicondylitis
• Presentation
• 40 to 50 yo
• Insidious onset - history of overuse
• Symptom 24-72 hours after activity
• Probably due to microscopic tears in the tendon.
• Pain over the lateral elbow that worsens with activity
and improves with rest.
• May radiate down the posterior aspect of the forearm.
• Pinpoint pain just distal to the origin of the ECRB.
• Pain mild to severe
Lateral Epicondylitis
• Treatment• Watchful waiting
• At 52 weeks, inj worse than PT and watchful waiting
• PT > watchful waiting at 5 weeks, with only slight improvement at 52 weeks
• NSAID’s• May offer short term relief
• Corticosteroid injection• Effective short term, not long term
• Surgery
• Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol. 2006 Jun. 35(6):371-7. [Medline].
• Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE. Comparison of autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study. J Hand Surg Am. 2011 Aug. 36(8):1269-72.
• Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 Nov 4. 333(7575):939.
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Lateral Epicondylitis
• Treatment
• ASTYM
• Stretching
Lateral Epicondylitis
• Treatment
• Eccentric Loading
• Dumbbell
• Weighted ball
• FlexBar
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Lateral Epicondylitis
• Treatment
• Anatomy Trains
• Superficial Back Arm Line
• Shoulder ER’s
• Posturing
Medial Epicondylitis
• “Golfers Elbow” – Medial Epicondylitis
• Degenerative state instead of a traditional inflammatory
• epicondylosis
• Med. Epi. = Common origin of the forearm flexor and
pronator muscles
• Most common site of pathology is the interface between
the pronator teres and the flexor carpi radialis origins• Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and
findings of histological, immunohistochemical, and electron microscopy studies. J Bone
Joint Surg Am. 1999 Feb. 81(2):259-78.
• Ljung BO, Forsgren S, Fridén J. Substance P and calcitonin gene-related peptide
expression at the extensor carpi radialis brevis muscle origin: implications for the etiology
of tennis elbow. J Orthop Res. 1999 Jul. 17(4):554-9
• Nirschl RP. Prevention and treatment of elbow and shoulder injuries in the tennis player.
Clin Sports Med. 1988 Apr. 7(2):289-308.
• Nirshal RP. Muscle and tendon trauma: tennis elbow. The Elbow and Its Disorders.
Philadelphia, Pa: WB Saunders Co; 1993. 481-96.
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Medial Epicondylitis
• Presentation• Aching pain over the medial elbow.
• Possible grip weakness.• Ulnar nerve symptoms are associated in up to 20% of
athletes with medial epicondylitis.
• Kohn HS. Prevention and treatment of elbow injuries in golf. Clin Sports Med. 1996 Jan. 15(1):65-83.
Medial Epicondylitis
• Treatment
• NSAID’s
• Controversial
– Decrease inflam vs bleeding[
• RICE
• Bracing
• Counterforce – cock up
• Surgery
• Plancher KD, Halbrecht J, Lourie GM. Medial and lateral Thurston AJ. Conservative and surgical
treatment of tennis elbow: a study of outcome. Aust N Z J Surg. 1998 Aug. 68(8):568-72.
epicondylitis in the athlete. Clin Sports Med. 1996 Apr. 15(2):283-305.
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Lateral Epicondylitis
• Treatment
• ASTYM
• Stretching
Lateral Epicondylitis
• Treatment
• Eccentric Loading
• Dumbbell
• Weighted ball
• FlexBar
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Lateral Epicondylitis
• Treatment
• Anatomy Trains
• Superficial Front Arm Line
• Shoulder ER’s
• Posturing
Thank youS