Chapter 1: Upper Extremity Disorders

• Most dislocations (95%) occur in ant-inf direction
• Ant-inf dislocation occurs when abd UE is forcefully ER --> causes tear of inf GH ligament, ant capsule, and occasionally glenoid labrum
• Post dislocations rare - occur with multidirectional laxity of GH joint (horizontal add and IR)

• Compression fracture of posterior humeral head (Hill-Sachs lesion)
• Tearing of superior glenoid labrum from ant-->post (SLAP lesion)
• Avulsion of anteroinferior capsule and ligaments associated with glenoid rim (Bankart's lesion)
• Bruising of axillary nerve

• Plain film imaging
• CT Scan
• MRI
• Apprehension test = positive

• Acetaminophen for pain
• NSAIDs (pain and inflammation)

• Pts should avoid apprehension position
• Joint mobs to correct biomechanical faults

• Traumatic: common in young throwing athletes
• Atraumatic: individuals with congenitally loose connective tissue around the shoulder

• Characterized by popping/clicking and repeated dislocation/subluxation of the GH joint
• Unstable injuries require surgery to reattach the labrum to the glenoid
• Bankart's lesions require surgery

• Acetaminophen for pain
• NSAIDs for pain and inflammation

• Emphasize return of function without pain
• Functional training
• Restoration of muscle imbalances
• Joint mobilizations
• For patients requiring surgery: shoulder kept in sling for 3-4 weeks, after 6 weeks = sport specific training (full fitness may take 3-4 months)

• Classified as either superior or inferior (position within glenoid socket)
• SLAP Lesion: tear of the rim above the middle of the socket that may also involve the biceps tendon
• Bankart's Lesion: tear of the rim below the middle of the glenoid socket, involves inferior GH ligament
• Tears may often occur with other shoulder injuries (i.e. dislocation)

• Shoulder pain that cannot be localized to a specific point
• Pain made worse by overhead activities or when the arm is held behind the back
• Weakness
• Instability in the shoulder
• Pain on resisted flexion of the biceps (bending the elbow against resistance)
• Tenderness over the front of the shoulder

• Made by cynical examinations through comparing results of AROM, PROM, resistive tests, and palpation
• MRI arthrograms very effective in identification
• "Gold standard" = through arthroscopic surgery of the shoulder

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

• Emphasize return to function without pain
• Functional training and restoration of muscle imbalances 
• Any underlying causes that contributed to shoulder injury (i.e. shoulder instability) should be addressed
• Joint mobs (to correct biomechanical faults caused by joint restrictions)
• Following surgery, shoulder in sling for 3-4 weeks. Sport specific training after 6 weeks (full fitness may take 3-4 months)

• Compression of neurovascualr bundle (brachial plexus, subclavian artery and vein, vagus and phrenic nerves, and sympathetic trunk) in thoracic outlet between bony and soft tissue structures
• Compression occurs when size or shape of thoracic outlet is altered

• Superior thoracic outlet
• Scalene triangle
• Between clavicle and 1st rib
• Between pec minor and thoracic wall

• Plain film imaging: identify abnormal bony anatomy
• MRI: identify abnormal soft tissue anatomy
• Electro-diagnostic test: assess nerve dysfunction
• Clinical examination: Adson's, Roos, Wright, and Costoclavicular test

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

• Includes postural reeducation
• Functional training and restoration of muscle imbalances
• Joint mobs
• Manipulations (typicallly 1st rib) to diminish pain and soft tissue guarding

• MOI: fall onto shoulder with UE adducted, or collision with another individual during sporting event
• Degree of injury graded from 1st - 3rd degree (Rockwood classification scale grades from I-IV)
• UE positioned in neutral with use of sling in acute phase -- avoid shoulder elevation during acute phase of healing
• Surgical repare is rare due to tendency of AC jt degeneration following repair

• Plain Film Imaging 
• Shear Test

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

• Return of function without pain
• Functional training
• Restoration of muscle imbalances
• Manual techniques to AC and SC joints and surrounding connective tissue (soft tissue/massage, joint oscillations, mobilizations)

• Subacromial and subdeltoid bursae (which may be continuous) have close relationship to RC tendons -- makes them susceptible to overuse
• Can also become impinged beneath acromial arch

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

• Tendons of RC susceptible to tendonitis, due to relatively poor blood supply near insertion of muscles
• Results from mechanical impingement of distal attachment of RC on anterior acromion and/or coracromial ligament with repetitive overhead activities

• MRI may be used - sometimes not sensitive enough for accurate assessment
• Supraspinatus test
• Neear's impingement test

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

Characterized by soft tissue inflammation of shoulder from impingement against acromion with repetitive overhead AROM

• Arthrogram
• MRI
• Neer's impingement test
• Supraspinatus test
• Drop arm test 

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

• Restoration of posture
• Correct muscle imbalances and biomechanical faults (strengthening, endurance, coordination, and flexibility exercises)
• Joint mobilizations
• Surgical repair = pt should avoid elevation greater than 90 degrees 

• Characterized by an irritation between the RC and greater tuberosity or posterior glenoid and labrum
• Often seen in athletes performing overhead activities
• Pain commonly noted in posterior shoulder

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

• Correction of muscle imbalances and biomechanics faults
• Joint mobilizations 

• Most commonly an inflammation of the long head of the biceps
• Results from mechanical impingement of proximal tendon between the anterior acromion and bicipital groove of the humerus  

• MRI may be used but sometimes not sensitivity enough
• Speed's test

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

Humeral neck fractures: frequently occur with a FOOSH among older osteoporotic women; generally does not require immobilization or surgical repair (fairly stable fracture)

Greater tuberosity fractures: more common in middle aged and elder adults; usually related to a fall onto the shoulder; does not require immobilization for healing 

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

• Emphasize return of function without pain
• Functional training and restoration of muscle imbalances
• Early PROM important in preventing capsular adhesions 

• Characterized by a restriction in shoulder motion as a result of inflammation and fibrosis of the shoulder capsule
• Usually due to disuse following injury or repetitive microtrauma
• Restriction follows capsular pattern of limitation
• Commonly seen in association with diabetes mellitus 

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

• Emphasizes return to function with out pain
• Joint mobs
• Functional training and restoration of muscle imbalances 

• Loss of motion in capsular pattern (flex>ext)
• Loss of motion in non capsular pattern as the result of a loose body in the joint, ligamentous sprain, and/or CRPS

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation

• Joint mobs
• Soft tissue/massage
• Modalities
• Flexibility exercises
• Functional exercises 
• Splinting

• Tennis Elbow
• More often a chronic degenerative condition of the ECRB tendon at its proximal attachment to the lateral epicondyle 
• Onset = gradual
• Usually the result of sports activities or occupations that require repetitive wrist extension or strong grip w/ the wrist extended 
• Must rule out involvement/relationship to c-spine condition

• Correction of muscle imbalances and biomechanics faults
• Endurance and strength exercises (emphasize eccentrics)
• Joint mobs
• Education on prevention
• Cryotherapy, thermotherapy, hydrotherapy, sound agents and TENS
• Counterforce bracing (reduces forces along ECRB)

• Golfer's elbow
• Usually a degenerative condition of pronator trees and FCR tendons at their attachment to medial epicondyle 
• Occurs with overuse in sports (baseball pitching, golf swings, swimming) or occupations that require a strong hand grip and excessive pronation of the forearm

• Complications include loss of motion, myositis ossificans, malalignment, neuromuscular compromise, ligamentous injury, and CRPS
• Supraconydlar fractures must be examined quickly for neuromuscular status (high number of neurological (radial nerve) and vascular structures that pass through this region (Volkmann's ischemia)) 
• Important to assess growth plate in youth 
• Fractures have a high incidence of malunion
• Lateral epicondyle fractures fairly common in young people (typically require ORIF to ensure absolute alignment) 

• Pain reduction and limiting inflammatory response following trauma and/or surgery
• Improve flexibility of shortened structures
• Strengthening
• Training to restore functional use of UE 

• Affects central and/or lateral aspects of capitellum or radial head 
• An osteochondral bone fragment becomes detached from articular surface, forming a loose body in the joint
• Caused by repetitive compressive forces between radial head and humeral capitellum
• Occurs in adolescents between 12-15 years
• Panner's disease

• Localized avascular necrosis of capitellum
• Leads to loss of subchondral bone with fissuring and softening of articular surfaces of radiocapitellar joint
• Etiology unknown
• Occurs in children age 10 and younger

• Rest with avoidance of any throwing or upper extremity loading activities
• When pt is pain-free, initiate flexibility and strengthening/endurance/coordination exercises
• Late phases of rehab = slowly increase load on joint 
• If symptoms persist, surgical intervention is necessary
• After surgery, initial focus is to minimize pain and swelling using modalities 
• Flexibility exercises immediately following surgery

• Occurs as result of repetitive valgus stresses to medial elbow with overhead throwing 
• Clinical signs = pain along medial elbow at distal insertion of ligament
• In some cases, paresthesias are reported in ulnar nerve distribution with positive Tinel's sign

• Initially, rest and pain management
• After resolution of pain and inflammation, strengthening exercises that focus on elbow flexors
• Taping for protection during return to activities 

• Various causes:
• Direct trauma at cubital tunnel
• Traction due to laxity at medial aspect of elbow
• Compression due to thickened retinaculum or hypertrophy of FCU muscle
• Recurrent subluxation or dislocation
• DJD that affects cubital tunnel

• Medial elbow pain
• Paresthesias in ulnar distribution
• Positive Tinel's sign 

• Occurs within pronator trees muscle and under superficial head of FDS
• Repetitive gripping activities required in occupations

• Aching pain with with weakness of forearm muscles
• Positive tinel's sign
• Paresthesia in median nerve distribution 

• Entrapment of distal branches (posterior interosseous nerve)
• Occurs within radial tunnel (radial tunnel syndrome) 
• Result of overhead activities and throwing

• Lateral elbow pain
• Pain over supinator muscle
• Paresthesias in radial nerve distribution (Tinel's sign may be positive) 

Electrodiagnostic Tests

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation
• Neurotonin for neuropathic pain 

• Early intervention = rest, avoiding exacerbating activities, NSAIDs, modalities, soft tissue/massage to reduce inflammation and pain 
• If abnormal neurotension is present, neurodynamic mobilization may be indicated
• Protective padding and night splints to maintain slackened position of nerves
• With reduction in pain and paresthesias, rehab program should focus on strengthening/endurance/coordination exercise of involved muscles to achieve muscle balance between agonists and antagonists, normal flexibility of shortened structures, and normalization of strength, endurance, and coordination
• Functional training
• Pt education
• Self-management techniques 

• Posterior dislocations = account for most dislocations at elbow
• Posterolateral most common: occur as result of elbow hyperextension from FOOSH
• Post dislocations frequently cause avulsion fractures of medial epicondyle secondary to traction pull of MCL
• Anterior and radial head dislocations rare 
• Complete dislocation = UCL will rupture with possible rupture in ant capsule, LCL, brachialis muscle, and/or wrist flex/ext muscles 
• Clinical signs = rapid swelling, severe pain at elbow, deformity 

• Initially = reduction of dislocation 
• If elbow is stable, there is an initial phase of immobilization followed by rehab focusing on regaining flexibility within limits of stability and strengthening 
• Surgery indicated for elbow that is not stable 

• Compression of median nerve at carpal tunnel of wrist due to inflammation of the flexor tendons and/or median nerve
• Result of repetitive wrist motions or gripping, with pregnancy, diabetes, and RA
• Must rule out potential c-spine dysfunction. TOS, or peripheral nerve entrapment 

Electrodiagnostic Testing 

• Exacerbation of burning, tingling, pins and needles and numbness into median nerve distribution at night
• Positive Tinel's sign and/or Phalen's test
• Long term compression --> atrophy and weakness of thenar muscles and lateral two lumbricals 

• Joint mobilizations
• Soft tissue/massage
• Modalities
• Flexibility exercises
• Functional exercises 

• Inflammation of EPB and APL tendons at first dorsal compartment 
• Results from repetitive micro trauma or as a complication of swelling during pregnancy
• Clinical signs = pain at anatomical snuffbox, positive Finkelstein's test, decreased grip and pinch strength

• Joint mobilizations 
• Soft tissue/massage
• Modalities
• Flexibility exercises
• Functional exercises 

• Most common wrist fracture
• Results from FOOSH
• Fractures are immobilized for 5-8 weeks
• Complication of median nerve compression can occur w/ excessive edema
• Characteristic "dinner fork" deformity of wrist and hand results from dorsal or posterior displacement of distal fragment of radius, with radial shift of wrist and hand 

• Early focus = normalizing flexibility 
• Joint mobs
• Soft tissue/massage
• Modalities
• Flexibility exercises 
• Functional exercises 

• Similar to Colles' fracture
• Distal fragment of radius dislocates in a volar direction --> causes characteristic "garden spade" deformity

• Results from FOOSH in younger person
• Most commonly fractured carpal 
• Complications include high incidence of avascular necrosis of proximal fragment of scaphoid secondary to poor vascular supply
• Carpals immobilized for 4-8 weeks 

• Early intervention includes maintenance of flexibility of distal and proximal joints while UE is casted 
• Later intervention = strength, stretching, joint and soft tissue mobs

• Observed as banding on palm and digit flexion contractures, resulting from contracture of palmar fascia that adheres to skin
• Men affected more than women
• Contracture usually affects MCP and PIP joints of 4th and 5th digits in non diabetic individuals and 3rd and 4th in individuals with diabetes 

• Flexibility exercises
• Splint fabrication/application
• Functional exercises for restoration of normal hand function
• PT following surgery includes wound management, edema control and progression of functional exercises 

• Results from rupture of central tendons slip of extensor hood
• Observed deformity = ext of MCP and DIP with flexion of PIP
• Commonly occurs following trauma or in RA with degeneration of central extensor tendon

• Edema management
• Flexibility exercises
• Splinting or taping
• Functional strengthening/endurance/ coordination 

• Results from contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons
• Observed deformity = flex of MCP and DIP with ext of PIP
• Commonly occurs following trauma or with RA following degeneration of lateral extensor tendons 

• Edema managemnt
• Flexibility
• Splinting/taping
• Strengthening
• Endurance
• Coordination

• Observed as thenar muscle wasting
• 1st digit moving dorsally until it is in one with second digit
• Results from median nerve dysfunction

Electrodiagnostic testing

• Edema management
• Flexibility
• Splinting/taping
• Strengthening
• Endurance
• Coordination

• Rupture or avulsion of extensor tendon at its insertion into distal phalanx of digit
• Observed deformity = flexion of DIP joint
• Usually occurs from trauma -- forcing distal phalanx into flexed position

• Edema management
• Flexibility
• Splinting/taping
• Strengthening
• Endurance
• Coordination

• A sprain/ruptur of UCL of MCP joint at 1st digit
• Results in medial instability of thumb
• Frequently occurs during fall while skiing, when increasing forces are plead on thumb through ski pole
• Immobilized fo 6 weeks 

• Edema management
• Flexibility
• Splinting/taping
• Strengthening
• Endurance
• Coordination

• Fracture of neck of 5th met
• Frequently sustained during fight or from punching a wall in anger or frustration 
• Casted for 2-4 weeks

• Edema management
• Flexibility
• Strengthening/Endurance/Coordination