Body Chart Initial Hypothesis? www.vompti.com L ATERAL E LBOW C ASE - PDF document

Property of VOMPTI, LLC Body Chart Initial Hypothesis? www.vompti.com L ATERAL E LBOW C ASE S TUDY Kristin Kelley, DPT, OCS, FAAOMPT Orthopaedic Manual Physical Therapy Series Charlottesville 2017-2018 Orthopaedic Manual Physical Therapy Series 2017-2018 Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Body Chart Initial Hypothesis? Subjective Exam • 45 y.o. female admin assistant referred to PT • Lateral epicondylalgia w/a script: “Elbow pain” • RCL injury/Posterolateral Rotary Instability • Pt states she began • (Radial nerve) PIN Entrapment having right elbow pain approximately 2 months • Radial tunnel syndrome ago after she began rock • C5, C6 nerve root/radiculopathy climbing. • C5, C6 disc, dural irritation, facet • CCO right elbow, arm and proximal forearm pain • Elbow joint dysfunction: RH, UH or prox RU most pronounced • Muscular strain: cervical and/or elbow laterally • R UE dominant Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 1

Property of VOMPTI, LLC Subjective Exam Subjective Asterisks • Aggs: elbow ROM (ext>flex), gripping, twisting, typing • Eases: R UE disuse in mid ROM position, PRN Aleve • Pain with gripping, twisting, reaching • Denies paresthesia in arm or hand and no previous elbow involvement on either side • MOI — gripping/pulling • PMH: unremarkable • Alleviation of pain with rest • Upon questioning, she stated she has some R Upper • No paresthesia Trap area soreness after working all day “but everyone has that….” • “upper trap” pain • Had been rock climbing approx 2x/week but had to • Her job — prolonged sitting, computer and stop last week b/c pain was too intense. phone work • Pain with computer work • DASH = 34.2 (0= no disability, 100 = max disability) Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Structures at Fault? Structure at Fault • Joints: -Joints – RH, UH, prox RU, C5-T2 facet, Rib 1,2 • Myofascial Tissue: -Myofascial – C 5-T2 paraspinals and multifidus, common Tissue extensor tendon, triceps, annular ligament, RCL • Neural Tissue: -Neural – Radial nerve, PIN, C6 (possibly C5 or C7), Lateral Tissue antebrachial cutaneous nerve • Other structures? Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 2

Property of VOMPTI, LLC Primary Hypothesis After Subjective Differential Diagnosis Exam • Lateral Epicondylalgia • Muscular Strain — forearm, UT, scalene, Levator • RCL injury/PLRI • PIN Entrapment • Radial Tunnel Syndrome • Cervical Radic • Elbow Joint dysfunction: RH, UH or prox RU Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Posterolateral Rotary Instability Posterolateral Rotary Instability Differential Diagnosis • • History – RCL insufficiency – Result of RCL injury – Lateral epicondyalgia – MOI: combo of axial – Radial tunnel syndrome compression, valgus stress, – Cervical spine referral supination forces Treatment • • Physical Exam – Current evidence of preferred – Vague lateral elbow pain, rehab n/a clicking, clunking worse – Protection of injured structure — with supination, elbow ext hinged elbow brace in pronation – Common to see secondary for 4-6 weeks w/avoidance of shoulder abd/IR to avoid varus lateral tendinopathy or position neural inflammation w/PLRI – ?surgical repair Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 3

Property of VOMPTI, LLC PIN Entrapment PIN Innervated Mucles • History – Compression of Radial Nerve or It supplies all the muscles on the radial side and dorsal surface of PIN at Arcade of Frohse due to the forearm, except the Anconæus, Brachioradialis, Extensor carpi radialis longus. repetitive pronation/supination It DOES supply: or trauma ECRB - deep branch of radial nerve • – Radial Tunnel = Pain • Extensor digitorum – PIN = Pain + Weakness • Extensor digiti minimi • Extensor carpi ulnaris – Pain to proximal ext mm • Supinator muscle - deep branch of radial nerve • Physical Exam • Abductor pollicis longus – (+) TTP distal to lateral • Extensor pollicis brevis epicondyle • Extensor pollicis longus • Extensor indicis – Pain with RSC supination Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com PIN Entrapment Radial Tunnel Syndrome • History • Differential Diagnosis – Compression of Radial Nerve at radial tunnel-from just proximal – Lateral Epicondylitis to the capitellum to edge of the – RCL Instability supinator. • Treatment – Neck of radius = Pain (commonly – No resisted supination or wrist nocturnal pain) extension activities – RTS = Pain, only weakness due to – Long-arm splint pain (no motor loss) • Elbow 90 deg, neutral forearm – Common w/repetitive forceful – May require surgical sup/pron (power lifters, tennis decompression players, swimmers) Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 4

Property of VOMPTI, LLC Radial Tunnel Syndrome • Physical Exam – (+) TTP neck of radius, prox forearm extensors – Pain with RSC supination w/elbow extended • Differential Diagnosis – Lateral Epicondylalgia, RCL instability, cervical radic • Treatment – NSAIDs – No resisted elbow extension, forearm pronation, and wrist flexion – Long-arm splint • Elbow 90 deg, neutral forearm Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Radial nerve entrapment sites Radial Neurodynamic Test • Juncture of the middle 1.Starting position-pt arm by and distal third of the arm (especially with side, elbow 90 deg, neutral fractures of the humerus), wrist/finger. Perform • Radial tunnel shoulder depression with • Proximal to the wrist anterior hip taking up slack between the brachioradialis and in nerves, NOT stretching. ECRL ( Wartenberg’s 2.Elbow extension Syndrome) 3.Internal – numbness, tingling, and weakness of the posterior Rotation/pronation aspect of the thumb Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 5