ABC's of Treatment Strategies for Upper Extremity Instabilities Tambra Marik, OTD, OT, CHT Rocky Mountain University Of

ABC’s of Treatment Strategies for Upper Extremity Instabilities

Tambra Marik, OTD, OT/L, CHT

Secrets to Stabilization Part 1 1

Objectives • Describe the basic functional anatomy and biomechanics of the shoulder, wrist and elbow • Implement the concepts of functional rehabilitation • Assess pathomechanics of instabilities of the shoulder, elbow and wrist • Utilize evaluation tests and interpret diagnostic values of tests for application to daily clinical practice • Implement neuromuscular training and core strengthening to treatment strategies

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THEMES

• Rehabilitation concepts – Themes of stabilization functional rehabilitation – Rest and immobilization required for healing – Specific structures require protection – Gradual ROM progressions based on soft tissue healing – The core matters – Gradual progression towards strengthening and return to previous level of function – Proximal and distal joint movement patterns addressed to avoid further injury – Proprioception training/sensorimotor activities

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1 THEMES: Secrets to Stabilization Functional Rehabilitation

Core

Motor Control

Dynamic Stability

Static Stability Secrets to Stabilization Part 1 4

Static Local Stability Global Stabilizers Stabilizers

Function Rehabilitation Core Stability

Dynamic Motor Stability Control

GlobalSecrets Mobilizers to Stabilization Part 1 5

Dysfunction Local Global Global Stabilizers Stabilizers Mobilizers • Decreased force • Abnormal Overactive & production • movement at 1 tight muscles segment Reflex inhibition • • Spasms • Reflex inhibition • Dysfunctional • Results in • Poor response to recruitment decreased load pattern movement • Poor movement patterns at patterns at several joints segment

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2 GLENOHUMERAL STABILIZERS

STATIC Static Motor • Ligaments/Capsule Stability Control • Geometry of GH joint • Glenoid Labrum • Negative intra-articular Pacinian Ruffini pressures Extreme Motion Extreme Motion Compressive Strength Tensile Strength

Finnoff J, Doucette S, Hicken G. Glenohumeral instability and dislocation. Phys Med and Rebab Clinics of N Amer, 2004;15:575-605.Secrets to Stabilization Part 1 7

Glenohumeral Static Stabilizers

Static Stability

• Ligaments • Labrum • Capsule • Boney Architect

http://www.ithaca.edu/faculty/lahr/LE2000/UE_Ind_Stud y_99/shoulder/edited/glenoid_fossa.jpeg

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Ligaments of the Shoulder Girdle • Sternoclavicular (SC) – Anterior, Posterior – Costoclavicular • Acromio-clavicular (AC) – Coracoacromial – Coracoclavicular (conoid, trapzoid) • Superior Transverse Ligament • Coracohumeral ligament (CHL) • Glenohumeral ligament (superior, middle, inferior) http://upload.wikimedia.org/wik ipedia/commons/3/3b/Gray326. png Secrets to Stabilization Part 1 9

3 Ligaments of the Shoulder Girdle

Sternoclavicular

Retrieved on 8/15/15 from: http://classconnection.s3.amazonaws.com/535/flashcards/3547535/png/sternoclavicular_j 14105C8D3116E509030.png • Interclavicular restrains inferior displacement (holds shoulder up) • Anterior/posterior restrains ant/post displacement • Costoclavicular restrains excessive rotation and medial/lateral displacement

Secrets to Stabilization Part 1

Mechanism of Injury SC ligament Direct or Indirect force

Anterior dislocation Posterior dislocation • 8 wks in sling • Posterior dislocation: 6-8 • Elbow/wrist ROM wks figure of eight clavicle 8 wks: ROM below 90° strap and gentle (gradual reduce sling wear) pendelums. Avoid flex and 12 wks: Full ROM and abduction above 90◦ strengthening Guan, J. J., & Wolf, B. R. (2013). Reconstruction for anterior Groh, G. I., Wirth, M. A., & Rockwood, C. A. (2011). Treatment of traumatic sternoclavicular joint dislocation and instability. Journal of Shoulder and posterior sternoclavicular dislocations. Journal of Shoulder and Elbow Surgery, Elbow Surgery, 22(6), 775-781. 20(1), 107-113

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Ligaments of the Shoulder Girdle • Acromio-clavicular

Retrieved on 8/15/15 from: https://s.yimg.com/fz/api/res/1.2/nRAxT99C962Y7olZJXIcWw-- /YXBwaWQ9c3JjaGRkO2g9NjEyO3E9OTU7dz02MjU- /http://classconnection.s3.amazonaws.com/184/flashcards/1904184/jpg/ 11353982940540.jpg

• Acromoclavicular restrains ant/post translation, provides horizontal stabilization • Coracoacromial restrains ant/post. translation • Coracoclavicular restrains vertical displacement

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4 Mechanism of Injury AC ligament Fall directly on shoulder

Types IV, V (Reconstruction Procedures) • 6-8 wks Gunslinger Shoulder Orthosis Types I & II • AROM elbow, wrist and hand 1 to 3 wks wear sling • • 7 to 10 days PROM to 90° flexion supine (discharge as pain subsides) • AROM 6 to 8 wks • Strengthening at 12 wks if no pain with • ROM and strengthening arom. Type III (conservative) • 12 to 16 wks gradual return to pre- • 3 to 4 wks wear sling injury activity level Johansen, J. A., Grutter, P. W., McFarland, E. G., & Petersen, S. A. (2011). Acromioclavicular joint injuries: indications • Progress ROM & strengthSecrets forto treatment Stabilization and treatment Part options. 1 Journal of Shoulder and Elbow Surgery, 20(2), S70-S82. 13

Glenohumeral Ligaments • Coracohumeral ligament (CHL)

• Glenohumeral ligament (superior, middle, inferior)

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Ligaments of the Glenohumeral Joint • Coracohumeral ligament (CHL)

• Superior glenohumeral ligament (SGHL)

• Middle glenohumeral ligament (MGHL)

http://upload.wikimedia.org • Inferior glenohumeral ligament (IGHL) /wikiped Ia/commons/3/3b/Gray326. png Posterior band glenohumeral ligament • Secrets to Stabilization Part 1 15

5 Ligaments of the Glenohumeral Joint/Coracohumeral

http://upload.wikimedia.org/wikipedia/commons/3/3b/Gray326.png • Coracohumeral ligament (CHL) Connects coracoid process to greater and lesser tuberosities of the humerus

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Ligaments of the Glenohumeral Joint/ (SGHL, MGHL, IGHL) • Superior glenohumeral ligament (SGHL) Connects anterosuperior edge of the glenoid to the lesser tubercle of the SGHL humerus MGHL • Middle glenohumeral ligament IGHL (MGHL) Connects supra-glenoid tubercle, superior labrum or scapular neck to Axillary lesser tuberosity Pouch • Inferior glenohumeral ligament (IGHL) http://upload.wikimedia.org/wikipedia/com Connects anteroinferior labrum and mons/3/3b/Gray326.png

glenoid lip to lesser tuberositySecrets to Stabilization Part 1 17

Stabilizers Against Anterior Translations • Humerus adducted: Subscapularis

• Humerus abducted 45°: Subscapularis, middle anterior GH ligament, and superior portion of inferior anterior GH ligament

• Humerus at 90° abduction: Inferior anterior GH ligament

Retrieved from: http://www.radsource. us/_images/0909_6.jpg Turkel et al 1981 Secrets to Stabilization Part 1 18

6 0 to 30 degrees

Boney Architect

90 degrees

45 to 60 degrees Antero-medial force

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Glenohumeral Static Stabilizers Static Stability • Ligaments • Labrum • Capsule • Boney Architect

http://www.ithaca.edu/faculty/lahr/LE2000/UE_Ind_Stud y_99/shoulder/edited/glenoid_fossa.jpeg

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7 Static Stabilizers Glenoid Labrum Fibrocartilage Structure • ^ depth of glenoid fossa by 50% • Provides attachment of GH ligaments • Firmly attached in all regions except loosely superiorly Illustration retrieved from” http://www.sportsinjuryclinic.net/ gallery/shoulder/glenoid_labrum2.jpg Secrets to Stabilization Part 1 22

Glenohumeral Static Stabilizers Static Stability • Ligaments • Labrum • Capsule • Boney Architect

http://www.ithaca.edu/faculty/lahr/LE2000/UE_Ind_Stud y_99/shoulder/edited/glenoid_fossa.jpeg

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Static Stabilizers

Negative Intra-articular Pressure • Creates a vacuum effect across GH joint • Primary stabilizer against inferior instability • Also prevents instability in other directions

Illustration retrieved on 2/26/12 from:Secrets to Stabilization Part 1 24 http://www.shoulderdoc.co.uk/images/uploaded/labrum_depth.jpg

8 Glenohumeral Static Stabilizers Static Stability • Ligaments • Labrum • Capsule • Boney Architect

http://www.ithaca.edu/faculty/lahr/LE2000/UE_Ind_Stud y_99/shoulder/edited/glenoid_fossa.jpeg

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Glenohumeral Static Stabilizers

• Ligaments Labrum • • Humeral • Capsule head to • Boney shaft angle Architect 130° to 150° Illustration retrieved on 4/11/10 from: http://www.acta-ortho.gr/v57t3/U1.jpg • Retroverted 30° Secrets to Stabilization Part 1 26

Defining Shoulder Instability

• Shoulder instability is the inability to maintain the humeral head in the glenoid fossa. Dislocation: the humeral head is forced completely out of its normal position in the glenoid fossa. Subluxation: the humeral head slips partially out of glenoid fossa causing symptoms Laxity: partial lost of glenohumeral articulation without symptoms

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9 Circle Concept of the Shoulder

Ant. Capsule Ant. Capsule

Humeral Humeral Head Head

Anterior Translation • Capsuloligamentous restraints act in a ring fashion • Translations of the humerus create tension on the same and opposite sides. Therefore, translation in one direction may require damage to restraints on the same and opposite sides of the joint. • Contra-coup concept is injury can occur to the opposite side of the injury Levine et al 2000 Secrets to Stabilization Part 1 28

Epidemiology of Shoulder Dislocations Acute • Approximately 24 out of 100,000 are estimated to have acute shoulder dislocations

• 4% to 8% of all injuries sustained by active population(Zebas et al 1995)

• TUBS: traumatic, unilateral, bankart

• High Risk Factors:

 Young males (ages 15 to 29 years old)  Dislocations most often occur from sports or recreation  Most frequently seen as a result of a fall  The estimated incident is on the rise (Zacchili & Owns, 2010)

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Acute Shoulder Dislocations

• High recurrent rate in younger population

(Zacchili & Owns, 2010)

No Recurrent Recurrent

< 20 yrs 20-40 yrs >40 yrs

Secrets to Stabilization Part 1 Holevius et al 2008 30 IncidenceDislocation ofRecurrent %

10 Sensorimotor Insufficiencies

• Recurrent anterior instability sensorimotor insufficiency increase with dominant side

involvement (Edouard, Gasq , Calmes & Degache, 2014)

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Etiology of Traumatic Shoulder Dislocations • Unidirectional from traumatic event (anterior is the most common)  Most commonly caused by a fall on an outstretched hand or a sudden forceful motion in the abd/er position  Bankhart  Superior Labrum Anterior Posterior (SLAP)  Most common direction of instability is anterior/inferior from falling in 90/90 position (ABD/ER)

(Zacchili & Owns, 2010)

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Special Tests Anterior Instability

Apprehension Test Relocation Test Apprehension & Relocation

Sensitivity .81, Specificity .98 (Farber et al 2006)

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11 Pathomechanics: Bankart Lesion/Anterior Instability • Instability of the anterior- inferior glenohumeral joint capsule. OR Bankart Lesion • Detachment of the http://images.conquestchronicles.com/images/admin anterior-inferior glenoid /shoulder_bankart_lesion_85905_2.jpg labrum from the glenoid rim.

Illustration from: http://www.ptclinic.com/medlibrary/ images/v2/slapbankart.gif

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Boney Bankart Lesions

Photo retrieved from Millet et al 2009

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Superior Labrum Anterior-Posterior SLAP • Fall on an outstretched abducted arm or sudden contraction of biceps tendon or repetitive stress. Or, repetitive

injury related to Illustration retrieved on 3/5/12 eccentric deceleration from:http://healingartsce.com/images/sh%20SLAP%20lesion.jpg “peel back

Illustration from: http://www.ptclinic.com/medlibrary/ images/v2/slapbankart.gif Secrets to Stabilization Part 1 36

12 Pathomechanics: Peel Back Mechanism in Throwing Athletes

Retrieved from: Braun S, Kokmeyer D, Millett P. Current Concepts Review: Shoulder Photo retrieved from: Braun, S., Injuries in the Kokmeyer, D., & Millett, P. J. (2009). Retrieved from: http://2.bp.blogspot.com/_ Throwing Athlete. Jour Bone & Jt Shoulder injuries in the throwing athlete. BsgqbRhgCnQ/SRtejHI0PvI/AAAAAAAAANA/ The Journal of Bone & Joint Surgery, 91(4), 966-978. vMjopqYdgrs/s400/SLAP-peel-back.jpg Surg, 2009;91(4): • High eccentric activity of the biceps during arm deceleration. • Torsional peel back force detaching labral anchor. Secrets to Stabilization Part 1 37

Pathomechanics: SLAP

• Type I/Fraying • Type II/Biceps & Labrum are becoming detached • Type III/Biceps & Labrum are stable on glenoid, but a flap hangs down Type IV/Bucket handle tear • Retrieved on 7-4-10 from:http://www.athleticadvisor.com/ extending into the biceps images/shoulder/SLAP/SLAP_types2. gif

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Special Tests for Superior Labrum Anterior Posterior (SLAP)

Active Compression Passive Distraction

ER IR Supinate Pronate

Active Compression & Passive Distraction Sensitivity .70, Specificity .90 (Hegedus et al 2012)

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13 Secrets to Stabilization Part 1 40

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Etiology: Atraumatic Shoulder Multidirectional Instabilities

• Instability from mirco-trauma from repetitive motions in one direction or multi-directional

Voluntary: Individual subluxes or dislocates volitionally AMBRI: atraumatic, multidirectional, bilateral, rehabilitation, inferior shift

Involuntary: Subluxes or dislocates involuntary

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14 Poll Question

Is the posterior inferior direction the most common dislocation of the shoulder?

a. Yes b. No

PROTECTIVE PHASE REHABILITATION

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REHABILITATION of Shoulder Dislocations: Protective Phase

Photo retrieved fro Heirdari et al 2014

• Glenohumeral joint is reduced and the arm is placed in a sling. • Current evidence does not support ER to avoid recurrent shoulder dislocation (Vavken etal 2014)

• Duration of immobilization (Patternson et al 2010) • ER with ABD may reduce the rate of recurrent dislocation/3 wk (HeidariSecrets 2014) to Stabilization Part 1 45

15 Important Considerations with Surgical Procedures PROTECT HEALING STRUCTURES

Arthroscopic Repair / Bankart • Remain in sling except for table slides and passive flexion to 90° • Gradual external rotation during reparative phase (passive ER gradual

stress at 3 to 4 wks post-op) Sperber et al 2001 • No combined ER and ABD during reparative phase • Gradual progression of ROM and light strengthening during remodeling (no forceful stretching)

Image retrieved from: • Progress strengthening during http://www.theshoulderdoc.com/content/assets/bankart_layout.gif maturation phase.

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Important Considerations with Concomitant Procedures PROTECT HEALING STRUCTURES

Arthroscopic Repair / SLAP Type II Protect repair (10:00-2:00) • Slow ER progressions limiting passive ER to 40° in scapular plane during reparative phase. • Avoid extension and horizontal abduction for ~4 wks PO, remain http://kneeandshoulderclinic.com.au/wp-content/uploads/SlapTear- in sling pic2.png • Avoid resistance to elbow

(extension and supination)Secrets to Stabilization Part 1 47

REHABILITATION of Shoulder Dislocations: Reparative Phase

• Continue immobilization • Maintain elbow and forearm motion • Maintain grip strength • Active assist to 90° in flexion and 60° scaption • Begin isometrics when sling is removed for external rotators • Avoid motions of abduction and external rotation Secrets to Stabilization Part 1 48

16 FUNCTIONAL EXERCISES REMODELING TO MATURE PHASE

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Core Transfers forces to limbs Stability (Beckman & Bachman, 1995) • Lumbopelvic region (inferiorly) • Abdominals (anteriorly) – Transversus abdominis (TA) – Internal & external obliques – Rectus abdominus • Diaphragm (superiorly) • Paraspinals and gluteals (posteriorly)

TA is the first muscle that activates when lifting arm

overhead (Richardson, 2014)

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Core Stability • Peate, Bates, Lunda, Francis & Bellamy (2007) – Core strengthening resulted in 62% reduction of lost time and 42% reduction of injuries. • Behm, Drinkwater, Willardson & Cowley (2011) – Stabilization exercises prevent low back dysfunction • Emery, De Serres, McMillan & Cote (2009) – Core training improved thoracic posture, abdominal strength and stabilized core posture with shoulder flexion • Miyake, Kobayashi, Kobayashi & Nakajima (2012) – Core strengthening improved upper extremity function • Nagai et al 2012 – Trunk rotation improvesSecrets scapulato Stabilization Part kinematics 1 51

17 SHOULDER STABILIZERS

DYNAMIC Dynamic Motor • Muscles Stability Control – Scapular Stabilizers Golgi Muscle Tendon – Rotator Cuff Spindles Muscles -Muscle contraction -Joint movement – Long head of -Joint position -Positions sense the biceps -Signals agonist to -Reflex muscle relax contraction Secrets to Stabilization Part 1 52 Finnoff J, Doucette S, Hicken G. Glenohumeral instability and dislocation. Phys Med and Rebab Clinics of N Amer, 2004;15:575-605.

Proprioception Conscious Sensations

Kinesthesia Position/Movement

Tension or Force

Proprioception Conscious Sensation

Sense of Balance

Sense of Effort

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Neuromuscular Control/Unconscious Stability • Force couples of glenohumeral joint provide information on compression – Muscle spindles provide information on position sense and reflexive muscle contraction – Golgi tendons are tension sensitive and signal agonist to relax • Compliment input from capsuligamentous input to extreme motions (Ruffini) and compressive (Pacinian)

18 Neuromuscular Control/Unconscious Stability

Image retrieved from:http://image.slidesharecdn.com/ anatomyofshoulderjoint2-130318210432-phpapp01/ 95/anatomy-of-shoulder-joint-vamshi-kiran-32-638.jpg?cb=1363640800

Shoulder Dynamic Stabilizers (Gibbons,Mottram & Comerford, 2001)

Local Stabilizers Global Stabilizers Global Mobilizer • Deep/close • Deep or • Superficial to axis of superficial • Force w/length changes movement • Controls • Primarily concentric • Constantly inner and • Recruited with high load modulating outer range & high speed in open kinetic chain • Constantly • Controls modulates eccentric force output motions • Highly • Highly proprio- proprio- ceptive ceptive

• Type I • Type IIaSecrets to Stabilization Part 1 56

Shoulder Dynamic Stabilizers (Gibbons,Mottram & Comerford, 2001)

Local Stabilizers Global Stabilizers Global Mobilizer • Rotator cuff • Teres major, • Rhomboids • Long head deltoids, • Pectoalis minor of the coraco- • Levator scapula biceps brachialis, • Latissumus dorsi upper & Pectoralis major • Lower and • middle middle • Short head of biceps trapezius trapezius,ser • Long head of triceps ratus • Latissimus dorsi -Abnormal movement anterior at 1 segment Decreased force • Overactive & tight muscles -Reflex inhibition production • Spasms -Poor response to Reflex inhibition • Results in decreased movement load Dysfunctional patterns at several joints -Poor movement recruitment pattern Secrets to Stabilization Part 1 57 patterns at segment

19 Early isometrics of external rotators

Isometric contraction side-lying (pushing down in table)

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REHABILITATION of Shoulder Dislocations: Remodeling Phase

Scaption 45° Scaption 90°

• Gradual motion and strengthening to 90°/90° (ER/ABD) • Progress positions as pain decreases • Proprioception training

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Progress Position

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20 Secrets to Stabilization Part 1 61

Progressing Proprioception Training

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Progressing Proprioception Training

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21 Secrets to Stabilization Part 1 64

Core Stability • SERAPE EFFECT – Transfers stored energy into potential energy. – Transverse abdominus will activate before the initiation of movement to brace the body before the core generates power.

Hodges & Richardson, 1996)

Decreased scapular upward rotation and increased scapular internal rotation in subjects with

Secretsshoulder to Stabilization Part 1instabilities (Struyf, Nijs, Baeyens, Mottaram66& Meeusen, 2011)

22 Gradually Add Increased Challenges

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Mature Phase: Work towards functional strengthening for return to previous activity level

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Proprioception

Muscle contraction/Joint Golgi Tendon position (signals agonist to relax) Musculotendinous

Joint movement, Muscle Spindles positions sense, reflex muscle contraction

Proprioception

Extreme Pacinian type receptors Motion/Compressive Strength

Capsuloligamentous

Extreme Motions/ Tensile Ruffini Receptors Strength

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23 Secrets to Stabilization Part 1 70

Poll Question

1. Is limiting passive external rotation appropriate after a SLAP or Bankart surgery?

a. Yes b. No

ELBOW INSTABILITIES

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24 ELBOW STABILIZERS

• STATIC • DYNAMIC – Boney Congruency – Biceps – Capsule – Brachialis – Medial Collateral – Brachioradialis Ligament – ECRL – Lateral Collateral – Triceps Ligament Complex Secrets to Stabilization Part– 1 Anconeus 73

Secrets to Stabilization Parthttp://www.daviddarling.info/images/humerus 1 74 .gif

Other Stabilizers: Elbow Capsule

• Small contributor as a passive soft tissue stabilizer (questionable) • Most lax at 80 degrees of flexion (consider this extensible meaning the capsule is not restraining) • Position of comfort after injury • Risk of flexion contracture

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25 Static Stabilizers

• Medial collateral ligament (MCL)

Subliime tubercle of proximal ulna • Lateral collateral ligament (LCL)

• Anterior Capsule • Humeroulnar Joint (taut with elbow ext) From Advanced Concepts of Hand Secrets to Stabilization Part 1 Pathology and Surgery 76

Post. Bundle taut in max. flexion

Anterior Bundle 3 functional fiber bundles

Adapted on 2/20/11 from: Callaway G, Field L, Deng X, Torzilli P, Obrien S, Altchek D, Warren R. (1997). Secrets to Stabilization Part 1 77 Bilomechanics of the Medial Collateral Ligament of the Elbow. J Bone Joint Surg AM,

Medial Collateral Ligaments

• Elbow extension stability to valgus stress – MCL contributes 30% – Anterior capsule 30% – Bony Articulation 40%

• Elbow at 90 degree flexion stability to valgus stress – MCL contributes 55% – Anterior capsule 10% – Bony articulation 35%

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26 Lateral Collateral Ligaments

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Lateral Collateral Ligaments • Annular ligament

• Radial collateral ligament

• Lateral ulnar collateral ligament (LUCL) – Provides stability to posterolateral rotation

Retrieved on 12/07/10 from; : http://www.biomech.com/files/article Accessory lateral collateral ligament_images/PainMgmt-Elbw_3.jpg • Secrets to Stabilization Part 1 80

Lateral Collateral Ligaments

• Elbow extension stability to varus stress – LCL contributes 15% – Anterior capsule 30% – Bony Articulation 55%

• Elbow at 90 degree flexion stability to varus stress – LCL contributes 10% – Anterior capsule 15% – Bony articulation 75%

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27 ELBOW STABILIZERS • DYNAMIC – Biceps – Brachialis – Pronators – Supinatos – Brachioradialis – Wrist/digit extensors & flexors – Triceps Anconeus – Secrets to Stabilization Part 1 82

Elbow Dynamic Stabilizers (Gibbons,Mottram & Comerford, 2001)

Local Stabilizers Global Stabilizers Global Mobilizer • Anconeus • Brachialis Biceps Brachii (long & short heads) (deep fibers) • Brachioradialis Triceps Brachii (long head) Wrist & Digit Extensors • Pronator • Triceps (medial & Pronator Teres Quadratus lateral heads) Wrist & Digit Flexors (deep fibers) • Anconeous • Supinator (superficial fibers) (deep fibers) • Supinator (superficial fibers) • Pronator Quadratus (superficial fibers) • ECU (ulnar head) • FCU (ulnar head) • APL Secrets to Stabilization Part 1 83

I. Elbow Pathology Ligamentous Lateral Collateral Ligament (LCL) • Ligamentous – Lateral collateral ligament sprain or tear is also associated with trauma and often occurs with a fracture – Mechanism of injury • Fall on outstretched hand (FOOSH) • Forced twisting of the arm with varus (lateral) forces

Secrets to StabilizationO’Driscoll Part 1 1992 84

28 Elbow pathology – ligamentous (LCL) • Ligamentous stress tests • Lateral Collateral Ligament (LCL) injury = Varus Stress Test • Elbow 20-30° flexion; forearm supinated • Examiner places one hand on medial elbow, the other on distal radial wrist • Apply medial force to wrist – this translates varus force to the elbow • Positive if painful or more lax than

contralateral Secrets to Stabilization Part 1 85

Elbow pathology – ligamentous (LCL) • Movement without stability is usually painful • Elbow typically becomes more unstable as it moves into extension. • Placing the elbow in 20-30 degrees of flexion unlocks the olecranon from the humerus.

• Should be rehabilitated in pronation b/c the elbow is more stable from varus forces in pronation

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Elbow pathology – ligamentous (LCL)

• Not all tears are repaired; sometimes they are left to heal on their own • This can lead to chronic instability • Ligament repair can occur if surgery is performed within 2-3 weeks of injury • Ligament reconstruction is chosen if injury is more than 3 weeks old • Palmaris longus is usually used for reconstruction

• If not repaired…

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29 Posterolateral Rotatory Instability (PLRI) Can result from a FOOSH with forearm supinated

I “snapping” II varus instability III Post. Dislocation Iv Complete instability Leads to ulna (moving with radius due to annular ligament) externally rotating away from trochlea (Picture resourced from Radsource: http://www.radsource.us/clinic/0901) Secrets to Stabilization Part 1 88

Special Tests: Lateral Elbow Posterolateral Rotary Instability

Push-up and Stand-up tests Sensitivity: 87.5%

Specificity: 100% (Regan et al 2006) Secrets to Stabilization Part 1 89

Rehab PLRI (LCL complex) Elbow pathology - ligamentous • General Post-op LCL Reconstruction Guidelines – Splint 90° flexion, pronated – AROM extension/flexion; extension limited to 60° initially and gradually increased – Forearm rotation from pronation to neutral only for 6 weeks – D/C splint at 6 weeks – Gradually resume supination

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30 Rehab PLRI (LCL complex) • Flexion and pronation increase the contact between the radial head and capitellum. • Studies have shown that the LCL deficient elbow is more stable in pronation. • Shoulder AB and IR increase varus stress to the elbow–so avoid this position with exercises. • If both medial and collateral ligaments have been repaired, elbow should be splinted in neutral rotation. Secrets to Stabilization Part 1 91 (Armstrong 2000, Dunning 2001)

Dynamic Stabilizers ent

Dynamic Stabilizers Against Varus Stress • Isometric strengthening EDC, ECRB &

ECRU (An, Kaufman & Chao, 1989)

Schickendantz, M (2002). Bindra & Bringer, 2010

Elbow pathology - MCL Medial collateral ligament injury • May have spontaneous failure characterized by a “pop” • Onset may be vague, characterized by failure to perform at less than normal ability: • Decreased accuracy • Decreased velocity • Decreased endurance

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31 Elbow pathology - MCL

MCL Injury • If no specific “pop” or rupture is noted, conservative management consisting of strengthening the muscles surrounding the joint, is pursued. • If surgery is required, ligament repair may be possible in nonprofessional athletes • Most professional athletes require ligament reconstruction, aka “Tommy John Procedure”.

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Special Tests: Medial Elbow Medial Collateral Ligament Instability

Valgus Stress Test: Moving Valgus: Sensitvity: 66% Sensitivity: 100% Specificity: 60% Specificity: 75%

Secrets to Stabilization Part 1 95 Elbow Videos\Moving valgus.AVI

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32 Secrets to Stabilization Part 1 97

Elbow pathology - ligamentous

Conservative Management MCL Injury • Protect – no overhead activity • AROM - sagittal plane • Strengthening - core, shoulder, elbow, and wrist • Thrower’s Ten Program for shoulder, elbow, forearm, and wrist • Evaluation of throwing technique • Advanced Thrower’s Ten Program

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Elbow pathology - ligamentous

• Post-operative management of MCL injury • Splint in neutral rotation, 90° flexion • Active elbow extension and flexion, with full extension limited initially • AROM digits and wrist; ok to grip • Isometric strengthening of shoulder. No external rotation of shoulder as it creates valgus stress at elbow • Splint D/C’d at 6 weeks • Progress through full ROM and into Thrower’s Ten

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33 MCL Strengthening Considerations

CLINICAL PEARL!! • Strengthen flexor carpi ulnaris, and flexor digitorum superficialis to increase stability • Radial head contributes to stability

• Start exercises in supination and progress to pronated position.

Schickendantz, M (2002). Secrets to Stabilization Part 1 100 Bindra & Bringer, 2010

Intermediate Phase Sub-Maximal Isometrics Medial Collateral Ligament Rehab.

• Strengthen with forearm in supination. FCU & FDS and isometric pronation.

Secrets to Stabilization Part 1 101

Advance to Mature Phase Motor Control / Proprioception Training Lubiatowski et al 2014. Elbow joint position sense after elbow arthroplasty. Jour of Shoulder & Elbow Surgery, 23:693-700. Decreased joint position sense compared healthy elbows

Secrets to Stabilization Part 1 102

34 Elbow Trauma Dislocations & Fractures

Dislocation Classification • Simple – Small osseous fractures not affecting joint stability – Described as posterior, anterior, medial, lateral • Complex – Described as posterior, anterior, medial, lateral, or divergent • Acute (less than 2 weeks) • Subacute (2 to 4 weeks) • Chronic (6 weeks ore more)

Sheps et al 2004

Normal Posterior Retrieved on 2/22/11 from:http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-821994-823277-1671248.jpg

Medial Lateral Divergent Retrieved on 2/22/11 from:http://boneandspine.com/wp-content/uploads/2009/02/lateral-dislocation-elbow.gif

35 Evidence for Early Motion in Simple Posterior Dislocations • Loss of extension is the most frequent complication

• Ross et al protocol: Immediate active motion combined with modalities to reduce pain and swelling and UE strengthening. Results of nearly full ROM within 5 degrees of extension. Ross et al (1999)

Sheps et al 2004

ELBOW TRAUMA

Secrets to Stabilization Part 1 107

Radial Head Fractures in Elbow Trauma • Terrible Triad – Posterior or posterolateral dislocation of ulnohumeral joint with fractures of the radial head and coronoid process. Avulsion of medial collateral ligament (MCL) and lateral collateral ligament (LCL) – Coronoid process provides stability • Buttress against posterior displacement of the ulna and contributes to varus stability (Budoff, 2012) • Essex Lopresti: radial head fracture, rupture of the interosseous membrane (IOM) resulting in forearm instability and proximal migration of the radius

36 Radial Head Fractures Internal Fixation or Radial Head Replacement

• Fragmentation of less than 3 fragments have improved

results with fixation (Ring & Jupiter, 2001) • Lateral collateral ligament protection may be required if ligament re-attached or involved, reattached after surgery (pronation) at 2 days post-op allow pro/sup with elbow flexed at 90

Internal Fixation

• Phase I – Early mobilization 3 to 5 days post-op/PROM gentle – Posterior elbow orthosis 90° flexion with forearm neutral – Regain motion 1 to 3 wks post-op AAROM (flex/ext, pro/sup) – CPM • Phase II (4 to 6 wks post-op) – Regain full motion and gradual strengthening • Phase III (6 to 12 wks) – Advance strengthening and closed chain exercises – Joint mobilizations – End range strengthening

Radial Head Replacement • Phase I (Week 1 to 3 post-op) – Early mobilization (orthosis CPM (forearm pronated or neutral), AROM wrist and hand during 1st week – Hinged elbow orthosis worn at all times – Advance elbow and forearm motion exercises. Elbow AAROM with gravity assisted extension. Position elbow at 90° flexion during forearm exercises – Consider edema glove for hand

• Phase II (Week 3-6 post-op) – Begin AAROM pro/sup, PROM elbow stretching to tolerance, initiate orthosis to increase flex/ext if needed, advance to AROM forearm rotation and elbow motion

• Phase III (Week 6-8 post-op) – Discharge hinged orthosis, begin isometrics, continue mobilization orthosis

• Phase IV (Week 8-12 post-op) – Light resistance gradually upgrade strengthening

37 Distal Humerus Intra-articular Fractures Fixation Plating (post-op 1 week): • Edema control • Long arm orthosis alternating between elbow flexion daily and elbow extension nightly • Elbow, shoulder, forearm, wrist, hand AROM every 1 to 2 hours Post-op 2 weeks: • Initiate scar management • Progress ROM each week

• Non-weight-bearing until fracture healed • Strengthening when fractured healed

CHALLENGE

38 Customizing Therapy to Patient

Should I incorporate CPM? • Indicated to prevent post-traumatic stiffness based on rationale: – Acute bleeding and edema result in swelling of peri-articular tissues limiting joint motion and ↑’ing pain – Moving the joint through its entire range can empirically prevent stiffness and edema – Subacute stage: deposition of extracellular matrix and granulation tissue; cpm used to accomplish full ROM (1 week to 4 weeks)

Should I Incorporate CPM?

Evidence Controversial • Phase I • CPM vs no CPM post open – Prevent joint stiffness – contracture release Lindenhovius et – Minimize edema al 2009) – Minimize hydrostatic – CPM vs no CPM total knee joint pressures arthroplasty (MacDonald et al 2000) (O’Driscoll & Giori, 2000)

Customizing Therapy to Patient

How do I protect soft tissue structures? • Lateral collateral ligament (LCL) protection may be required if ligament reattached or involved. • Protect LCL with the patient Hand on forehead supine and placing forearm in pronation during ROM maintaining pronation • May allow pro/sup with elbow flexed at 90 at 2 days post-op • Avoid adduction and internal rotation of the shoulder limiting varus stress (Dunning et al 2001)

39 Customizing Therapy to Patient

What muscles can I begin isometric strengthening for stability?

Dynamic Stabilizers Against Varus Stress • Isometric strengthening EDC, ECRB &

ECRU (An, Kaufman & Chao, 1989)

Schickendantz, M (2002). Bindra & Bringer, 2010

Customizing Therapy to Patient

How do I protect soft tissue structures? • Medial collateral ligament (MCL)l Hinged orthosis with forearm in supination to block end range extension gradually add ~10° extension weekly • Elbow motion performed within safe arc and forearm supinated • Avoid external rotation and abducted positions of the shoulder during early phases of healing limiting valgus stress

Customizing Therapy to Patient

What muscles can I begin isometric strengthening for stability?

Dynamic Stabilizers Against Valgus Stress • Isometric strengthening flexor pronator mass, flexor carpi ulnaris, and flexor digitorum superficialis to increase

stability (Park & Ahmad, 2004)

Schickendantz, M (2002). Bindra & Bringer, 2010

40 Customizing Therapy to Patient

How should I position the forearm during elbow ROM?

Protect LCL w/forearm pronated

Protect MCL w/forearm supinated

Poll Question

Which of the following shoulder motions will place the most stress on a healing medial collateral ligament? a. Adduction combined with internal rotation b. Abduction combined with external rotation c. Forward flexion d. Extension with internal rotation

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Customizing Therapy to Patient

What are the signs of heterotopic ossification?

• Risk Factors: > 1 reduction (Shukla et al 2015) , head injuries (Garland & O’Hollaren, 1982), burns, operative care >

48 hours after injury (McLauglin1955), floating

fractures (Bauer et al 2012)

• Signs & Symptoms: – Decreased ROM – Increased pain – Localized edema – Increase in temperature (Hinck, 1994)

41 Customizing Therapy to Patient

What are the symptoms of ulnar nerve involvement? Clinical Presentation • Paraesthesia at ring and small fingers • Elbow pain • Weakness in grip Clinical Management • Nerve gliding, elbow orthosis nocturnally, protect cubital tunnel

Customizing Therapy to Patient

• What type of orthosis should I use when contracture has developed, static progressive or dynamic?

Picture retreived from: http://www.dynasplint.com/uploads/pages/36_original.jpg Photo retrieved from: http://www.remingtonmedical.com/Content/img/products/detail/big/1- T55.jpg Elbow Static Progressive vs. Dynamic Orthosis

Lindenhovius, A., Doomberg, J., Brouwer, K., Jupiter, J., Mudgal, C., Ring, D. (2012). Dynamic Versus Static Progressive Elbow Splinting for Posttraumatic Elbow Stiffness. Jour of Bone & Joint Surg Amer, 94A(8):694-700.

42 • Lindenhovius, A. et al 2012  Results  3 months: No significant differences  6 months: DASH scores significantly improved in static progressive group  12 months: No significant difference between groups for ROM and DASH scores

• 6 month results: • Dynamic orthosis: ROM improved 40° • Static progressive: ROM improved 39° • 12 month results: • Dynamic orthosis: ROM improved 47° • Static progressive: ROM improved 49°

Customizing Therapy to Patient

– Most gains are in the first 3 months – No statistical significant difference for elbow ROM between the static progressive and dynamic orthosis – Regaining elbow motion factors: Comfort, optimism, confidence &self-efficacy to perform elbow stretching Patients can continue to make ROM gains for 12 months Patients with an elbow contracture uncommonly request surgery

Customizing Therapy to Patient

Custom or pre-fabricated?

• PROS CONS Custom fabrication allows for • Fabrication time between 30 improved fit • and 60 minutes depending on • Easy to make adjustments for experience level patient’s comfort • Elbow flexion and extension • Easy don/doffing & cleaning motion limited to length of • Hinge placement can be hinge modified

129

43 Customizing Therapy to Patient Custom or pre-fabricated?

• PROS CONS

• Pre-fab: short wearing time • Could be limited by insurance • Light weight & easy fitting with authorization measurements • Modifications to orthosis could d • Easy don/doffing & cleaning be more timely • Results can reach up to 170° of • Can be high profile depending flexion and -10° of extension on order • Patient can track progress on 130

Customizing Therapy to Patient

Poll Question

Is it safe to begin early ROM in a type one radial head fracture that is minimally displaced?

a. Yes b. No

132

44 WRIST/HAND INSTABILITIES

Bony Anatomy

• 2 long bones – Radius & Ulna • 8 carpal bones – Proximal & distal rows • 14 phalanges

• 5 metacarpals 134

FUNCTIONAL MOTIONS

• FLEXION • EXTENSION • RADIAL DEVIATION • ULNAR DEVIATION • CIRCUMDUCTION • DART THROW AXIS Retrieved on 05/01/09 from: www.dkimages.com/.../Darts/ Darts-15.html

45 Carpal Row Movements during Flexion/Extension • Distal carpal row follows the direction of movement of metacarpals #2,3. • Proximal row moves with the distal row, but there is more motion between the individual bones. • Flexion: Proximal row glides dorsally and capitate glides dorsally on lunate. Retrieved on 05/01/09 from: http://www.andysleigh.com/ Extension: Proximal row glides WristAndForearm/tutorial/ • wrist/page5a.html volarly and capitate glide volarly.

Carpal Row Movements during Radial/Ulnar Deviation Reciprocal Motion • Ulnar Deviation: Distal row moves ulnarly and the proxmial row extends and translate radially.

• Radial deviation: Distal row moves radially and the proximal

row flexes and translate ulnarly. Retrieved on 05/01/09 from: www.davidlnelson.md/ Lichtman_talk.htm

Berger, 1996.

Osseous Morphology & Kinematics

Radius & Ulna • Distal radius articulates with proximal row at scaphoid fossa and lunate fossa. Retrieved on 05/01/09 from: www.answers.com/topic/u • Ulna does not articulate lna with the carpus. Triangular disc articulates Retrieved on 5/03/09 From: www.hughston.com/ with carpus at distal ulna. hha/a_13_3_1.htm

46 WRIST ARTICULATIONS Consists of: • Radiocarpal Joint Midcarpal Joint Radiocarpal Joint • Midcarpal Joint

Distal • Distal Radioulnar Radioulnar Joint Joint Retrieved on 01/23/09 from: http://www.med.mun.caanatomyts/msk/ • Interosseous Joints xarpus.gif

Wrist Ligaments • Intrinsic ligaments Volar View exist between carpal bones in capsule • Extrinsic ligaments oblique orientation b- w peripheral of wrist to carpal bone & superficial to capsule • Radioulnar ligament

Picture retrieved on 02/08/09 from: www.uphs.upenn.edu/.../html/oj12sp99p27.html

Important Stabilizers Intrinsic • Scaphoid-lunate • Lunotriquetral

Extrinsic Volar: Radioschapocapitate, radiolunotriquetral, short radiolunate ligaments Dorsal: dorsal radiocarpal ligament

Photo from Lichtmen & Wroten Jour Hand Surgery 2006

47 Examining the Wrist Column Concept

Radial Dorsal Central Ulnar Lateral Column Central Column Medial Column Scaphoid Lunate Trapezium Capitate Triquetrum Trapezoid Hamate Ulna Lateral Radius Medial Radius 142

Radial Wrist • THUMB CMC OA Ulnar Wrist

• Lunotriquetral Tear (Dissociative) Dorsal Central • Triangular Fibrocartilage •Scaphoid-Lunate Tear Complex Tear (TFCC)

THUMB CARPAL METACARPAL OSTEOARTRHITIS

(THUMB CMC OA, BASAL JOINT OA, DEGENERATIVE JOINT DISEASE)

48 DEFORMITY PATTERNS

Zig Zag Reverse (most common) Zig Zag

MP hyper-extension, IP MP hyper-flexion, IP hyper-flexion resulting hyperextension in CMC instability resulting in CMC instability

Static Thumb Stabilizers

Photo retrieve from:

http://www.eatonhand.com/ mus/thumbmus.gif

• Anterior Oblique/dAOL (Beak Ligament) • Posterior Oblique/POL • Intermetacarpal/IML • Dorsal Intermetacarpal/DIML • Dorsal radiocarpal/DRL Photo modified from: Tan J, Xu J, Zie R, Deng A, Tang J. In vivo length and changes of ligaments stabilizing the thumb carpometacarpal joint. J Hand Surg, 2011;36A:420-427.

FPL Primary Flexor

MP volar plate stretched dAOL lax MP Hyper-ext Thumb Adduction Diminished Proprioception TM Joint

49 CMC Grind Test 1. Stabilize the trapezium with one hand. 2. Grasp the first metacarpal. 3. Compress the metacarpal base to the trapezium while applying an axial load to the metacarpal. 4. Pain is a positive test.

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Conservative Treatment • Soft Tissue Release of Adductor

• Mobilize CMC joint – Gentle Distraction Arm behind back. Hold involved thumb while the weight of arms provides distraction

Technique from: O’Brien V, Albrecht J. Fine Tuning the Care of the Painful Thumb. ASHT Instructional Course Webinar, 2012.

50 Conservative Management

• Neuromuscular re- education and strengthening for thumb stabilizers • Strengthen thumb intrinisics • Strengthen thumb and wrist extensors • Teach Functional Pinch

Poll Question

Which of the following exercise is most appropriate to strengthen for individuals with thumb CMC osteoarthritis? a. Flexor pollicis longus b. Adductor pollicis c. Adductor digiti minimi d. Extensor pollicis brevis, opponens pollicis, abductor pollicis brevis, 1st dorsal interossei

152

Radial Wrist Ulnar Wrist • THUMB CMC OA • Lunotriquetral Tear (Dissociative) Dorsal Central • Triangular Fibrocartilage •Scaphoid-Lunate Tear Complex Tear (TFCC)

51 Tendencies of the Scaphoid and Lunate

• Scaphoid flexes • Without ligament support it will tilt volar • Dorsal intercalculated instability DISI

• Triquetrum extends • Without ligament resort it will tilt dorsal • Volar intercalculated instability VISI

Dorsal Central Wrist Scaphoid-Lunate Dissociative • History & Clinical presentation: – Hyper-ext /UD injury – Radial sided pain – Click and/or clunk – Weakness of grip – Limited wrist ROM – Positive Watson’s test – Ring sign on AP view

155

Scapholunate Dissociation Dorsiflexion Intercalculated Segment Instability (DISI)

52 Watson’s test: Provocative test for scaphoid instability.

Procedure: • Ulnar deviate the wrist with ext • Pressure to palmar aspect of distal scaphoid Positive Test: Proximal pole • Then, radial of scaphoid shifts or jumps deviate the wrist dorsally within the with flexion scaphoid fossa.

158

Ballotment Test for S-L Instability • Stabilize the lunate b/w the thumb and index finger of one hand • Stabilize the scaphoid between the thumb and index finger of the other hand. • Push the scaphoid in a volar to dorsal direction Positive Test: Discomfort may suggest injury to S-L ligament.

159

53 Rehabilitation of S-L Instability Grade I Sprain: • Follow the stages of soft tissue healing • Inflammatory to proliferation: Immobilize in thumb spica with light AROM (dart throwers) & neuro-muscular re-ed • Proliferation/Remodeling: AROM, PROM with emphasis on dart thrower’s position • Mature: Strengthening with emphasis on dart thrower muscles 160

Poll Question

A dorsal inter-calculated instability (DISI) is described as: a. Lunate and triquetrum tilts dorsally b. Scaphoid and lunate tilt dorsally c. Scaphoid and trapezium tilts dorsally d. Hook of the hamate tilts dorsally

161

Radial Wrist • DE QUERVAINS Ulnar Wrist • THUMB CMC OA • SCAPHOID FRACTURE • DISTAL RADIUS • Lunotriquetral FRACTURE Tear (Dissociative) Dorsal Central • Triangular Fibrocartilage •Scaphoid-Lunate Tear Complex Tear (TFCC)

54 Ulnar Wrist Lunotriquetral Dissociation

• Clinical presentation: – Pain with ulnar and supination of the fa – Tender at L-T joint – Patient c/o weakness and giving away – Unable to lift heavy items Illustration retrieved on 1/22/12 From: http://www.expertconsultbook. com/expertconsult/b/bbmapAsset? Positive ballotment of lunotriquetral appID=NGE&isbn=978-1-4160-5279- – 1&eid=4-u1.0-B978-1-4160-5279-1.. 00015-0..f19&assetType=full

Dissociative Lunate-Triquetrum VISI Volar Intercalated Instability

Illustration retrieved on 1/22/12From: http://www.expertconsultbook. com/expertconsult/b/bbmapAsset? appID=NGE&isbn=978-1-4160-5279- 1&eid=4-u1.0-B978-1-4160-5279-1..00015-0..f19&assetType=full Mechanism of Injury • Fall on outstretched hand

Shoulder ER, forearm supinated and • 164 wrist extended and radial deviated

Lunotriquetral ballottement test (Regan Shuck): • Procedure: Stabilize the lunate with the thumb and index fingers of one hand while the other hand attempts to displace the pisotriquetral unit volarly then dorsally. Sensitivity: 33-100% Specificity: no value Positive result: Laxity, pain, or crepitus.

55 Secrets to Stabilization Part 1 166

Rehabilitation of LT Instability Grade I Sprain: • Follow the stages of soft tissue healing • Inflammatory to proliferation: Immobilize in wrist orthosis, light arom & • neuro-muscular re-ed • Proliferation/Remodeling: AROM, PROM with emphasis on dart thrower’s position • Mature: Strengthening with emphasis on dart thrower muscles *Consider taping for neuromuscular re-ed 167

Ulnar Sided Wrist Pain Clinical Presentation of TFCC Tear • Ulnar sided wrist pain • Pain with palpation in region of TFCC • Pain with active ulnar deviation • Positive TFCC load test Pain with forearm rotation • Retrieved from: www.hughston.com/ • Audible click with rotation hha/a_13_3_1.htm • Pain with pronated grip

168

56 TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC)

• Normal axial load of radius is 80% and ulna is 20%

• The TFCC functions to transmit 20% of the axially applied load from the ulnar carpus to the distal ulna. It is a major stabilizer of the distal radial ulnar

Illustration from: Palmer A, Bille B, Anderson A. joint. Acute Injuries of the Distal Radioulnar Joint: Tears by the Triangular Fibrocartilage. Distal Radiouulnar Joint, Chapter 24. 169

Stabilizers of the Ulnar Wrist • Static Stabilizers • Dynamic – Sigmoid Notch Stabilizers – Dorsal/Volar – Pronator radioulnar ligaments Quadratus – TFCC – ECU – FCU

Image from:http://upload.wikimedia.org/wikipedia/ 170 commons/1/15/Gray424.png

Triangular Fibrocartilage Complex (TFCC)

• Palpate for tenderness

Fovea sign: Tenderness b/w FCU tendon and ulnar styloid process 171

57 TFCC or Ulnocarpal Abutment TESTING • Axial load compression with wrist in ulnar deviation. Glide volar and dorsally.

Positive Test: Reproduction of pain, clicking or crepitus Ulnocarpal Stress Test

173

Poll Question

Which is the following best describes the triangular fibro-cartilage complex? a. Redistributes force from the ulna to the radius b. Is highly vascular in the central portion c. Re-distributes 20% of the force from the ulnar carpus to the distal ulna and is contributor to the stability of the distal radioulnar joint d. Clinically presents as radial wrist pain 174

58 Rehabilitation for Ulnar Wrist Pain

• Follow the stages of soft tissue healing • Inflammatory to proliferation: Immobilize in wrist orthosis, light arom & neuro-muscular re-ed • Proliferation/Remodeling: AROM, PROM • Mature: Strengthening with emphasis on dynamic stabilizers Isometric contraction of *Consider taping for neuromuscular pronator quadratus in re-ed supination for DRUJ stability

175

Phase I (~6 wks): Long arm removeable orthotic with forearm and wrist in neutral. Gentle AROM.

Phase II (~6 to 8 wks): Removable wrist splint with periodic

gentle ROM Picture retrieved on YOSHIAKI et al 2004 (cuff vs ulnar gutter) 4/10/11 from: http://www.wristwidget.co m/uploads/1/8/8/5/18855 Progressive ROM and gentle strengthening 52/3998400.jpg?164x203

Phase III (~12 weeks): Gradual return to sport or work as pain is decreased

Injuries to the central region are not amenable to repair due to avascularity

Trial Ulnar Wrist Support

1.Cut 3-4” piece of velcro. 2.Cut hole and 2 tails.

3.Apply hook to each tail.

59 Procedures for Distal Radial Ulnar Joint (DRUJ) Instability

• Soft tissue reconstruction • Suave Kapandje • Darrah • Hemiresection-Interposition Arthroplasty (HIT) • Implant arthroplasty

Retrieved on 11/27/11 from; http://www.orthoteers.org /images/uploaded/Sauve.jpg Photo retrieved from: Kaiser et al, 2008.

Retrieved on 12/10/11f from: Fornalski S, Hay Q, Gupta R. Chronic Instability of the Distal Radioulnar Joint: A Review. Univ Of Penn Ortho Jour, 2000;13:43-52.

General Progression Concepts with Stabilization

Proliferation/Regeneration Phases • Gradual return to AROM and gentle PROM at wrist and forearm (gradual progression to end range pro/sup) Maturation Phase (6 to 12 weeks) • Gentle strengthening and activity as tolerated • Full activity as tolerated

GENERAL REHAB CONSIDERATIONS

• Which orthotic limits forearm rotation best? –Muenster –Sugartong –Antipronation Slaughter et al 2010

60 Conclusion • Sugartong restricts pronation significantly better than all other orthotics • Anti-pronation demonstrated significantly better results limiting forearm pronation as compared to the wrist orthotic • Anti-pronation splint may be uncomfortable due to placement on ulnar styloid • Neither Muenster or Sugartong completely immobilized rotation • 3 subjects reported Sugartong most comfortable and 2 reported Muenster most comfortable Slaughter et al 2010

Poll Question

Should forearm rotatiion strength and ROM be phased in gradually as the patient gains strength following a surgical reconstruction of the distal radial ulnar joint?

a. Yes b. No

182

General Concepts for Wrist Rehabilitation

61 Proprioception Training Conscious Rehabilitation Phase I: Conscious joint control

Phase II: Sense joint motion without audiovisual cues

Phase III: Strengthening specific muscles to enhance joint stability

Phase IV: Unconscious Rehabilitation Hagert, E. (2010)

Conscious Rehabilitation Phase I

• Edema Control • Pain Control (visual analog scale) • Promote Safe Motion Diagram retrieved on 7/15/11 from: http://0.tqn.com/d/ergonomics/1/0/C/-/-/- /painscale.jpg

Conscious Rehabilitation Phase II & III Conscious joint control • Mirror therapy • Active reproduction of joint angle; accuracy of joint re-positioning

Hagert, E. (2010)

62 Conscious Rehabilitation Phase IV Sense Joint Motion without Audiovisual Cues • Motion detection (detection of passive motion) – Degree of joint angle at which motion is detected

Hagert, E. (2010)

Conscious Rehabilitation Phase V Strengthen specific muscles to enhance joint stability • Eccentric training • Co-activation training

Hagert, E. (2010)

Phase VI UNCONSCIOUS NEUROMUSCULAR REHABILITATION Reactive muscle activation

Hagert, E. (2010)

63 Phase VI UNCONSCIOUS NEUROMUSCULAR

REHABILITATION Hagert, E. (2010) Reactive muscle activation

Light Ball Toss

Gentle Oscillations

Oscillating Technique Isometric Stabilization

Sensori-motor Re-training

Image retrieved from: http://nivea.psycho.univ-paris5.fr/ CogSysZurich2010/How%20to%20build%20a%20robot%20t hat%20feels_ fichiers/image153.png

191

Sensorimotor Retraining 1. Use chopsticks to pickup varying items and separate items 2. Finding dry beans in putty 3. Molding specific shapes 4. Card turning 5. Rhythmic stabilization

Research pediatric sensorimotor activities for more ideas.

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64 THANK YOU!

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References 1. Angst, F., Schwyzer, H. K., Aeschlimann, A., Simmen, B. R., & Goldhahn, J. (2011). Measures of adult shoulder function: Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and its short version (QuickDASH), Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) Society standardized shoulder assessment form, Constant (Murley) Score (CS), Simple Shoulder Test (SST), Oxford Shoulder Score (OSS), Shoulder Disability Questionnaire (SDQ), and Western Ontario Shoulder Instability Index (WOSI). Arthritis care & research, 63(S11), S174-S188. 2. Bot, S. D. M., Terwee, C. B., Van der Windt, D. A. W. M., Bouter, L. M., Dekker, J., & De Vet, H. C. W. (2004). Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature. Annals of the rheumatic diseases, 63(4), 335-341. 3. Braun, S., Kokmeyer, D., & Millett, P. J. (2009). Shoulder injuries in the throwing athlete. The Journal of Bone & Joint Surgery, 91(4), 966-978. 4. Crisco, J. J., Heard, W. M., Rich, R. R., Paller, D. J., & Wolfe, S. W. (2011). The mechanical axes of the wrist are oriented obliquely to the anatomical axes. The Journal of Bone & Joint Surgery, 93(2), 169-177. 5. Hagert, E. Proprioception of the Wrist Joint: A ReviewmOf Current Concepts and Possible Impllications on the Rehabilitation of the Wrist. Jour Hand Ther, 2010;23:2-17 6. Heidari, K., Asadollahi, S., Vafaee, R., Barfehei, A., Kamalifar, H., Chaboksavar, Z. A., & Sabbaghi, M. (2014). Immobilization in external rotation combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation. Journal of Shoulder and Elbow Surgery, 23(6), 759-766. 7. Itoi, E., Hatakeyama, Y., Kido, T., Sato, T., Minagawa, H., Wakabayashi, I., & Kobayashi, M. (2003). A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. Journal of shoulder and elbow surgery, 12(5), 413-415. 8. Levine, W. N., & Flatow, E. L. (2000). The pathophysiology of shoulder instability. The American journal of sports medicine, 28(6), 910-917 9. Kocher, M. S., Horan, M. P., Briggs, K. K., Richardson, T. R., O'Holleran, J., & Hawkins, R. J. (2005). Reliability, validity, and responsiveness of the American Shoulder and Elbow Surgeons subjective shoulder scale in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis. The Journal of Bone & Joint Surgery, 87(9), 2006-2011. 10. Millett, P. J., & Braun, S. (2009). The “bony Bankart bridge” procedure: A new arthroscopic technique for reduction and internal fixation of a bony Bankart lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 25(1), 102-105. 11. Vavken, P., Sadoghi, P., Quidde, J., Lucas, R., Delaney, R., Mueller, A. M., ... & Valderrabano, V. (2014). Immobilization in internal or external rotation does not change recurrence rates after traumatic anterior shoulder dislocation. Journal of Shoulder and Elbow Surgery, 23(1), 13-19. 12. Paterson, W. H., Throckmorton, T. W., Koester, M., Azar, F. M., & Kuhn, J. E. (2010). Position and duration of immobilization after primary anterior shoulder dislocation. The Journal of Bone & Joint Surgery, 92(18), 2924-2933. 13. Paschos, N. K., Mitsionis, G. I., Vasiliadis, H. S., & Georgoulis, A. D. (2013). Comparison of early mobilization protocols in radial head fractures. Journal of orthopaedic trauma, 27(3), 134-139. 14. Slaughter, A., Miles, L., Fleming, J., & McPhail, S. (2010). A comparative study of splint effectiveness in limiting forearm rotation. Journal of Hand Therapy, 23(3), 241-248. 15. Wright, R. W., & Baumgarten, K. M. (2010). Shoulder outcomes measures. Journal of the American Academy of Orthopaedic Surgeons, 18(7), 436-444.

References . Angst, F., Schwyzer, H. K., Aeschlimann, A., Simmen, B. R., & Goldhahn, J. (2011). Measures of adult shoulder function: Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and its short version (QuickDASH), Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) Society standardized shoulder assessment form, Constant (Murley) Score (CS), Simple Shoulder Test (SST), Oxford Shoulder Score (OSS), Shoulder Disability Questionnaire (SDQ), and Western Ontario Shoulder Instability Index (WOSI). Arthritis care & research, 63(S11), S174-S188. . Bot, S. D. M., Terwee, C. B., Van der Windt, D. A. W. M., Bouter, L. M., Dekker, J., & De Vet, H. C. W. (2004). Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature. Annals of the rheumatic diseases, 63(4), 335-341. . Braun, S., Kokmeyer, D., & Millett, P. J. (2009). Shoulder injuries in the throwing athlete. The Journal of Bone & Joint Surgery, 91(4), 966-978. . Crisco, J. J., Heard, W. M., Rich, R. R., Paller, D. J., & Wolfe, S. W. (2011). The mechanical axes of the wrist are oriented obliquely to the anatomical axes. The Journal of Bone & Joint Surgery, 93(2), 169-177. . Groh, G. I., Wirth, M. A., & Rockwood, C. A. (2011). Treatment of traumatic posterior sternoclavicular dislocations. Journal of Shoulder and Elbow Surgery, 20(1), 107-113. . Guan, J. J., & Wolf, B. R. (2013). Reconstruction for anterior sternoclavicular joint dislocation and instability. Journal of Shoulder and Elbow Surgery, 22(6), 775-781. . Hagert, E. Proprioception of the Wrist Joint: A ReviewmOf Current Concepts and Possible Impllications on the Rehabilitation of the Wrist. Jour Hand Ther, 2010;23:2-17 . Heidari, K., Asadollahi, S., Vafaee, R., Barfehei, A., Kamalifar, H., Chaboksavar, Z. A., & Sabbaghi, M. (2014). Immobilization in external rotation combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation. Journal of Shoulder and Elbow Surgery, 23(6), 759-766. Secrets to Stabilization Part 1 195

65 • .Hodges, P. W., & Richardson, C. A. (1996). Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine, 21(22), 2640- 2650 • Itoi, E., Hatakeyama, Y., Kido, T., Sato, T., Minagawa, H., Wakabayashi, I., & Kobayashi, M. (2003). A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. Journal of shoulder and elbow surgery, 12(5), 413-415. • Johansen, J. A., Grutter, P. W., McFarland, E. G., & Petersen, S. A. (2011). Acromioclavicular joint injuries: indications for treatment and treatment options. Journal of Shoulder and Elbow Surgery, 20(2), S70-S82 • Levine, W. N., & Flatow, E. L. (2000). The pathophysiology of shoulder instability. The American journal of sports medicine, 28(6), 910-917. • Liemohn WP, Baumgartner TA, Gagnon LH (2005). Measuring core stability. J Strength Cond Res, 19(3):583-6. • Lubiatowski, P., Olczak, I., Lisiewicz, E., Ogrodowicz, P., Bręborowicz, M., & Romanowski, L. (2014). Elbow joint position sense after total elbow arthroplasty. Journal of Shoulder and Elbow Surgery, 23(5), 693- 700. • Kocher, M. S., Horan, M. P., Briggs, K. K., Richardson, T. R., O'Holleran, J., & Hawkins, R. J. (2005). Reliability, validity, and responsiveness of the American Shoulder and Elbow Surgeons subjective shoulder scale in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis. The Journal of Bone & Joint Surgery, 87(9), 2006-2011. • Millett, P. J., & Braun, S. (2009). The “bony Bankart bridge” procedure: A new arthroscopic technique for reduction and internal fixation of a bony Bankart lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 25(1), 102-105. • Miyake, Y., Kobayashi, R., Kelepecz, D., & Nakajima, M. (2013). Core exercises elevate trunk stability to facilitate skilled motor behavior of the upper extremities. Journal of bodywork and movement therapies, 17(2), 259-265. Secrets to Stabilization Part 1 196

• Nagai, K., Tateuchi, H., Takashima, S., Miyasaka, J., Hasegawa, S., Arai, R., ... & Ichihashi, N. (2013). Effects of trunk rotation on scapular kinematics and muscle activity during humeral elevation. Journal of Electromyography and Kinesiology, 23(3), 679-687. • Paterson, W. H., Throckmorton, T. W., Koester, M., Azar, F. M., & Kuhn, J. E. (2010). Position and duration of immobilization after primary anterior shoulder dislocation. The Journal of Bone & Joint Surgery, 92(18), 2924-2933. • Peate, W. F., Bates, G., Lunda, K., Francis, S., & Bellamy, K. (2007). Core strength: a new model for injury prediction and prevention. J Occup Med Toxicol, 2(3), 1-9. • Pizzari, T., Wickham, J., Balster, S., Ganderton, C., & Watson, L. (2014). Modifying a shrug exercise can facilitate the upward rotator muscles of the scapula. Clinical Biomechanics, 29(2), 201-205. • Potvin JR, Brown SH: An equation to calculate individual muscle contributions to joint stability (2005). J Biomech, 38(5):973- 80. • Struyf, F., Nijs, J., Baeyens, J. P., Mottram, S., & Meeusen, R. (2011). Scapular positioning and movement in unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability. Scandinavian journal of medicine & science in sports, 21(3), 352-358. • Vavken, P., Sadoghi, P., Quidde, J., Lucas, R., Delaney, R., Mueller, A. M., ... & Valderrabano, V. (2014). Immobilization in internal or external rotation does not change recurrence rates after traumatic anterior shoulder dislocation. Journal of Shoulder and Elbow Surgery, 23(1), 13-19. • Wright, R. W., & Baumgarten, K. M. (2010). Shoulder outcomes measures. Journal of the American Academy of Orthopaedic Surgeons, 18(7), 436-444.

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66 • .Hodges, P. W., & Richardson, C. A. (1996). Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine, 21(22), 2640- 2650 • Itoi, E., Hatakeyama, Y., Kido, T., Sato, T., Minagawa, H., Wakabayashi, I., & Kobayashi, M. (2003). A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. Journal of shoulder and elbow surgery, 12(5), 413-415. • Johansen, J. A., Grutter, P. W., McFarland, E. G., & Petersen, S. A. (2011). Acromioclavicular joint injuries: indications for treatment and treatment options. Journal of Shoulder and Elbow Surgery, 20(2), S70-S82 • Levine, W. N., & Flatow, E. L. (2000). The pathophysiology of shoulder instability. The American journal of sports medicine, 28(6), 910-917. • Liemohn WP, Baumgartner TA, Gagnon LH (2005). Measuring core stability. J Strength Cond Res, 19(3):583-6. • Lubiatowski, P., Olczak, I., Lisiewicz, E., Ogrodowicz, P., Bręborowicz, M., & Romanowski, L. (2014). Elbow joint position sense after total elbow arthroplasty. Journal of Shoulder and Elbow Surgery, 23(5), 693- 700. • Kocher, M. S., Horan, M. P., Briggs, K. K., Richardson, T. R., O'Holleran, J., & Hawkins, R. J. (2005). Reliability, validity, and responsiveness of the American Shoulder and Elbow Surgeons subjective shoulder scale in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis. The Journal of Bone & Joint Surgery, 87(9), 2006-2011. • Millett, P. J., & Braun, S. (2009). The “bony Bankart bridge” procedure: A new arthroscopic technique for reduction and internal fixation of a bony Bankart lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 25(1), 102-105. • Miyake, Y., Kobayashi, R., Kelepecz, D., & Nakajima, M. (2013). Core exercises elevate trunk stability to facilitate skilled motor behavior of the upper extremities. Journal of bodywork and movement therapies, 17(2), 259-265. Secrets to Stabilization Part 1 199

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Patient Function and Goals

• Patient’s functional activity – Validated outcome assessments for shoulder instabilities include: • Oxford shoulder instability questionnaire • Shoulder instability questionnaire • Western Ontario shoulder instability index • The American Shoulder and Elbow Surgeons subjective scale • Disability of the arm, shoulder and hand (DASH) • Constant Murley shoulder assessment Shoulder pain and disability index • Secrets to Stabilization Part 1 201

67 Elbow Joints Kinesiology Humeroulnar Joint: Hinge-joint that flexes and extends Open Pack: 70° flex/10° supination Closed Pack: ext/supination Humeroradial Joint: Hinge-joint that flexes and extends Open Pack: ext/sup. Closed Pack: 90° flex/5° sup. Proximal Radioulnar Joint: Pronation and supination Open Pack: 70° flex/35°Sup\

http://upload.wikimedia.org/wikipedia/com Closed Pack: 5°sup/ext ns/thumb/2/21/Gray330.png/271px- Secrets to Stabilization Part 1 Gray330.png 202