12/20/2016

Radiocarpal Mobilization of the

2017 EATA Student Conference Mary L. Mundrane-Zweiacher MPT, ATC, CHT [email protected]

Radiocarpal Joint Distal Radioulnar Joint (DRUJ)

Midcarpal Joint Carpometacarpal Joint

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First CMC Joint

The Extrinsic Muscles: The Extrinsic Hand Muscles: Volar Aspect Volar Aspect • Palmaris longus • Flexor carpi radialis • Flexor Digitorum • Flexor carpi ulnaris Profundus (FDP) • Flexor Pollicis Longus • Flexor Digitorum • Flexor Digitorum Superficialis (FDS) Profundus (FDP) • Flexor Digitorum Superficialis (FDS)

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FDS FDP

The Extrinsic Hand Muscles: Visible Extensor Mechanism Dorsal Aspect • Extensor Pollicis Longus (EPL) • Extensor Pollicis Brevis (EPB) • Abductor Pollicis Longus (APL) • Extensor indicis • Extensor Digitorum Communis (EDC)

The Extrinsic Hand Muscles: The Intrinsic Hand Muscles Dorsal Aspect • Extensor carpi radialis • Lumbricales longus ( ECRL) • Dorsal Interossei • Extensor carpi radialis • Palmar (Volar) brevis (ECRB) Interossei • Extensor carpi ulnaris •Thenar Muscles • Extensor digiti minimi • Hypothenar Muscles • Adductor Pollicis

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The Intrinsic Hand Muscles The Intrinsic Hand Muscles

• Lumbricales • Lumbricales • Dorsal Interossei • Dorsal Interossei • Palmar (Volar) • Palmar (Volar) Interossei Interossei • Thenar Muscles •Thenar Muscles • Hypothenar Muscles • Hypothenar Muscles • Adductor Pollicis • Adductor Pollicis

Volar Plate Pulley Systems of the Hand

The Lymphatic System Myofascial/Skin

• It is the only system that can remove large • The dorsum of the hand is very different molecule substances such as excess plasma than the palm proteins, hormones, fat cells, and waste products from the interstitium that you see in chronic • The palmar fascia has longitudinal, edema. The lymphatics are tubes which are in the transverse, and vertical fibers dermis layer of the skin; they rely on changes in • The vertical fibers run superficially to interstitial pressure to open and close stabilize the thick palmar skin (pressures>60mmHg will collapse the tubes).

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Phases of Connective Tissue Nerves Healing

•Median • Inflammatory Phase •Ulnar • Fibroplastic Phase •Radial • Remodeling Phase

Inflammatory Phase Fibroplastic Phase

• vasodilation • re-epithelialization causing wound closure (skin) • fibroplasia – fibroblasts are activated and move • hyperemia along the fibrin meshwork to generate new • increased cell permeability collagen, elastin, GAG’s, proteoglycans, and glycoproteins • increased vascularity • neovascularization – regeneration of small blood • cell migration vessels • debris removal • wound contraction • collagen with random alignment

Normal Remodeling Phase Mechanics • consolidation phase • Osteokinematics • increased wound strength • Arthrokinematics • realignment of collagen – Accessory Motion I • reduction of abnormal cross links – Accessory Motion II • maturation phase – the scar links change from weak hydrogen bonds to strong covalent bonds

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Osteokinematics Arthrokinematics

• Movement of the bony segments around a • Accessory motion I - joint motion that occurs joint axis as a result of active contraction of muscle – generally these motions are described as roll, • AROM/AAROM/PROM spin, and slide • Examples – flexion • Accessory motion II – these motions are the – Knee extension result of an outside force which takes the joint beyond anatomical ROM

Mobilization Principles Synovial Joint Dysfunctions

• Arthrosis • Edema Mobilization (Acute versus Chronic) • Degeneration • Joint Mobilization • Capsular Restriction/Tightness • Scar Mobilization • Relative capsular fibrosis • Mobilization • Joint Effusion • Neural Glides

Edema Mobilization (Acute Edema Mobilization (Acute versus Chronic) versus Chronic) • Acute – the venous system relies on valves, the • Chronic – the lymphatic system relies on changes heart pumping, and muscle pumping to remove in interstitial pressure to remove large molecule low plasma protein swelling (acute edema) substances - the treatment goal for acute edema is to • - the treatment goal for chronic edema is to decrease the fluid flow into the tissue/interstitium reduce the excess plasma proteins in the by: interstitium by stimulating the lymphatics by: -ice -coban/edema glove -compression/higher pressure devices -contrast bath -elevation -edema massage (light) to dorsum

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Light pressure Too much pressure

Chronic Edema Mobilization Joint Mobilization

• This treatment can also include Manual Edema • Indications for joint mobilization Mobilization (MEM) which incorporates the following: –pain -light proximal to distal, then distal to proximal – swelling/edema massage of the skin – muscle spasm -specific pre and post exercises – capsular/ligamentous tightness/connective -massaging the lymph node areas proximal to the tissue change edema **bony or cartilage block may limit joint motion -the massage must follow the direction of but is not appropriate for joint mobilization lymphatic pathways

Physiologic Effects of Joint Convex-Concave Rule Mobilization • Decrease edema • When a convex surface moves on a concave • Increases capsular extensibility surface, the convex articular surface moves • Nutrition by movement of synovial fluid in the opposite direction as the • Muscle relaxation by the oscillating osteokinematic motion rhythm • When a concave surface moves on a convex • Decrease pain by increasing surface, the concave articular surface moves proprioceptive input and inhibiting ongoing in the same direction as the osteokinematic nociceptive input motion

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End Feels that are Normal or End Feel Pathologic include: • capsular • The resistance felt by the clinician at the end • ligmentous range of a passive joint motion. • bony • soft-tissue approximation • muscular

End Feels that are Strictly Pathologic include: Grades of joint mobilization

• muscle-spasm • I – small amplitude at beginning of joint range • II – large amplitude that does not reach limit of • abnormal capsular joint range • boggy • III – large amplitude that is up to the limit of joint • springy rebound range • IV – small amplitude at end of joint range • empty • V – small amplitude, high velocity through limit of joint range (manipulation) • low load stretch at end range

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Criteria for proper mobilization Open-packed/Closed-packed grade selection Position

•The degree of pain or protective muscle spasm • Open-packed (Loose-packed) – the position of a during joint motion assessment (irritability) joint in it’s ROM where the synovial joint surfaces are least congruent •The degree of restriction of joint play • the capsule will have the most extensibility • skill and experience of the operator • the joint surface contact areas are reduced • The greater the irritability, the lower the grade of • Closed-packed – the position of the joint where mobilization used the two joint surfaces are most congruent -Grade I-II – pain, swelling, and muscle spasm • the ligaments and capsule of the joint are -Grade III-IV – joint capsule limitation maximally tight

Contraindications Contraindications

Absolute Relative • an undiagnosed lesion -pregnancy • joint ankylosis -joint effusion • closed packed position -rheumatoid arthritis • where the integrity of the ligaments has -metabolic disease (TB, etc) been compromised (ex. steroid use) -internal derangement **asthmatics** -hypermobility • active inflammatory and infective arthritis -bony malalignment

Guidelines for joint Guidelines for joint mobilization mobilization

• The athlete must be relaxed • Mobilization techniques can be used for • The clinician must be comfortable with the assessment or treatment technique • Slight distraction while mobilizing the joint allows • The mobilization should be relatively painfree better glide and comfort • One hand must stabilize while the other hand • Gliding mobilizations are applied parallel to the performs the mobilization treatment plane and performed in the direction that • The more surface area that is contacted increases was shown to be restricted the comfort of the athlete as long as the clinician’s • One joint and one mobilization should be done at hand placement is accurate a time

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Guidelines for joint mobilization Scar Mobilization

• mobilization can vary in movement terms • A tendon cannot slide if it is stuck to the of: skin or the tissues underneath • -direction • -a scar that is adhered to tendon adds • -velocity resistance to the tendon • -amplitude • -Mild scar restriction – sometimes gentle • re-assessment must be done before and massage or tendon function is enough to after mobilization techniques remodel the tissue

Scar Mobilization

• Moderate scar restriction – stabilize the scar with manual contact or other substance (such as elastomere) • -mobilize the tendon that is adhered by active contraction • Established scar – • -low load, long duration stretch

Elastomere

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Tendon Mobilization Differential Tendon Gliding

• can get adhered at a fracture site as the • The 5 tendon gliding positions (see figure 1) bone is healing. • - with wrist fractures, always work to restore • -extensors sliding proximally fisting first • -maximal excursion between the FDS and • -prevention – start tendon gliding exercises FDP ASAP • -maximal FDP tendon excursion • Keeps the mobility of the tendons and fingers while the bone heals • -intrinsics (lumbricals and interossei) • Prevents swelling from accumulating between the • -maximal FDS excursion tissue layers

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It is crucial to do differential tendon gliding exercises in the case of pip joint injuries because that is where the FDP has to slide between the split in the FDS

Joints must be moved through their newly acquired range Neural Glides actively • New motor programs have to be established • Common Median Nerve glides – • It is easier to teach a new skill than correct – See Figure 2 an existing one • The muscle spindles/golgi tendon organs/joint receptors have to be educated about where the new “normal” is • “Place-holds” at end range

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Wrist

Joint Mobilization • Normal wrist anatomy must be considered Techniques while mobilizing the component (ex. alignment of the 1st CMC joint should be maintained)

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Normal CMC Position

Wrist

• The radiocarpal and ulnomeniscotriquetral joints’ closed packed position is full extension. The midcarpal joint’s closed packed position is full extension as well. • Normal joint arthrokinematics are as follows:

Wrist Dorsal glide of prox carpal row

• Wrist flexion – convex on concave – so the distal carpal row glides dorsally on the proximal carpal row, and the proximal carpal row glides dorsally on the and . The scaphoid actually glides further than the other proximal carpals causing it to supinate as well.

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Dorsal glide into flexion

Wrist Volar glide of prox carpal row

• Wrist extension – the distal carpal row glides volarly on the proximal carpal row, and the proximal carpal row glides volarly on the radius and ulna. The scaphoid also pronates

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Wrist For RD

• Radial deviation – the proximal carpal row flexes, glides dorsally, and translates ulnarly. The distal carpal row extends, glides volarly, and translates radially. • Ulnar deviation – the proximal carpal row extends, glides volarly, and translates radially. The distal carpal row flexes, glides dorsally, and translates ulnarly.

For UD

Wrist

• Pronation – see DRUJ • Supination – see DRUJ

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Distal Radioulnar Joint Distal Radioulnar Joint

• The DRUJ closed packed position is 5 • Pronation-the radius crosses the ulna by degrees supination gliding volarly and rotating volarly and • The movement of the radius on the ulna is a medially. combination of rolling and sliding. • Supination-the radius glides dorsally and rotates dorsally and laterally

Volar Glide For Pronation

Dorsal Glide For Supination

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Poor force distribution

Special Considerations When Treating Hand or Wrist Injuries

• Infection • Clean laceration versus a crush or shear type injury • Smoking • Mobilize the joint and then have them do the function that is limited

Elbow mob 0deg End Range Extension Loss

• The anatomy of the MCL and medial epicondyle must be considered • The MCL is most elongated when it has to go over the epicondyle at 30deg flexion

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Elbow mob 30deg Thank You to My Son, Lee, and the Staff at Bayhealth Rehab Services

The NATA and EATA are OUR Thank You Associations!!

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