Sports med 2 Head Body Base Distal
Phalanges Middle Distal
Proximal Proximal
Head Metacarpals Body 1st Metacarpal Base Trapezoid HamateHamateHamate Trapezium Carpals PisiformPisiform Capitate Triquetral Scaphoid Lunate Olecranon Lateral Fossa Epicondyle Medial Epicondyle Capitulum Trochlea Trochlea Olecranon Olecranon
Ulna Radius
Interosseous Membrane Anterior Posterior Transverse Ulnar Carpal Ligament Collateral Ligament Radial Collateral Ligament Humerus Annular Ligament Biceps Brachii Tendon
Radius Triceps Brachii Tendon Medial Collateral Ligament Olecranon Bursa Ulna
Humerus Annular Ligament Lateral Biceps Brachii Tendon Epicondyle Lateral Radius Collateral Ligament
Olecranon Ulna Biceps Brachii
Brachialis
Brachioradialis Supinator Pronator Teres
Flexor Carpi Radialis Palmaris Longus Flexor Carpi Ulnaris
Pronator Quadratus Triceps Flexor Brachii Digitorum Superificalis
Anconeus Quick Question?
What was more difficult during the knee and shoulder unit: Injuries or Special tests Elbow
Sports med 2 Movements • Carrying angle – Females 10-15 degrees, Males 5 degrees • Flexion – 145 degrees • Extension: ?? • Pronation – 80 degrees • Supination – 85 degrees Articulations
• Consists of 3 separate joints – Humeroulnar – Humeroradial – Proximal radioulnar Ligaments and Bursae
• Medial collateral ligament – Prevents valgus forces • Lateral collateral ligament – Prevents varus forces (uncommon) • Annular ligament – Stabilizes head and neck of radius (strong) • Olecranon bursa – Between olecranon process and skin Musculature
• Biceps Brachii, Brachialis, brachioradialis – Elbow flexion • Triceps brachii, anconeus – Elbow extension • Pronator teres and quadratus, supinator – Pronation and supination Nerve/Blood Supply
• Median Nerve • Radial Nerve • Ulnar Nerve – Funny bone • Radial Artery • Ulnar Artery Assessment
• History – Land on tip of bent elbow? (most common MOI) – Overuse from throwing? – Over extension? – Location and duration of pain? – Positions that increase or decrease pain? – Previous elbow injuries? – Locking or crepitation w/movement? YOUR TURN TO PRACTICE: HISTORY
• Turn to someone near you and give different history questions back and forth until someone repeats, cannot think of one or lists something that does not belong. • Start first with: – Elbow questions – General questions – Any other specific joint questions
NO NOTES, PHONES, FRIENDS; JUST YOU Assessment
• Observations – Deformities, swelling – Carrying angle • Normal 5-15 degrees • Too little or too great could = fx – Decreased flexion or hyperextension – 45 degree angle, posterior observation of epicondyles and olecranon process to make isosceles triangle YOUR TURN TO PRACTICE: OBSERVATION • Turn to someone DIFFERENT and give different observations back and forth until someone repeats, cannot think of one or lists something that does not belong. • Start first with: – Elbow observations – General observations – Any other specific joint observations
NO NOTES, PHONES, FRIENDS; JUST YOU Assessment • Bony Palpations – Medial epicondyle – Lateral epicondyle – Olecranon process – Radial head – Radius – ulna Assessment • Soft tissue palpations – Anterior • Biceps brachii • Brachialis • Brachioradialis • Pronater teres – Posterior • Triceps Brachii • supinator – Medial • Medial collateral ligament – Lateral • Lateral collateral ligament • Annular ligament YOUR TURN TO PRACTICE: PALPATION
• Turn to someone DIFFERENT AGAIN and give different palpations back and forth until someone repeats, cannot think of one or lists something that does not belong. • Start first with: – Elbow observations – General observations – Any other specific joint observations
NO NOTES, PHONES, FRIENDS; JUST YOU Strains • MOI: FOOSHA = hyperextension • S/S – AROM or RROM= pain – Point tender • TX – RICE possibly a sling – Cryotherapy, US, rehab – X-ray if severe
Special Test: MMTs Elbow MMTs
• Flexion • Extension • Pronation • Supination • Write in the muscle for each action
YOUR TURN Elbow Dislocation • MOI – FOOSHA, or severe twist with flexion – Ulna and radius are pushed posterior (most common) • S/S – Severe pain, swelling and disability – Deformity – Probable radial head fx • TX – Ice, sling, check circulation – Refer for x-ray and reduction Elbow Fractures • MOI – FOOSHA, or direct blow • S/S – Possible visible deformity – Hemorrhage, muscle spasm, and swelling • TX – Stabilize, monitor distal pulse – Refer for x-ray, splint 6-8 weeks
https://www.youtube.com/watch?v=MzJP4oiPz3k Medial Collateral Lig. (MCL) sprain • MOI – Valgus force from repetitive trauma – Tennis, golfing, throwing • S/S – Pn. On medial aspect of elbow – Parasthesia, and laxity • TX – Rest, NSAIDs, strengthening, correct form
Special Test: Valgus Test Valgus Stress Test
Picture Procedure/Positive Diagnosis Apply a medial force MCL sprain (valgus) to the elbow at 0 and 30 degrees to see laxity bilaterally or pain Varus Stress Test
Picture Procedure/Positive Diagnosis Apply a lateral force (varus) LCL sprain to the elbow at 0 and 30 degrees to see laxity bilaterally or pain Volkmann’s Contracture
• MOI – Complication of serious elbow injury – Muscle spasm, swelling, or bone pressure on the brachial artery • S/S – Pn. In the forearm that is worse when fingers are passively extended – Decreased or absent brachial and radial pulses • TX – Removal of constricting casts, wraps or braces, elevation – Can become permanent Ulnar Nerve Injuries • MOI – Pronounced valgus at the elbow – friction problem – Dislocation or pinched by a ligament during flexion activities • S/S – Paresthesia to fourth and fifth fingers • TX – Conservative, avoid activities that aggravate nerve – Possible surgery to move nerve anteriorly Special Test: Tinels Sign Tinel’s Sign
Picture Procedure/Positive Diagnosis Stabilize wrist and tap the Ulnar nerve compromise ulnar groove (nerve) to see athlete complains of tinging down arm Epicondylitis • MOI – Lateral (tennis elbow) • Tennis, baseball, swimming, golfing • Repeated forearm flexion and extension – Medial (pitchers or golfers elbow) • Repetitive wrist flexion, valgus stress on elbow • S/S – Aching pn. During and after activity – decreased ROM – hand weakness • TX – RICE, NSAIDS, US – ROM, PRE, Deep friction massage – Elbow sleeve or band just below the bend of the elbow
Special Test: Epicondylitis tests Cozen’s Test
Picture Procedure/Positive Diagnosis Stabilize elbow and put Lateral epicondylitis or pressure over lateral tennis elbow epicondyle as you resist wrist extension; athlete complains of pain at lateral epicondyle Medial epicondylitis Test
Picture Procedure/Positive Diagnosis Stabilize elbow and put Medial epicondylitis or pressure over medial Little League elbow epicondyle as you resist wrist flexion; athlete complains of pain at medial epicondyle Olecranon Bursitis
• MOI – Direct blow • S/S – Pain, severe swelling, point tenderness • TX – Acute= ice, compression – Chronic = compression, modalities, aspiration – Padding for play Wrist/Hand Sports med 2 Articulations • Radiocarpal – Flexion, extension, abduction, and circumduction • Carpal – Gliding joints – Stabilized by anterior, posterior, and connecting ligaments • Metacarpal – Flexion, extension, abduction, adduction, circumduction • Phalangeal – Hinge joints – Proximal interphalangeal (PIP), Distal interphalangeal (DIP) Ligaments
• Wrist – Ulnar Collateral ligament • Ulna to pisiform – Radial collateral ligament • Radius to scaphoid – Transverse carpal ligament • Roof of the “carpal tunnel” • Phalanges – Collateral ligaments Muscles • Flexors – Palmar surface – Flexor digitorum superficialis, flexor digitorum profundus • Extensors – Dorsal surface – Extensor digitorum longus, • Intrinsics – Abduction and adduction MMTs
• Flexion • Extension • Ulnar deviation • Radial Deviation • Finger Abduction • Finger Adduction Blood/Nerve Supply
• Nerves – Ulnar, radial – Median • Enters palm through carpal tunnel • Arteries – Radial – ulnar Allen’s Test
Picture Procedure/Positive Diagnosis Athletes open & closes fist Radial or ulnar artery x3-4 and then closes, ATC compromise covers both arteries then releases one to see blood return to that side of the hand; repeat with other artery Assessment
• History – MOI – Location and type of pain? – Increases or decreases pain? – History of trauma or overuse? – Any therapy given in the past? Assessment
• Observations – Hand usage like writing, unbuttoning shirt – Open and close hand • Fully? Rythmically? – Touch thumb to each fingertip – Flat knuckle – Color of fingernails • Pale= poor circulation Assessment • Bony Palpations • Scaphoid (anatomical snuffbox) • Lunate • Hamate (hook) • Metacarpals • Phalanges (proximal, middle, and distal) Assessment
Soft Palpations • Triangular fibrocartilage (TFCC) • Collateral ligaments of phalanges • Flexor and extensor muscles Tenosynovitis
• MOI – Repetitive use and overuse of tendons and their sheaths • S/S – Pn with use, pn w/passive stretching – Tenderness, swelling over tendon • TX – Ice massage, NSAIDS, rest – ROM, contrast baths, US, PRE
Special Test: Finkelsteins Finkelstein’s Test
Picture Procedure/Positive Diagnosis Athlete closes thumb Tenosynovitis around same fist as ATC applies gentle ulnar deviation to see pain on radial side Carpal Tunnel Syndrome
• MOI – Inflammation in the carpal tunnel, compresses median nerve – Repeated flexion, or direct blow • S/S – Tingling, numbness, weakness • TX – Rest, immobilization, NSAIDS – Possible surgery
Special Test: Phalens Phalen’s Test
Picture Procedure/Positive Diagnosis Athlete places both palms Carpel tunnel syndrome together and presses at least a minute to see pain at carpal tunnel Wrist Sprains (most common)
• MOI – Falling on hyperextended wrist – Violent flexion or torsion • S/S – Pn, swelling, decreased AROM • TX – RICE, splinting, analgesics – Tape, strengthening
Special Test: Glide Glide Test
Picture Procedure/Positive Diagnosis Stabilize the distal forearm A/P laxity=transverse and grasp carpals, glide sprain into A/P, R/U to see laxity R laxity=RCL sprain compared bilaterally U laxity=UCL sprain Gamekeepers Thumb
• MOI (skiiers, tacklers) – Sprain of UCL ligament of MCP joint of thumb – Forceful abduction with hyperextension • S/S – Pn, weak pinch, – Tenderness and swelling • TX – Refer – Splint 3 weeks
Special Test: Valgus/Varus Valgus/Varus Test
Picture Procedure/Positive Diagnosis
Stabilize each bone with Valgus laxity=MCL sprain at fingers, apply appropriate the joint tested force with thumbs at joint Varus laxity=LCL sprain at to see laxity compared the joint tested bilaterally Triangular Fibrocartilage Complex Injury (TFCC) • MOI – Forced hyperextension • S/S – Pn along the ulnar side of wrist – Extension = pn, difficulty – Swelling later on • TX – refer Wrist Ganglion • MOI – appears slowly, contains clear mucinous fluid – Repeated hyperextension • S/S – Bump on dorsal wrist – Occasional pn, increases w/wrist extension – Cystic structure is soft, rubbery, or hard • TX – Aspiration and chemical cauterization, pressure pad – Surgical removal Scaphoid Fx (most common)
• MOI – FOOSHA, compresses scaphoid between radius and carpals • S/S – Point tenderness in snuff box – Pn. With thumb compression and radial deviation • TX – Splint and refer for x-ray – Untreated leads to necrosis Hamate (hook) Fx
• MOI – Direct blow from racket, bat, sports stick, club • S/S – Wrist pn and weakness – Point tender • TX – Refer for x-ray – Doughnut pad Colles Fx
• MOI – Fx to distal end of radius or ulna – FOOSHA, or hyperextension • S/S – Visible deformity – Swelling and pn • TX – Ice and splint – refer Boxers (5th metacarpal) Fx
• MOI – Direct axial force (punching) – Getting stepped on • S/S – Pn and swelling • TX – RICE, analgesics, refer – Splint 4 weeks, early ROM
Special Test: Compression Compression Test
Picture Procedure/Positive Diagnosis
ATC applies compress Fracture of specific down axis of bone with phalange/metacarpal finger in extension to see pain at injury sight Mallet Finger
• MOI – Direct blow to extended finger • S/S – Pn at DIP – unable to extend finger • TX – RICE – Splinted 24 hr/day, 6-8 weeks Boutonniere/Button hole Deformity
• MOI – Trauma forcing the DIP into extension and PIP into flexion • S/S – Pn and inability to extend the PIP – Swelling, obvious deformity • TX – Ice – Splint PIP in extension5-8 weeks – Flex distal phalanx Jersey Finger
• MOI – Most often in the ring finger – Grabs a jersey, ruptures flexor tendon • S/S – DIP joint cant be flexed – Finger stuck in extension • TX – No surgery = never flex DIP again – Surgery = 12 weeks of rehab Phalanx Fractures
• MOI – Stepped on, torsion, hit by a ball • S/S – Pn and swelling – TTP at fx site • TX – Splint in slight flexion – Refer for xray
Special Test: Tap/Percussion Tap/Percussion Test
Picture Procedure/Positive Diagnosis
ATC taps down axis of bone Fracture of specific with finger in extension to phalange/metacarpal see pain at injury sight Subungual Hematoma
• MOI – Contusion/crushing • S/S – Slow or immediate bleeding into the nail bed – Extreme pn – Bluish/purple nail bed • TX – Ice, elevation – Drill a small hole in nail bed EVAL Practice
• Partner up (no groups) • ATHLETE: pick a scenario and act like injury • SAT: use your SOAP note and HOPS to figure out what the injury is • Switch
• Do as many as you would like Elbow/wrist/hand Rehab
Sports med 2 Phase 1 Elbow
• General Body conditioning • ROM – Joint Mobilizations • Inferior, anterior and posterior glides – Humeroulnar traction – Passive stretching • Low force and long duration • Flexion and extension • Strengthening – Low resistance, high reps • Flexion, extension, pronation, supination, grip, and shoulder Phase 1 Wrist/Hand • General Body Conditioning • ROM – Traction, joint mobilizations – Stretching PROM • Extension, flexion • Strength – Towel/flex bar twists – Wrist roll – Flexion and extension (no or decreased weight) – Ulnar/radial deviation (no or decreased weight) – Pronation/supination (no or decreased weight) – Grip • Web, stress ball, machine, rubberbands • Neuromuscular control – Coin pickup – Tying shoes/knots – Buttoning buttons
Phase 2 Elbow
• General body conditioning • Proprioception • Strengthening – PNF, Isokinetic – PRE • Tubing, weights, or manual resistance • ROM – Joint mobilizations – Stretches
Phase 2 Wrist/Hand • General Body Conditioning • ROM – Traction, joint mobilizations – Stretching AROM • Extension, flexion • Strength – Towel/flex bar twists (thicker bar) – Wrist roll (more weight) – Flexion and extension (dumbbells/bands) – Ulnar/radial deviation (dumbbells/bands) – Pronation/supination (dumbbells/bands) – Grip • Web, stress ball, machine, rubberbands • Neuromuscular control – Coin pickup – Handwriting – Buttoning buttons Phase 3 Elbow
• General Body Conditioning • Functional Progressions – Swimming – Throwing – Pushups – Sitting pushup – Weight shifting on ball Phase 3 Wrist/Hand
• General Body Conditioning • Sports specific activities • Full grip strength is goal Buddy Tape: Watch and practice Finger Splint: Watch and Practice REHAP APPLICATION 1. Use the injuries from the eval last class and make a rehab program for this athlete (3 days) – Athlete comes in Monday’s, does the exercises at home and comes back 2 more weeks. 2. Imagine what you would see each time the athlete comes in – Must be able to progress