Anne Marie C Zeller, MSc, DO

Family Medicine Resident: Year 2

Undergraduate Osteopathic Manipulative Medicine Fellow- Graduated Chief

Faculty: Michael P. Rowane, DO, MS, FAAFP, FAAO

Discuss common causes and diagnoses in

regards to adolescent shoulder and elbow pain

Discuss basic tenets of examination of

shoulder, elbow, and wrist

High-yield and efficient osteopathic

manipulative medicine treatments for

shoulder, elbow, and wrist

Practice , Practice, Practice!

MUST consider the maturation of the physis

or growth plates

Weakness at the physis and decreased

resistance to shear and tensile forces compared

to the surrounding ligaments, tendons, and

muscles, PREDISPOSE this population to

injury.

• Repetitive micro trauma or overuse mechanisms:

1. Acceleration: Athletes uses optimum load to generate force

• Example: racquet and pitching sports

2. Dynamic force: arm is moving against sustained resistance

• Example: swimming

3. Static force: action of the shoulder muscles when then are held in a constant position with isometric contraction

• Example: dancer or gymnast

• Worst position: abducted to 90⁰, externally rotated, and extended. – MOST tension on anterior

articular capsule and anterior glenohumeral ligament

– Rotator Cuff and deltoid active

– Subscapularis is compromised • Accerate forward: pectoralis

and subscapularis are required to quickly internally rotate the humerus – ANOTHER bad biomechanical

position for shoulder

1) Glenohumeral Joint

2) Sternoclavicular and Acromioclavicular Joints

3) Scapulothoracic Joint

Remember: Shoulder Pain is NOT JUST Rotator

Cuff! Shoulder involves Ribs, Thoracics,

Lumbars, Cervicals, Cranial bones

Innominates, and Sacrum

Epidemiology, Pathology and OMM treatment

• Traumatic events makes up 86% of

Glenohumeral instability in adolescent athletes

16 and older.

• Skeletally mature athletes with GH instability

= surgery due to 80-90% recurrence rate

• Skeletally immature athletes = EXTREMELY

careful in evaluating because of the high

chance of fracture of proximal humerus.

• 90% of traumatic dislocation • Mechanism of Injury: high energy injury of a fall

on an outstretched hand while shoulder in abduction and external rotation

• S/S: “dead arm”- transient loss of sensation or numbness in involved extremity (axillary nerve), obvious deformity, pt hold arm internally rotated, + anterior apprehension test

• Diagnosis: Pt history, physical exam, x-rays • Treatment: Primary- closed reduction of

dislocation, Secondary- surgery due to recurrence rate with conservative treatment .

8

Hill-Sachs Fracture

and Bankart Lesion

Hill-Sachs (Blue

Arrow): compression

fracture at the

posterolateral head of the

humerus due to

impingement against

anterior rim of glenoid

fossa when the humeral

head dislocates.

Bankart Lesion (Red

arrow): avulsion of

anteroinferior glenoid

labrum where the

inferior glenohumeral

ligament attaches

• < 5% of traumatic shoulder dislocations • MOI: Fall on an outstretched hand with shoulder

in adduction and internal rotation or direct anterior trauma. – Example: Offensive Linemen: forward flexed and

internally rotation of shoulder for blocking • S/S: May not have deformity, + posterior

apprehension test, complain of shoulder pain and have limited external rotation with <90⁰ shoulder flexion

• Treatment: rotator cuff rehab is most successful after closed reduction

• Majority are bilateral, multidirectional • Hypermobility (generalized joint laxity) of joints from

sports that weaken rotator cuff from overhead motions

– Examples: gymnastics and swimming

• S/S: nonspecific shoulder pain, feeling of shoulder dislocation with overhead activities, hyperextension of other joints of UE, + apprehension signs, + sulcus sign, strength deficits in rotator cuff muscles and scapular stabilizers (serratus anterior, pectoralis, and latissimus dorsi)

• Treatment: conservative rehab with strengthening NOT stretching exercises

• Proximal humeral epiphysiolysis • MOI: repetitive strain injury to proximal humeral

epiphysis from overtraining and improper biomechanics seen in over-head sports. (Example: Baseball)

• Ages: 11-15 • S/S:

– Pt has pain in superior lateral aspect of the shoulder with dynamic/resisted over-head activites

– palpation of proximal humeral epiphysis is tender

– active ROM is full and pain free

– resisted muscle testing in over-head position reproduces pain.

– X-ray is BEST visualization of pathology

Rule out: Fracture and Dislocations with

history, physical exam and X-rays or MRI

Cautions: chronic dislocations, joint

hypermobility, recent shoulder surgery

Contraindications: Septic joint, acute

dislocation, fracture, cancer

1. Dr. grasps humeral shaft with

both hands and fingers

interlock on medial side

(avoiding NV bundle)

2. Dr. pushes with both

hypothenar eminences against

humeral shaft. Cause humeral

head to become abducted as the

humerus is adducted by pt.

3. Pt places his ipsilateral hand on

the opposite side of his chest

(causing internal rotation and

adduction)

4. Pt moves elbow forward and

backward (internal and external

rotation)

5. Dr. determines which direction

enhances balanced tension.

6. Pt is instructed to maintain arm

in the position.

7. Dr. fine tunes the tensions at the

GH joint to achieve balanced

tension.

1. Pt is seated and facing

Dr. Dr. places thumbs

along superior portion

of the clavicles, just

distal to the SCM

insertion

2. Pt. drapes arms over

Dr.’s and flexes head

and neck. Allows

fingers to sink into the

supraclavicular space

3. Pt breathes deeply.

During inhalation, the

Dr. resists the superior

movement of the

supraclavicular fasciae

4. During exhalation, the

pt. exaggerates flexed

posture of head and

neck as the Dr. follows

tissues as they descend

into the thoracic inlet

According to Sutherland model, the

claviopectoral fascia has a similar role to the

interosseous membranes of the forearm and

lower leg in that it guides and limits

movement of the bone.

Serratus anterior, rhomboid and teres major

are viewed as the functional ligaments of the

joint.

BLT treatment presented addresses Serratus

anterior, subscapularis, rhomboid, latissimus

dorsi, teres major and lower trapezius muscles.

1. Pt seated. Dr. uses thumb as a fulcrum beneath the scapula in the axilla.

2. Palmar surface of thumb is placed on the lateral surface of the 2nd and 3rd rib with the tip facing posteriorly. Anterior to the latissimus dorsi

3. Dr. gently slides her thumb posteriorly along the surface of the rib until it rests between the scapula and rib.

4. Dorsal surface of thumb on subscapularis. Plantar surface of thumb contacts the serratus anterior.

5. Dr. places other hand over the posterior aspect of the scapula. Base of hand at Apex and finger grasp the spine of the scapula

6. Dr.’s posterior hand protract, retract, adduct, abduct, elevate and depress the scapula to achieve balanced tension in all tissues attached

OMM Treatment of Ribs, Cranial bones,

Cervical Vertebrae, Thoracic Vertebrae,

Lumbar Vertebrae, Innominates, Sacrum with

S/CS, ME, Indirect Myofascial, Still, or FPR.

Extensive information on Throwing and other

sport mechanisms in the shoulder and its

contributions to shoulder injury and pain

33

ECRL: Extensor Carpi Radialis Longus ECRB: Extensor Carpi Radialis Brevis EDC: Extensor Digitorum Communis ECU:Extensor Carpi Ulnaris CET: Common Extensor Tendon

AL: Annular Ligament RCL: Radial Collateral Ligament LUCL: Lateral Ulnar Collateral Ligament

Precipitated by activities that require repetitive

wrist extension, radial deviation and forearm

supination

Examples: Hammering, painting, tennis

backhand

34

Patient typically reports an insidious onset but

will often relate a history of overuse without

trauma.

Pain with gripping objects (“coffee cup sign)

and shaking hands (“politician’s sign”)

Numbness or tingling: Suggest radicular

symptoms

35

Musculoskeletal and Neurologic Exam 1st!

Tenderness with palpation at origin of Extensor

Carpi Radialis Brevis (ECRB)

Tenderness with resisted supination

Resisted Wrist Extension Test

Enhanced by:

▪ Straightening elbow

▪ Making a fist

▪ Pronating the forearm

▪ Radially deviating wrist

36

Middle Finger Test

Resist the extension of the proximal

interphalangeal joint of 3rd digit

Stresses the extensor digitorum and ECRB

Positive if pain is over the lateral epicondyle.

37

Posterior interosseous nerve entrapment (radial

tunnel syndrome)

Osteoarthritis

Cervical radiculopathy

Musculocutaneous nerve entrapment

Radiocapitellum Osteochondritis dissecans lesions

Lateral collateral ligament strain

Stress Fracture

Humeral Fracture

Synovitis of the radiohumeral joint

38

39

PL: Planaris Longus PT: Pronator Teres FCR: Flexor Carpi Radialis FDS: Flexor Digitorum Superficialis FCU: Flexor Carpi Ulnaris

AL: Annular Ligament MCL: Medial Collateral Ligament

Forceful and/or

continuous flexion and

pronation at the wrist

Activities requiring a

large amount of

stabilization applied by

the wrist

Common Activities Examples: Racquet sports

Swimming

Swinging a Golf Club

Throwing

Computer Keyboard

Playing Piano

Certain occupations Examples

▪ Carpenters

▪ Plumbers

▪ Meat cutter

40

Pain and tenderness along medial elbow

extending into forearm

Difficulty gripping without pain

Decreased wrist strength

Tightness/stiffness when stretching elbow and

wrist

41

Testing for Valgus Stability in Extension:

MCL

Anterior Capsule

Bony articulations

42

Fracture

Osteochondritis dissecans

Osteoarthrosis

MCL injury

Little League elbow- increased valgus angle in

adolescent throwing athletes

Flexor-Pronator Strain

Ulnar neuropathy (neuritis, entrapment)

Pediatric- avulsion fracture

43

44

45

Diagnose and treat Somatic Dysfunctions in:

Cervical spine, Thoracic spine, Ribs , Scapula, and Clavicle

To reduce and/or correct somato-somatic reflexes and some of the myofascial pain referrals

To improve the venous and lymphatic drainage

OMT Techniques Presented Address:

Radial Head

Humero-Radial Joint

Humero-Ulnar Joint

Distal Radio-Ulnar Joint

Carpal Joints

Patient seated with elbows flexed at 900 and forearms at 00 of pronation and supination (thumbs up).

Then check for supination or pronation restrictions. The radial head moves posteriorly with pronation and

anteriorly with supination. Therefore a pronated forearm (with restricted

supination) will have a posterior radial head somatic dysfunction.

Supinated forearm (with restricted pronation) will have an anterior radial head somatic dysfunction.

50

Example: Pt is restricted in PRONATION, Freedom of Motion is in Supination Diagnosis: Anterior Radial Head

51

Step 1 Step 2

Step 4 Step 3

*Sit next to patient as depicted to make this work

* Start in full Pronation and end in full Supination

52

Step 1 Step 2

Mobilization of distal radioulnar joint – isometric; to 4th barrier in pronation, repeat in supination

– Treat restrictions of pronation/supination (proximal or distal)

– Free-up the interosseous membrane*

– Improve venous and lymphatic return • (carpal tunnel syndrome)

*Piano key sign

Patient is supine

Right arm abducted 45 degrees

Hand positioned midway between

supination and pronation (thumb

up towards ceiling).

Both hands are placed around the

elbow and motion is medial and

lateral to produce the articulation

of the radial head with the ulna or

humerus or articulation of the

humeroulnar joint.

53

**Examine for Valgus/Varus instability before performing technique

54

•Fingers should be applying lateral traction to the

thenar & hypothenar eminences and the thumbs

should be applying pressure to gently separate the ulna

and radius from the carpal bones

•Wrist Flexion, Extension, Radial and Ulnar Deviation

55

Anterior Tender Points

Elbow is flexed fully.

Forearm is pronated and arm

is internally rotated - so back

of hand approximates chest.

Forces are pronation of the

forearm and internal rotation

of the humerus until a position

of comfort is found.

Hold this position for 90

seconds and then slowly

return to neutral.

Retest for tenderness.

Coronoid TP- Same position

but external rotation of the

humerus 56

ALWAYS perform a musculoskeletal and neurologic exam FIRST

OMT learned today for shoulder and elbow Glenohumeral Joint

Sternoclavicular and Acromioclavicular joint

Scapulothoraic joint

Radial Head

Humero-Radial Joint

Humero-Ulnar Joint

Distal Radio-Ulnar Joint

Carpal Joints

1) Wojtys E. et al. “Sports injuries in the immature athlete.” Orthop Clin North Am 1987; 18 (4):

689-708.

2) Ogata et al.early development and ossification of the human clavicle—an embryologic

study.1990, Vol. 61, No. 4 , Pages 330-334

3) Gardner E.”The embryology of the clavicle.” Clin Orthop 1968;58:9

4) Carreiro, Jane D.O. Pediatric Manual Medicine. (2009). Churchill Livingstone.

5) BRIAN L. MAHAFFEY, M.D.PATRICK A. SMITH, M.D. “Shoulder Instability in Young

Athletes.” American Family Physician

6) Lawton RL et al. “Pediatric shoulder instability: presentation, findings, treatment, and outcomes.”

J Pediatric Orthop 2002.; 2252-61.

7) Good CR et al. “Traumatic shoulder dislocation in the adolescent athlete: advances in surgical

treatment.” Curr Opin Pediatr 2005; 17:25-9.

8) Jakobsen BW et al. “Primary repair versus conservative treatment of first-time traumatic anterior

dislocation of the shoulder: a randomized study with 10-year follow-up.” Arthroscopy 2007; 23

(2): 118-23.

9) Krabak et al. “Shoulder and Elbow Injuries in the Adolescent Athlete.” Phys Med Rehabil Clin N

Am. 19 (2008) 271-285.

10) American Osteopathic Association. Foundations in Osteopathic Medicine. (2003)

11. Young et.al (2011) “Lateral Epicondylitis.” 5-minutle Sports

Medicine Consult. Lippincott Williams & Wilkins. 12. Zeisig E. et al.(2006) Extensor origin vascularity related to pain

in patients with Tennis elbow. Knee Surg Sports Traumatol Arthrosc.14(7):659.

13. Walz D, et al (2010). Epicondylitis: Pathogenesis, Imaging, and Treatment. Radiographics. 30: 167-184.

14. Gruchow (1979). “Epidemiologic Study of Tennis Elbow. Incidence, recurrence, and effectiveness of prevention strategies”. American Journal of Sports Medicine. 7(4): 234-238.

15. Young et.al (2011) “Medial Epicondylitis.” 5-minutle Sports Medicine Consult. Lippincott Williams & Wilkins.

16. Smidt, N. et al (2002). “Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomized controlled trial.” Lancet. 359: 657-662.

59

17. Bisset L, et al. (2005) “A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. 39: 411-422.

18. Grewal R. (2009) “Functional outcome of arthorscopic extensor carpi radialis brevis tendon release in chronic lateral epicondylitis.” Journal of Hand Surgery. 34: 849-857.

19. Des Moines University OMM Department. “Treatment of Elbow Somatic Dysfunctions Laboratory Handout.” Updated 2010.

20. Figueroa J. Professional collaboration with AOA Lateral and Medial Epicondylitis Lecture.

21. Lewis D. Upper Extremity IV Lab and Lecture. Spring 2011. Des Moines University.

22. Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual. Volume 1. Upper Half of Body. 2nd Ed. Baltimore, Williams & Wilkins, 1999, pp. 485-907 60

Spencer Sequence

Step 1: Extension

Isometric

Contraction the

patient is trying to

flex shoulder is

used to lengthen

the Pectoralis

Major, Pectoralis

Minor and anterior

deltoid

Spencer Sequence

Step 2: Flexion

Isometric

contraction of

Patient extending

shoulder engages

latissimus dorsi,

teres major and

minor, posterior

deltoid

Spencer Sequence

Step 3: Circumduction

without traction

Spencer Sequence

Step 4: Circumduction

with Traction

Spencer Sequence

Step 5: Abduction

Isometric

Contraction of

patient adduction

engages Pectoralis

Minor, Teres

Minor, and

Infraspinatus

Spencer Sequence

Step 6: Adduction

Isometric

contraction of

patient pushing

elbow superior

engages

subscapularis

and teres major

Spencer Sequence

Step 7: Internal

Rotation

Isometric

contraction pt.

pushes elbow

posterior

(external

rotation)

engages the

supraspinatus

and

infraspinatus

muscles

Spencer Sequence

Step 8: Abduction with

Resisted Traction

Structures referring to the lateral elbow

Scalenes

Supraspinatus

Teres Minor

Deltoid

Triceps

Subclavius Pictures of Trigger Points, Referral Patterns, and Stretches in Appendix of Powerpoint Slides

Lateral and Medial Epicondylitis- Anne Marie C. Zeller 70

Structures referring to the medial elbow

Latissimus Dorsi

Subscapularis

Triceps

Sternalis

Serratus Posterior Superior

Pictures of Trigger Points, Referral Patterns, and Stretches in Appendix of Powerpoint Slides

Lateral and Medial Epicondylitis- Anne Marie C. Zeller 71

Identify the trigger points:

Taut band

Tender to palpation

Recognition of Pain

Referral of pain (“triggers pain somewhere else”)

Treat by stretching

May use spray and stretch

Treat by needling

Dry needle or infiltrate trigger point with lidocaine

Lateral and Medial Epicondylitis- Anne Marie C. Zeller 72

73

74