Manual Therapy Interventions for Wrist Pain€¦ · Amanda A Grant PT, DPT, FAAOMPT, MTC, CLT, OCS...
Transcript of Manual Therapy Interventions for Wrist Pain€¦ · Amanda A Grant PT, DPT, FAAOMPT, MTC, CLT, OCS...
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Amanda A Grant PT, DPT, FAAOMPT, MTC, CLT,OCS
and
Matthew L. Daugherty, PT, DPT, MOT, OTR/L,FAAOMPT, MTC, OCS
Manual Therapy Interventions for Wrist Pain
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Disclosure
Both speakers are employed by the University of St. Augustine for Health Sciences (USAHS).Some manual treatment techniques are taught at USAHS.No relevant financial relationship exists.
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Objectives
1) Describe the influence of biomechanical and anatomical structures on wrist pain.
2) Identify, through differential diagnosis, impairments at the wrist, radiohumeraljoint, distal radioulnar joint, and TFCC.
3) Demonstrate and integrate manual therapy intervention techniques in the management of wrist pain.
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Wrist Anatomy - Review
Distal Radioulnar
Radiocarpal
Midcarpal
Carpal metacarpal
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Wrist Pain Differential Diagnosis
Big things to look for….HistoryMOINature/location of Pain
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Compensatory Movements with Limited Pronation or Supination
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Limited Pronation with Shoulder Compensation
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Limited Supination with Shoulder Compensation
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Radiohumeral and RadioulnarJointRelationship
CompensationsLacking pronation results in increased GH abduction and CMC flexion or opposition
Irritation of APL and EPB
Lacking supination results in increased GH adduction and ER, and wrist ulnar deviation
Strain to TFCC
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CMC Joint AROM Assessment of Opposition
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Adductor PollicisAttachments:Transverse head:
anterior body of the third metacarpal
Oblique head:bases of the second and the third metacarpals and the adjacent trapezoid and capitate bones medial side of the base of the proximal phalanx of the thumb and the ulnar sesamoid
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Adductor Pollicis Length Assessment
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Radio-humeral and RadioulnarJoint Relationship
Kinetic chainThe body will compensate in the presence of dysfunction
“There is no prediction for a normal compensation BUT there are some common occurrences.”Patla, C. JOSPT 2000
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Examination for Joint Mobility for Supination/Pronation Impairments
Ulna-meniscal triquetral joint
Distal radius-ulna joint (DRUJ)
Proximal radio-humeral joint
Must check alignment prior to assessment and manipulation
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DRUJ Assessment
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DRUJ Assessment
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Proximal Radio-Humeral Joint
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Proximal Radio-Humeral Joint Assessment and Treatment
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Proximal Radio-Humeral Joint-Assessment and Treatment
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Ulna-Meniscal-Triquetral Joint(UMT Volar Glide)
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UMT Volar glide
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UMT Volar glide
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Wrist Case #125 y.o. female c/o sx beginning after 2 day bike ride (totaling >150 miles)
Paresthesia in ulnar nerve distribution (digits IV ulnar half and V) volarly only.Sensory changesDifficulty in separating fingers/ Wartenberg signHand clumsinessHand weakness and loss of grip power and dexterity
MOI: Prolonged wrist extension with elbow locked in extension, and pressure through ulnar border of the hand/wrist
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Ulnar Tunnel Syndrome
3 potential sites of entrapment
Just proximal to or within Guyon’s Canal (sensory and motor involvement)
Between abductor digiti minimiand flexor digiti minimi (motor only)
Distal end of Guyon’s canal (sensory only)
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Unique interventions to Case #1
UMTVDistal RadioulnarjointProximal Radioulnar joint
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UMT Volar Glide
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Wrist Case #2
45 y.o. male chief c/o chronic proximal wrist pain
Located centrally and points to dorsal, distal forearm surface.Avid mountain bikerNo recent MOI
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Wrist Case #2
Long history of going ‘over the bars’, Fall on outstretch hand (FOOSH) injuries.
Pain worsens with wrist extension, particularly when loaded-closed chain and in pronation or supination.
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Unique interventions to Case #2
Distal Radioulnar joint
Lateral Carpal Glide
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DRUJ Instability
Physical ExamAROM
PROM (Classical)
Joint Mobility
Special TestsDRUJ instability test
Reprinted from Rehabilitation of the Hand and Upper Extremity, 201113
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Distal Radio-Ulnar Joint
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DRUJ Treatment
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DRUJ Treatment
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DRUJ Instability Management
Minimize mal-alignmentExternal Stabilization
TapingExternal bracing
Internal Stabilization Must be initially done with alignment or bracingStrengtheningProprioception/stabilization therex
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Lateral Carpal Glide-Option #2
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Lateral Carpal Glide-Option
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Lateral Carpal Glide-Gripping
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Lateral Carpal Glide-Open Chain Flexion and Extension
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Lateral Carpal Glide-Closed Chain
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No success distally????
Assess proximally
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Wrist Case #3
27 y.o. female with chief c/o sudden onset wrist pain.
Located on ulnar side of wrist .Recreational tennis player and works out at gym 3+ days/week.Recent MOI-recent pain after gym workout 1 week ago.Getting better but still has 3/10 pain with gripping activities and lack of full grip strength.
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Wrist Case #3
Joint and TendonopathyImpairments???
Unsatisfactory response to distal (wrist) treatment
Distal Radioulnar Joint GlidesLateral Carpal Glide
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Unique interventions to Case #3
Proximal Radio-Humeral Joint Glides
Lateral Glide of Ulna
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Proximal Radio-Humeral Joint-Treatment
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Lateral Glide of Ulna
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Lateral Glide of Ulna
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Lateral Glide of Ulna
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Lateral Glide of Ulna-Treatment
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Lateral Glide of Ulna –Supportive Treatment
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Lateral Glide of Ulna –Supportive Treatment
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Closing Remarks
Kinetic chainThe body will compensate in the presence of dysfunction
“There is no prediction for a normal compensation BUT there are some common occurrences.”Patla, C. JOSPT 2000
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Closing RemarksDon’t give up!
Assess the kinetic chain proximally and distally.
“Foot/ankle” of the UE.
PT’s need to be treating the entire UE, including hand and wrist.
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Thank you for the opportunity to share our clinical pearls with you.
Special Thanks to Megan Dawson and Morgan O’Clair
Questions???
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Reference1. Bisset LM, Collins NJ, Offord SS. Immediate effects of 2 types of braces on pain and grip strenth in
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