OMT for the Upper Extremity: Elbow, Forearm and Wrist · • Know how to diagnose and treat carpal...
Transcript of OMT for the Upper Extremity: Elbow, Forearm and Wrist · • Know how to diagnose and treat carpal...
OMT for the Upper Extremity: Elbow, Forearm and Wrist
Carlton A Richie III, D.O.
Midwestern University
Clinical Associate Professor of OMM
Nathan Nakken, D.O.
Midwestern University
Clinical Assistant Professor of OMM
1
Learning Objectives• Review the anatomy and motions of the upper extremity with emphasis on the elbow, forearm & wrist
• Understand the common somatic dysfunctions of the elbow, forearm and wrist including radial head and carrying angle
• Describe common orthopedic problems of the elbow, forearm, and wrist as well as their mechanism of dysfunction, and treatment options including OMT
• Have an enhanced palpatory sense of the structures
• Diagnose and treat dysfunction in pronation & supination of the elbow joint with muscle energy and counterstrain
• Know provocative test for lateral epicondylitis
• Know how to treat forearm dysfunction with muscle energy
• Know how to diagnose and treat carpal tunnel syndrome using OMT
2
Speaker Disclosures
• We have no disclosures
3
Special Thanks!
4
Shannon Scott, DO FACOFP
Sean Reeder, DO, Associate
Dean
Rich Dobrusin, DO
Lab Outline:
Lab Outline
• Motion Testing
• Sensory Testing
• Provocative Tests
• Muscle Energy of the forearm
• HVLA of the radial head• Counterstrain of the medial/lateral epicondyle
• Flexor Retinaculum Stretch
• Opponens Roll
• Self Stretches
5
Upper Extremity Lecture Outline
Elbow6
Ulnohumeral joint | Elbow1
• This is “the elbow”
• Hinge joint
• Capsule Strong Medially-Laterally Weak A/P
Strengthened by muscle tendons that cross over the elbow
• Ulnar collateral ligament “Primary elbow stabilizer” Injured in repetitive overhead
throwing (i.e. pitching)
7
Radial
collateral lig.
Ulnar
collateral
lig
Joint capsule
Radioulnar joint | Elbow, forearm, wrist1
• Proximal joint
Allows pivoting action
Pronation/supination
A/P glide of the radial head
Flexion – radial head glides Anteriorly
SD
8
Functional Anatomy |Annular Ligament
• Encircles the radial head
• Strong fibers
Continuous with:
Radial collateral ligament
Joint capsule
9
Annular ligament
Olecranon bursa
Olecranon bursitis21
• Basics Inflammation of a bursa
• Tx OMT (structural findings, SCS,
lymphatic tx)
Modify activity (stop leaning on elbow)
Rest
Ice
NSAIDs
Corticosteroid injections (if failed conservative tx)
Bursal excision (last resort) 10
Nursemaid’s ElbowRadial head subluxation
• Basics:
Subluxation of the radial head
Caused by traction
Annular lig. Slides over the radial head
• S/S:
Usu. hold arm against body, pronated, elbow slightly flexed
11Uptodate, Nursemaid Elbow
Treatment for Nurse Maid’s Elbow
• OMT to reduce: Moderate pressure over the radial head
Hyperpronate the wrist
“May repeat up to 2 times (ensure no signs of fx)
This method is more successful than supination method
Alternate: Place thumb over radial head
Supinate
Then flex the affected elbow (quickly)
Lab today Will learn SCS for radial head – good to reduced pain
and swelling after your reduce the subluxed radial head
Tx early to avoid possible fibrosis 12
Anatomy | Muscles13
Elbow Flexors1
• Primary flexor
Brachialis
• Secondary flexor
Biceps
• Innervation
Musculocutaneous n.
14
Brachialis
Biceps
Elbow Extensors1
• Primary Triceps
• Secondary Anconeus
• Innervation Radial n.
15
Triceps
Anconeus
Wrist Extensors1
• Primary
Extensor carpi radialis longus/brevis
Extensor carpi ulnaris
• Innervation
Radial n.
16By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See
"Book" section below)Bartleby.com: Gray's Anatomy, Plate 418, Public Domain,
https://commons.wikimedia.org/w/index.php?curid=527307
Lateral Epicondylitis
• Pain in the upper forearm and elbow
• Ages 30-60s, peak in 40s
• Overuse injury of the forearm muscles in: extension of wrist
supination
• Risk factors: Screwdriver (carpenters, supinator attaches to lateral
epicondyle)
Painting (painters) Plumbers
Racquet sports (poor technique) Direct blow to the lateral elbow
• Symptoms Lifting palm down hurts (forearm extensors)
Patients complain they can’t open doors or start their car without pain.
17
Lateral Epicondylitis• Diagnosis
Have pt grab the back of a chair and try to lift it→ pain at the elbow.
Applying pressure one finger breath below the lateral epicondyle in the Losee position (pt’s elbow flexed to 90 deg then placed across abdomen with palm facing up) will reproduce pain.
18
Elbow
Lateral Epicondylitis Physical Exam
Physical Exam:
• Lifting, especially with the palm
facing down increases the pain;
• Holding lightweight object such as
a cup may be difficult
• Swelling may be present but
minimal (Remember your
palpation of the joint capsule-it is
only palpable if abnormal!)
• Then perform a provocative
test…see figures
Elbow
Lateral Epicondylitis Provocative Test:
• Indication: suspected lateral
epicondylitis (tennis elbow)
• Contraindication: can’t follow
command/ fracture
• Description: with affected elbow
at 180 degrees and shoulder forward
elevated to 90 degrees and wrist at 0
degrees extend the 3rd finger
against operators index finger that
is applying a downward force. A
positive (+) test is one that
reproduces pain in the affected
lateral epicondyle
Elbow
Lateral Epicondylitis Differential Diagnoses (Ddx)
1. Fracture of the radial head
2. Osteoarthritis
3. Osteochondral loose body,
4. Radial nerve irritation in the
upper forearm (fascia, fascia,
fascia!)
5. Elbow synovitis
6. Calcification of the extensor
muscle at the attachment to
the lateral epicondyle
7. Triceps tendonitis.
Treatment of Lateral Epicondylitis
• OMT
• Activity modification Rest
More flexible racquet
Lower string tension
Larger grip
Home exercise—stretch!
• Ice, NSAIDs, PT
• Tennis elbow brace w/activities until pain free
• Steroid oral/injections22
https://www.braceability.com/pro
duCarpal Tunnel
Syndrome/counterforce-tennis-
elbow-brace
Elbow
Lateral Epicondylitis: Treatments
• Relative rest • Eliminate aggravating movements (stop
using your forearm?!)• General stretching & forearm
strengthening exercises • Use of tennis elbow forearm strap during
activities • Osteopathic manipulation • Heat or ice • NSAIDs or oral steroids• Injectable steroid into the “maximum
area of tenderness” • In refractory cases a surgical fasciotomy
and tendon transfer may be required
OMT for Lateral Epicondylitis
• Direct: Myofascial Release
• Indirect: SCS lateral epicondyle/forearm extensors, Myofascial Release
• Lymphatic:
Proximal to distal: thoracic inlet, abdominal diaphragm, eeffleurage of the upper extremity
Arm Shake
• 90-95% respond to conservative treatment (asymptomatic in 3 wks)
24
Golfer’s Elbow- Medial Epicondylitis (less common)
25
Except in Arizona!
Medial Epicondylitis
• Basics
Pain in the forearm flexors and medial epicondyle
Repetitive use injury with flexion of wrist
26
Wrist Flexors1
• Primary
Flexor carpi radialis (median n.)
Flexor carpi ulnaris (ulnar n.)
27
Flexor Carpi
Radialis
Flexor Carpi
Ulnaris
• Primary
Pronator terres
Pronator quadratus
• Secondary
Flexor carpi radialis
• Innervation
Median n.
28
Pronator
terres
Flexor Carpi
Radialis
Pronator
quadratus
Wrist pronators1
Elbow
Counterstrain of Medial and Lateral Elbow:
• Indications: tennis elbow (lateral) golfer’s elbow (medial)
• Contraindications: Fracture in the area used to treat the somatic dysfunction. A torn
ligament if positioning would risk further damage
Technique: indirect
• Medial = at or near the medial epicondyle of the humerus associated with common
flexor tendon and the attachment of the pronator teres muscle.
• Lateral = On the anterolateral aspect of the radial head at the attachment of the
supinator
Lateral Medial
Elbow
Counterstrain of Medial and Lateral Elbow:
1. Radial head/Lateral
Epicondyle-hold in full extension
then fully supinate& abduct
(fig 1)
2. Pronator /Med Epicondyle-
The patient's elbow is flexed, the
wrist is markedly pronated, and
the forearm is slightly adducted
(fig 2)
Fig 1
Fig 2
Forearm31
FOOSH InjuriesPronation- Posterior Radial Head
(dorsal glide)
Supination-Anterior Radial Head
(volar glide)
• Anterior radial head
Decreased posterior glide
32
• Posterior radial head
Decreased anterior glide
Anterior
Posterior
Forearm
Physiology
• The radius and ulna can be thought of conceptually as two cones lying next to each
other but pointing in opposite directions.
This permits supination and pronation as the
radius ROLLS around the ulna.
Anatomy Terms:o Volar refers to the palm
o Dorsal is posterior
o Ventral is anterior
Forearm
Physiology
Date of download: 5/15/2019 Copyright © Wolters Kluwer
From: Upper Extremities
Forearm supination
A.During supination, as the distal radius
moves posteriorly, the radial head
(proximal) glides anteriorly.
B.Reciprocal motion occurs at the proximal
and distal radioulnar joints during
pronation and supination.
Foundations of Osteopathic Medicine: Philosophy,
Science, Clinical Applications, and Research, 4e, 2018
(Illustration by W.A. Kuchera, DO, FAAO, with permission.)
Forearm
Physiology
Date of download: 5/15/2019 Copyright © Wolters Kluwer
Forearm pronation
A.Reciprocal motion occurs at the proximal
and distal radioulnar joints during pronation
and supination.
B.B. During pronation, as the distal radius
moves anteriorly, the radial head (proximal)
glides posteriorly.
(Illustration by W.A. Kuchera, DO, FAAO, with permission.)
Foundations of Osteopathic Medicine: Philosophy,
Science, Clinical Applications, and Research, 4e, 2018
From: Upper Extremities
Forearm
Physiology
• The radius and ulna can be thought of conceptually as two cones lying next to each
other but pointing in opposite directions. This
permits supination and pronation as the
radius ROLLS around the ulna.
Think of the elbow position as a teeter totter
Forearm
Physiology
• Remember WE MUST think in the Anatomic Position for the radial head
Forearm
Motion Testing
• Patient attempts to extend/supinate elbows while maintaining forearms together…this
allows the physician to compare normal from
the dysfunctional side
• See figure (18.65)
Forearm
Muscle Energy of Forearm: Treatment of FOOSH injuries
RESTRICTED SUPINATION (likes to
pronate):
1. Lateral hand stabilizes the flexed elbow (at
90degrees) and monitors the radial head
2. The medial hand supinates the forearm to the
barrier
3. The patient performs 3-5 muscle contractions in the pronation direction for 3-5 seconds each
against resistance offered by the physician’s
medial hand
4. The physician engages a new SUPINATION
barrier after each patient effort
Of note: we all live in a pronation world (e.g. typing)
so the supination restriction is the most common
restriction
Forearm
Muscle Energy of Forearm:Treatment of FOOSH injuries
RESTRICTED PRONATION (likes to
supinate):
1. The lateral hand stabilizes the flexed elbow
(at 90 degrees) and monitors the radial head.
2. The medial hand pronates the forearm to the
barrier.
3. The patient performs 3-5 muscle contractions in the supination direction for 3-5 seconds
each against resistance offered by the
physician’s medial hand.
4. The physician engages a new PRONATION
barrier after each patient effort.
Forearm
Muscle Energy of Forearm:Treatment of FOOSH injuries
RESTRICTEDEXTENSION (likes
to flex):
1. Patient sitting on table facing the
physician
2. Doctor’s medial hand grasps the distal
supinated forearm with the lateral
hand stabilizing the elbow.
3. The patient’s elbow extension barrier is
engaged.
4. The patient then performs a series of 3-
5 muscle contractions in the flexion
direction 3-5 seconds each against the
doctor’s resistance
5. The goal is to get to 180 degrees or
equal to the unaffected side when
complete
Forearm
HVLA of Radial Head:
• Remember HVLA is a direct “into the barrier
technique”
→If the radial head is anterior we must drive it
posterior
→If the radial head is posterior we must drive it
anterior
• Indication: supinated or pronated forearm
• Contraindication: radial head fracture Joint
hypermobility Local metastasis Ligament
disruption
• Category = direct
• →Motion test both before and after each
technique
Forearm
HVLA of Posterior Radial Head
Treatment of FOOSH injuries
HVLA for Restricted Supination
(Posterior or Dorsal Radial Head)-elbow likes to pronate
= most common!!!
Technique:
1. Operator stands in front of patient grasping proximal forearm with index
finger of lateral hand overlying posterior (dorsal) aspect of radial head
(fig 18.67)
2. The operator then engages the barrier of extension, supination, and slight
adduction.
3. The operator then thrusts in an anterior(ventral) direction (fig 18.68).
Forearm
HVLA of Anterior Radial Head
Treatment of FOOSH injuries
HLVA for Restricted Pronation = likes to supinate
(Anterior or Volar Radial Head)
Technique:1. The operator pronates and flexes the patient’s forearm while the
thumb holds the radial head posteriorly (in a dorsal position)
(fig 18.69 then fig 18.70)
2. When barrier is engaged, an increasing elbow flexion thrust is
performed.
What is it?
45
Case:• A 35-year-old competitive weightlifter presents with exercise
induced pain, and tightness in the right forearm that begins 20-30 minutes after heavy lifting. The pain usually resolves within 15-30 minutes of leaving the gym. Physical exam reveals tenderness to palpation over all the musculature of the anterior forearm. What is the best diagnosis?
a. Carpal tunnel syndromeb. Exertional compartment syndrome
c. FOOSH injury
d. Medial epicondylitise. TFCC injury
f. Ulnar nerve entrapment
46
Case:• A 35-year-old competitive weightlifter presents with exercise induced pain, and
tightness in the right forearm that begins 20-30 minutes after heavy lifting. The pain usually resolves within 15-30 minutes of leaving the gym. Physical exam reveals tenderness to palpation overall the musculature of the anterior forearm. What is the best diagnosis?
a. Carpal tunnel syndrome (pain/paresthesias of the first 3.5 digits of the hand)b. Exertional compartment syndrome (pain out of proportion, pain with passive
movement, paralysis, paresthesia or numbness, pulselessness or pallor)c. FOOSH injury (no h/o fall on an outstretched hand)
d. Medial epicondylitis (good thought, forearm flexors attach here, and pain can radiate down the forearm, additionally workouts can cause repetitive use injuries, but no mention of any pain over the epicondyle)
e. TFCC injury (pain on the medial aspect ulnar side of the wrist)f. Ulnar nerve entrapment (pain/numbness on the 1.5 digits (ulnar side), claw hand,
weakness in grip strength, inability to make a fist)
47
Compartment Syndrome21
• Symptoms (6 P’s): Pain out of proportion Pressure (muscle tightness)
Paresthesia or numbness Pulselessness
Pallor Paralysis
• Diagnosis Compartment pressure >30-40
mmHg
• Tx Urgent fasciotomy to prevent muscle
ischemia and rhabdomyolysis
48
https://www.youtube.com/watch?v=Q5Rrch-0TBA
Volkmann's Contracture
• Basics Permanent flexion contracture
Caused by ischemia often secondary to increased compartment pressure
Any of the elbow or upper arm fx can cause this
• Tx Emergency
Restore blood flow
Reduce compartment pressure
49
Carrying Angle
• F > M Men 5°, females 10-12°
• Increased carrying angle seen in: Females
Obesity
Trauma
Chronic Somatic Dysfunction
• Symptoms1: Medial/Lateral epicondyle pain (confused with
med/lateral epicondylitis)
Wrist pain
Forearm tightness
• Increased carrying angle = increased risk of ulnar nerve neuropathy.14
50
Functional Anatomy | Carrying Angle
Increased Decreased
51
Olecranon moves
medially- adduction
Distal Ulnar & Wrist -
abduction
Olecranon moves
laterally - abduction
Distal Ulnar & Wrist -
adduction
Wrist52
Radiocarpal joint | wrist1
• True wrist joint:
Carpal bones
Radius
Articular disc
• Motions
Abduction/adduction
Flexion/extension
Combined = circumduction
53
Smith’s/Colles’ fracture21,12
• Basics Fx distal radius
Most common fx in adults (1.5% of all ED visit) Common fx with osteoporosis
Typically caused by FOOSH
Colles’ fx = dorsal displacement
Smith’s fx = palmar displacement
• Diagnosis “Dinner fork" deformity
Wrist x-ray A/P, lateral and oblique views
• Tx Nondisplaced - immobilization in a splint or cast
Displaced - closed reduction and possible surgical fixation
OMT distal to the site of fx to: Reduce swelling (lymphatic tx)
Balance innervation to the arm (T1-4) 54
Intercarpal joints1
• Synovial joints
• Mnemonic: Sally Left The Party To Take Cathy Home Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate
55
Nerves and Entrapments56
Brachial Plexus
• C5-C8 and T1
• Osteopathic
considerations:
Scalenes
Clavicle
1st rib
Pec Minor
• By Gray - Gray's
Anatomy, Public
Domain,
https://commons.wikime
dia.org/w/index.php?cur
id=4245589
57
By Gray - Gray's Anatomy, Public Domain, https://commons.wikimedia.org/w/index.php?curid=4245589
DTRs
Biceps (C5)
Brachioradialis (C6)
Triceps (C7)
58
Sensation | Dermatomes of the UE
• Lateral arm (C5)
• Lateral forearm (C6)
• Index and middle finger (C7)
• Medial forearm (C8)
• Medial arm (T1)
• Axilla (T2)
59
Nerve Entrapments1
• Ulnar = Cubital
tunnel/Guyon's canal
• Radial = Radial tunnel syndrome/Posterior
interosseous syndrome
• Median = carpal tunnel syndrome/pronator
syndrome
60
Case:
• 21 y.o. male complains of medial L elbow pain. He sustained an injury to the L elbow 6 weeks ago after falling off of his motorcycle. X-rays in the ER were negative for fracture. Wrist flexion draws the hand laterally. There is difficulty making a fist due to paralysis of most intrinsic hand muscles. Flexing the 4th and 5th digit is difficult causing a claw hand appearance. There is loss of sensation to those digits on the palmar aspect. What is the best diagnosis?
A. FOOSH Injury B. carpal Tunnel syndrome
C. Ulnar nerve entrapment D. TFCC injury
E. Increased carrying angle61
Case:• 21 y.o. male complains of medial L elbow pain. He
sustained an injury to the L elbow 6 weeks ago after falling off of his motorcycle. X-rays in the ER were negative for fracture. Wrist flexion draws the hand laterally. There is difficulty making a fist due to paralysis of most intrinsic hand muscles. Flexing the 4th and 5th digit is difficult causing a claw hand appearance. There is loss of sensation to those digits on the palmar aspect. What is the best diagnosis?
A. FOOSH Injury (probably did have a FOOSH, but what is causing all the ulnar nerve dysfunction – medial elbow not near radial head)
B. Carpal tunnel syndrome (Numbness of 3.5 digits, median not ulnar nerve)
C. Ulnar nerve entrapment (lateral deviation- ulnar nerve runs flexor carpi radialis, paralysis of intrinsic muscles –ulnar n. innervates the lumbricals, claw hand – flexor digitorum profundus gets innervation from median as well as ulnar nerve)
D. TFCC injury (pain on the medial aspect of the wrist, fall on an extended pronated wrist)
E. Increased carrying angle (medial glide of the olecranon, adduction of the elbow with abduction of the wrist and ulna)
62
Ulnar Nerve | Cubital tunnel syndrome1
• Basics Compression at the elbow =
cubital tunnel
• Symptoms Ache medial elbow
May radiate to forearm and ulnar 1.5 digits
• Diagnosis Pain with tapping the medial
elbow
Pain with prolonged flexion
Hypothenar atrophy (ulnar) Grip weakness (interossei)
Claw hand 63
Ulnar Nerve Entrapment | Guyon’s canal
64
Ulnar nerve palsy—
(clawhand)
The shaded areas represent
the usual distribution of
anesthesia.
Handlebar neuropathy
Treatment• OMT
• Activity modification: Stop resting your medial
elbow on the desk
• NSAIDs
• Brace
• Elbow pad
• Surgery: Ulnar nerve transposition
65
Radial Nerve | Radial Tunnel Syndrome1,12,
• Basics Compression of deep branch of
radial nerve as it enters the supinator
• Symptoms Pain like lateral epicondylitis
Often misdiagnosed Epicondylitis that doesn’t get
better
• Diagnosis Forced flexion of 3rd digit
against resistance = Radial tunnel syndrome12
66
Median Nerve | Pronator Syndrome1
• Basics Proximal compression
As passes through the pronator terres m.
• Symptoms Pain in the prox. forearm
• Diagnosis Sensory changes in first 3.5 digits
Pain worse with pronation against resistance
67https://scarysymptoms.com/2015/07/what-is-pronator-syndrome-causes/
Case: • A 39 y/o female card dealer comes to your office with complaints of
nocturnal bilateral hand paranesthesia and several month history of slow onset fatigue. Eating and sleeping habits have been consistent with hrs of sleep per night. On physical exam you note mild thenar wasting. Tapping over the transverse carpal ligament reproduces her symptoms. Blood work comes back 2 days later with the following results: WBC 3.9, Hg 12.2, urine hCG neg, TSH 24 mU/L. What would be the best referral for this patient?
a. Endocrinology
b. Hematology
c. OB/Gynd. Orthopedics
e. Sleep medicine
68
Case:• A 39 y/o female card dealer comes to your office with complaints of
nocturnal bilateral hand paranesthesia and several month history of slow onset fatigue. Eating and sleeping habits have been consistent with hrs of sleep per night. On physical exam you note mild thenar wasting. Tapping over the transverse carpal ligament reproduces her symptoms. Blood work comes back 2 days later with the following results: WBC 3.9, Hg 12.2, urine hCG neg, TSH 24 mU/L. What would be the best referral for this patient?
a. Endocrinology
b. Hematology
c. OB/Gynd. Orthopedics
e. Sleep medicine
69
So what was going on with this patient?
• Neuropathy secondary to Hypothyroidism
• Did she have Carpal Tunnel Syndrome?
Probably on the R, but note it did not stay better with surgery.
• MORAL of the story:
Treat the PATIENT, not symptoms!
70
Median Nerve | carpal Tunnel Syndrome1
71
Ap
plied
An
atom
y of th
e wrist, T
hum
b, and
Han
d, 108
Carpal Glide1
• When the wrist extends →
Carpal bones glide anteriorly (ventrally displaced)
Can narrow carpal tunnel
Just the opposite with Flexion SD
• FOOSH injuries (are wrist
extension injuries)
Expect to find ventrally displaced carpal bones
Triquetral
72
Carpal Tunnel Syndrome1
• Basics 25.6 cases/200,000 work hours
Carpal Tunnel Syndrome affects 10% of all workers
• Symptoms Pain refers to forearm, neck
Worse at night
Flick sign
• Diagnosis Weakness/atrophy of thenar?
(late sign)
EMG (gold standard)
Osteopathic considerations Pt may have extended wrist
somatic dysfunction
Resulting in anterior glide of the carpal bones (carpal bones prefer ventral glide)
Commonly will have Flexion somatic dysfunction of the wrist
Tight forearm flexors
73
Wrist
Anatomy
carpal Tunnel Syndrome
• Symptoms15: Late signs:
weakness, atrophy of the thenar eminence Weakness with
thumb abduction (opposable thumb)
Recurrent branch of the median nerve
75
Causes of Carpal Tunnel SyndromeCommon15:
1. Pregnancy2. With repetitive wrist
motions3. Diabetes4. Rheumatoid Arthritis5. There is also familial carpal
tunnel syndrome6. Thickened flexor
retinaculum7. Ganglion cyst or mass
compressing the nerve
Less common15:
1. Acromegaly 2. localized amyloidosis3. Chronic renal failure4. Leukemia5. Hypothyroidism6. Hyperparathyroidism
76
Functional Anatomy | Median Nerve
77
Median Nerve16:-C6-T1
-Innervates the flexors and pronators
-Note the palmaris Longus tendon over the top
Flexor Retinaculum (FR)↑ Fluid→ swelling→
FR may eventually
scar and thicken
Carpal Tunnel
Provocative Tests for Carpal Tunnel:
3 Provocative Tests:
1. Tinel’s
2. Phalen’s & reverse Phalen’s
3. Carpal tunnel Compression Test
Indication: suspected carpal tunnel
syndrome
Contraindication: absence of tissue
integrity (open wound/fracture/recent
surgery/crush injury)
Technique: provocative
Carpal Tunnel
Provocative Tests
Tinel Sign: With your index finger, strike the median nerve where it passes through
the carpal tunnel, under the flexor retinaculum and volar carpal ligaments. A tingling
sensation radiating from the wrist to the hand along the median nerve distribution is a
positive Tinel’s sign, indicative of carpal tunnel syndrome.
median nerve distribution is a positive Tinel’s sign, indicative of carpal tunnel syndrome.
Carpal Tunnel
Provocative Tests
• Phalen’s: The symptoms of carpal tunnel
syndrome(Carpal Tunnel Syndrome) are
reproduced by having the patient hold his
wrists in maximum flexion against each other
for upwards of one minute
• Reverse Phalen’s: The symptoms of Carpal
Tunnel Syndrome are reproduced by having
the patient hold their wrists in maximum
extension (praying hands) for up to one
minute. This test could be helpful in
determining the degree of Carpal TunnelSyndrome.
Carpal Tunnel
Provocative Tests:
Median Nerve Compression
(Durkan's) Test
In this test the examiner presses firmly with the
thumb over the space between the flexor carpi
radialis and palmaris longus tendons at the distal
flexion crease. This is the point where the median
nerve enters the carpal tunnel.
-compression is held upwards of 1 minute
-a positive test is one where neurologic
symptoms occur in the median n. distribution
-this is the most sensitive of all tests for Carpal
Tunnel Syndrome
Treatment of carpal Tunnel Syndrome
• Ergonomics Modify activities
Wrist splint 2-6 wks15
• +/- NSAIDs
• OMT Treat cervical
Thoracic
Scalenes
1st rib
Clavicle
Pec minor
Transverse carpal ligament
Carpal bones
• Home stretches
• If not improving: Corticosteroid injection
Surgical consultation If weakness, or thenar muscle atrophy
82
Osteopathic Considerations in Carpal Tunnel Syndrome
• Carpal Tunnel Syndrome is related to forearm flexor hypertonicity17
• SCM spasm causes forearm flexor hypertonicity17
• Scalene Reflex Pressure on the transverse carpal
ligaments in goats showed firing of the scalenes on EMG20
40 mmHg fired ipsilateral scalene 100 mmHg fired the contralateral
scalene too
83
Scalene pain patterns, Myers, 4618
Osteopathic considerations in treatment1
• Carpal bones Ventrally displaced carpal
bones
• Transverse carpal ligament Still’s technique of the wrist
and direct carpal ligament release (lab today)
• Double crush Experiment on dog sciatic n.
did not show decrease in nerve conduction. Needed two points of nerve impingement23-24
Scalenes
Clavicle
1st rib
Pec minor
• Fascia of the forearm Remove restrictions on the
median n.
84
OMT for Carpal Tunnel Syndrome | Balance sympathetics1
• Sympathetics, fascia and blood flow Abramson et.al. showed ↓
blood supply to a nerve will ↓ conduction velocity25
• Internal rotation of the temporal bones ↑ sympathetic tone
If found treat the temporal bones
• Upper thoracics Larson added that upper
thoracic lesions alter the vasomotor tone to the UE26
Also ribs
This will balance sympathetic tone: Improve blood flow
Increase nerve function
↓ lymph/venous congestion
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OMT for Carpal Tunnel Syndrome | Decrease congestion1
• Venous/Lymph drainage
Check fascial restrictions to lymph/venous drainage. Sunderland showed lymph and venous congestion contribute to Carpal Tunnel Syndrome28
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OMT for Carpal Tunnel Syndrome | Tx the C-spine1
• C-spine
Hurst et. Al showed a relationship between cervical spine arthritis and b/l Carpal Tunnel Syndrome27
Brachial plexus
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Wrist
Flexor Retinaculum Stretch :
“A.T. Still’s Wrist Technique”
Indication: carpal tunnel syndrome
Contraindication: fracture can’t follow commands,
pain in firing muscles
Technique: direct
Wrist
Flexor Retinaculum Stretch:
• This technique is intended to stretch the flexor tendons of the wrist, to stretch the Flexor Retinaculum, causing a decreased
pressure on the contents of the carpal tunnel. The Flexor
Retinaculum Stretch is highly useful for treating both carpal
tunnel and general wrist motion restrictions.
Technique
• Patient position: seated on the table
• Physician position: standing facing the patient
A. The physician interlaces his or her fingers of both hands and encircles
the patient’s wrist. The physician’s thenar eminence should contact the
patient’s wrist over the Flexor Retinaculum (picture A ).
B. As firm compression is provided by the physician, the patient actively
opens and closes hand 5-10 times (picture B). This results in
distraction. Release and retest
A
B
Wrist
Opponen’s Roll: aka “Sucher Technique”
• Indication: carpal tunnel syndrome
and desire to stretch the transverse
carpal ligament
• Contraindication: severe pain with
trying to perform procedure
• Technique: direct
Wrist
Opponen’s Roll:
• This maneuver stretches the muscles and the ligamentous attachments of the wrist, which releases pressure on the
Median nerve.
Technique:
• Patient Position: Seated on the table.
• Physician Position: Standing facing the patient
1. The patient’s hand is held palmar side up.
2. Grasp the patient’s hand by placing your thumbs over the hypothenar and thenar eminencies.
3. Simultaneously, abduct, extend and laterally rotate
(supinate) the thumb, while adducting, extending and
internally rotating (pronate) the fifth digit along the axis of
the first metacarpal bone. Begin gently and increase pressure to patient’s tolerance.
4. An alternative hold for better leverage involves the physician
lacing his or her fifth digits in the patient’s first and fourth
web spaces with thumbs over the hypothenar and thenar
eminences.
Wrist
Self Stretches for Carpal Tunnel Syndrome:
Extension-Dorsiflexion stretch
Technique:
• Patient position: standing, with side to be treated
next to wall but far enough away to allow full elbow
extension.
1. Place your hand flat against a wall with fingers
pointing up and elbow fully extended….forearm is
PRONATED
2. Lean into the wall, causing extension across theflexor retinaculum.
3. Hold for 5 seconds, relax, then repeat.
Technique:
• Patient position: Same as above for last stretch
1. Same stretch as above except this time fingers point
down…forearm is SUPINATED
Wrist
Self Stretches for Carpal Tunnel Syndrome:
Flexion-Palmar Flexion stretch
Technique:
• Patient position: Same as for
above stretch
1. Place the back of your hand, fingers
pointing up, flat on the wall. Make
sure elbow is fully
extended…SUPINATED forearm
2. Lean into the wall, causing a
flexion stretch across the flexor
retinaculum.
3. Hold for 5 seconds, relax and
repeat.
94
Is there evidence OMT helps with carpal tunnel syndrome?
• Ramey, KA “MRI assessment of changes in swelling of wrist structures following OMT in patients with carpal tunnel syndrome” AAO Journal 1999, 2 (Vol 9) 25-31
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95
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96
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97
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