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EAST CUMBRIA VOCATIONAL
TRAINING SCHEME
Musculoskeletal
Upper Limb
Differential Diagnosis
• Local Problem
• Referred pain
• With paraesthesia/anaesthesia always
check spine
• Local and referred can exist together
Assessment
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Subjective
Objective:
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Range of movement – how far and quality
Soft tissue structures
Nerve
Palpation
• Cyriax Orthopaedic Medicine
Soft Tissue Healing
– Bleeding (injury to max 24 hours)
– Inflammation (essential for tissue repair starts
within 2 hours and can last up to 2 weeks)
– Proliferation (starts 24-48 hours, reaches a
peak at 2-3 weeks when the bulk of the scar
tissue is formed, and lasts several months)
– Remodelling (results in an organised and
functional scar starts about 2 weeks and goes
on for months)
Soft Tissue Injury
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Physiotherapy Treatment
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Frictions
Soft tissue mobilisation
Exercises
Acupuncture
Trigger point release
Electrotherapy
Re-education of movement
Shoulder Joint Complex
Shoulder Joint Complex
• Scapulothoracic Joint
• AC and SC Joints
• Glenohumeral joint – ball and socket, head of
humerus articulates in the glenoid cavity of the
scapula deepened by the glenoid labrum
• Large ROM
• Unstable
• Supported by ligaments and rotator cuff muscles
Posterior Shoulder
Fracture Clavicle
• Fall onto an outstretched arm or shoulder.
• Collision with opponent in a contact sport
• Usually fractured in middle third and is very
painful.
• Treatment: immobilise for pain relief, analgesia,
mobilise and strengthen shoulder
Acromioclavicular Joint
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Fall onto tip of shoulder, elbow or outstretched hand
Pain felt over the tip of the shoulder-epaulette
Tender over the AC Joint
Depending on the severity of the injury a step may be
visible if ligament rupture
Positive Scarf test
Degenerative osteoarthritis especially active sporty
people
Overuse can provoke traumatic arthritis
Treatment: rest, ice use of sling, strapping, analgesia,
exercises, surgery if chronic ?steroid injection
Glenohumeral Joint
Shoulder Dislocation
• Common traumatic injury – usually anterior.
• Arm usually in abduction and lateral rotation
• Posterior 3%(fall onto outstretched hand,
epileptic seizures)
• Causes damage to joint capsule, tendon,
ligament and glenoid labrum. Also nerve,
vascular damage.
• Can be recurrent problem
• Treatment: reduction, immobilise, rehabilitation
• Surgery may be necessary
Posterior Shoulder
Rotator Cuff Injury
• Supraspinatus and infraspinatus most commonly
affected.
• Sports involving shoulder rotation/over arm mvt.
• Acute Tear:
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– sudden powerful action or fall onto outstretched hand
at speed
• – sharp pain.
• - limited mobility
• - inability to abduct shoulder
Rotator Cuff Injury
• Chronic: develops over period of time overuse &
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usually associated with impingement syndrome
Usually found on the dominant side
More often an affliction of the 40+ age group
Pain is worse at night, and can affect sleeping
Gradual worsening of pain, eventually some weakness
Eventually unable to abduct arm (lift out to the side)
without assistance or do any activities with the arm
above the head
Some limitations of other movements depending on the
tendon affected
Impingement Syndrome
generic term rotator cuff lesions
• caused by the rotator cuff and long head of biceps
tendons becoming irritated and inflamed as they pass
under the acromion - Subacromial Space. Tendons
become thickened and are impinged further. Eventually
partial or complete tears can occur
• Can be due to: - bony changes of the acromion
• - poor scapular control, athletes swimming/throwing
• - overuse , cumulative microtrauma
• - muscle imbalance
• Treatment: rest, ice, frictions, nsaids, correct posture,
correct movement pattern in sport, sub acromial steroid
injection, surgery last resort
Adhesive Capsulitis
(Frozen Shoulder)
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40-70 age range.
3% of the population affected
slightly higher incidence in women
five times higher prevalence in diabetics.
Often no significant reason for problem
although it can follow trauma, illness or
surgery
Adhesive Capsulitis
(Frozen Shoulder)
• Painful Stage: short duration suggests shorter
recovery refered pain distally more severe
• ache, pain at night unable to lie on affected side. 2-9
months
• Freezing Stage: Increasing symptoms
• ache, restriction of mobility, problems with daily
activities. 4-12 months
• Thawing Stage:
• Decrease pain and stiffness. 5-12 months.
• Treatment: analgesia, Steroid injections, mobilising
and strengthening exercises, MUA.
Elbow Joint
Arthritis , older patient history of recurrent
joint pain over months or years
• Loose body , typically ‘twinges’ of pain
and locking although tennis elbow can
cause twinge on gripping
• Treatment:refer young person for loose
body surgical removal/manipulate older
analgesia, ?steroid injection,rehabilitation
Tennis Elbow
• Tennis Elbow: overuse or repetitive strain caused
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by repeated extension of the wrist against resistance.
Symptoms:
Pain and weakness on gripping and lifting activities.
Pain on extending the wrist and or fingers against
resistance.
Tenderness on palpation around the lateral epicondyle at
common extensor origin
• Treatment: frictions, ultrasound, exercises
• acupuncture, injection, support, surgery.
Golfers Elbow
• Golfers elbow: overuse injury affecting common
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flexor origin. Common in throwers and golfers.
Symptoms:
pain and weakness on resisted wrist and finger flexion,
forearm pronation.
tenderness on palpation over the common flexor origin
Treatment: as for tennis elbow
Wrist Fracture
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Colles fracture: 25% of all fractures
fall onto outstretched hand,
dinner fork deformity
Smiths fracture:
fall onto flexed wrist or backward fall onto
outstretched hand.
• Rehabilitation: reassurance, mobilisation and
strengthening programme
• Complex Regional Pain Syndrome
Wrist
• Repetitive Strain injuries: occupational – typing, using
computer mouse, manual/production line workers,
cleaners, musicians or sport related - racket sports.
• exacerbated by poor posture, inadequate wrist support
or desk set-up, poor sporting technique or inadequate
equipment.
• Symptoms: Pain, dull ache, throbbing, tingling,
numbness, tightness.
• Treatment: ice, rest, work place assessment, regular
breaks, local treatment of symptoms, steroid inj
Carpal Tunnel Syndrome
• Compression of the median nerve as it passes through
the carpal tunnel. Three times more common in women
and affects dominant hand more commonly
• Causes: pregnancy, hypothyroid, traumatic injury,
overuse, arthritis, use of vibrating equipment.
• Symptoms: ache/pain in wrist, forearm and radiation
into thumb and 2-4 fingers, worse at night, burning and
tingling into same area, weakness of fingers.
Carpal Tunnel Syndrome
• Tests:
• Tinels sign - Tap with two fingers over the palm side of
the wrist - positive if any symptoms are reproduced.
• - Phalens test - Place hands in front at chest height with
the fingers of the two hands touching. Flex the wrists and
put the backs hands together. Hold for a minute.
Symptom reproduction is a positive.
• Treatment: Conservative initially, rest, splint, ice,
medication, stretching and strengthening, injection and
surgery if conservative measures fail .
De Quervian’s Tenosynovitis
• inflammation of the abductor pollicis longus and
extensor pollicis longus tendon sheaths
• Causes: repetitive wrist and hand movements –
production line work, tennis, squash or
badminton canoeing.
• Symptoms: crepitus, local tenderness and swelling
over radial wrist , positive Finkelstein’s test (thumb
flexion, wrist adduction)
• Treatment: rest, splint, physio, injection.
Scaphoid Fracture
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Most frequently injured carpal bone
Fall onto outstretched hand (younger age group)
10-15% not identified on initial Xray
Complications of non union, avascular necrosis
Symptoms: local pain and tenderness in the
anatomical snuff box
• Treatment: as a fracture with immobilisation and
then rehab.
Thumb and Finger Hyperextension
• Hyperextension injury strain of ligaments of the
metacarpo-phalangeal joint or phalangeal joints.
• common in skiing (thumb), contact sports and ball sports
e.g. rugby, goal keeper, basketball and netball
• Symptoms: Pain with thumb extension, in the web of
the thumb when it is moved, swelling over the MCP joint,
laxity and instability in the joint.
• Treatment: RICE, exercises to regain mobility and
strength, may need strapping to return to sport initially
Hand
• Trigger finger/Thumb
• Dupuytrons contracture
• Arthritis in small joints 1st MCP most
commonly
• Treatment : analgesia, steroid injection if
appropriate to trigger finger/joints if
meets criteria refer for surgery
Neck Pain-upper limb symptoms
could be refered
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Red flags :Under 20 or 1st episode over 55
Vertebrobasilar /carotid artery symptoms
Trauma
Malignancy /Osteoporosis history
Constant/unremitting pain /rest pain
Systemically unwell, fever weight loss
Drug use/immunosuppression
Nerve signs in more than one root
History
• Occupation, hobbies,sports
• Age, onset duration,
• Refered arm pain from a disc lesion
usually >35yrs
• Site and spread of pain
• Exacerbating/relieving factors
• Dizziness/drop attacks
• PHx medications
Management
• If no trauma/instability gentle mobilisation,
physio, analgesia , if worsening neurological
symptoms or nerve root pain unresolving after 6
weeks refer neurosurgeon.
• Cervical traction/manipulation should not be
done unless properly trained and
contraindications excluded
• Yellow flags-social problems , mental illness,
gain from medical problems benefits etc
passivity and inactivity, symptoms and signs
don’t fit .
Bibliography
• Turner, Howard., Diagnosis of the Sporting
Shoulder; Sportex Medicine 9, Jan 2001.
• Henry, Gray., Anatomy of The Human
Body.
• Cyriax, J., Textbook of Orthopaedic
Medicine,
• www.electrotherapy.org