1
Q
What is double crush syndrome?
A
- an asymptomatic site of peripheral nerve compression that predisposes that nerve for increased risk of injury at a different location
- debated in the literature as a thing; however a good reminder clinically that there are multiple regions where a nerve may be compressed
2
Q
How long may nonoperative treatment last prior to a surgical intervention being considered for peripheral nerve injury/compression?
A
- 4 months; nerve tissue is slow healing
3
Q
What are general interventions for management of nonoperative nerve disorders?
A
- rest/immobilization w/ splinting (reduce aggravation of tissue)
- modalities (pain control)
- interventions to surrounding structures to reduce potential for tension on the nerve
4
Q
Is nerve gliding appropriate for management of a nerve disorder?
A
- it can be. There is debate on whether it does what it is supposed to do
- Should be considered on an individual basis depending on the injury. Could theoretically be helpful or detrimental depending on the structural situation
5
Q
How quickly do nerves grow?
A
- ~1mm a day or 1 inch a month
6
Q
What is cubital tunnel syndrome?
A
- inflammation of the ulnar nerve as it passes through the medial tunnel of the elbow.
7
Q
What are the sides of the cubital tunnel?
A
- medial epicondyle and olecranon (walls)
- aponeurosis (roof)
- UCL, the joint capsule, and olecranon
8
Q
What are common mechanisms for cubital tunnel syndrome?
A
- traction (throwers; extreme valgus stress on arm)
- longstanding valgus deformity
- sustained flexion positions (long distance cyclists)
9
Q
What is the differential dx for a cubital tunnel syndrome?
A
- cervical radiculopathy
- TOS
10
Q
What are 4 tests with sens/spec data for a cubital tunnel syndrome (ulnar neuritis?
A
- Tinels
- Elbow flexion test: pt flexes elbow past 90* w/ full supination and wrist extension. Hold for 60”.
- pressure provocation test: Apply pressure to cubital tunnel for 30”.
- scratch collapse test: Pt resists shoulder ER B, while therapist scratches in region of cubital tunnel. Potential allodynia results in symptomatic side “collapsing” w/ reflexive inhibition of ER.
- specificity is .98 or higher for all of them
11
Q
How is Tinel’s done for a cubital tunnel syndrome?
A
- tap the ulnar nerve at its most exposed point….see if it reproduces symptoms.
12
Q
How is the elbow flexion test performed?
A
- pt seated. Maximally ER the shoulder, flexes the elbow fully, and extends the wrist. Hold for 1 minute.
- positive with reproduction of symptoms (ulnar nerve)
13
Q
How is the pressure provocation test performed?
A
- Clinician puts pressure on the ulnar nerve at the cubital tunnel, with the pt’s arm in the elbow flexion test position (shoulder ER, elbow flx, wrist ext) for 30 seconds.
- positive with reproduction of symptoms
14
Q
How is the scratch collapse test performed?
A
- pt with arms at sides, elbows bent to 90*, fingers outstretched. Pt resists IR force from therapist at distal forearm. After a few seconds, the therapist releases the force and scratches the affected cubital tunnel, then immediately reapplies the force
- considered positive with momentary loss of ER force on the effected side with reapplication of force by clinician
- not super sensitive, but good specificity
15
Q
A cubital tunnel syndrome is the ___ most common entrapment of the UE.
A
- 2nd
16
Q
What is the success rate in the literature for nonoperative management of mild-moderate ulnar irritation?
A
- 50%
17
Q
What is likely the most effective intervention for mild-moderate ulnar neuritis?
A
- pt education to avoid activities/postures that will aggravate the neuritis (e.g., excessive elbow flexion, or external pressure on the cubital tunnel/nerve)
18
Q
How long is it appropriate to trial a night split for an ulnar neuritis? What elbow position is appropriate?
A
- ~4-6 weeks
- 30-45* flexion and full supination
- most likely for mild symptoms
19
Q
T or F;
Aggressive stretching is important to restore mobility to tissues during management of an ulnar neuritis.
A
- F; shouldn’t be done in early stages
20
Q
Other than splints, what can be used for external management of an ulnar neuritis?
A
- elbow pads, etc to reduce compression at the cubital tunnel
21
Q
What elbow/wrist positions, and activites should be avoided with early management of an ulnar neuritis?
A
- avoid >90* flexion at elbow
- activities that require excessive wrist/finger flexion
- positions of valgus stress at the elbow
22
Q
Is daytime immobilization of the elbow ever appropriate for a cubital tunnel syndrome (ulnar neuritis)?
A
- yes for more moderate/severe presentations
- PROM may be important to avoid development of elbow stiffness
23
Q
What are considerations for execution of strength training with an ulnar neuritis?
A
- avoid terminal end ranges at the elbow
- avoid valgus stress
- avoid aggravation of symptoms
24
Q
Are aggressive soft tissue mobilization techniques appropriate for management of an ulnar neuritis?
A
- they can be, but not appropriate until final stages of rehab, and only if deemed necessary
- can include active release, scar mobilization, nerve gliding
25
What movements are restricted during the first few weeks post-op for ulnar neuritis management?
- wrist extension and forearm supination
| - pts will likely be immobilized for 1-3 weeks; degree of flx will depend on the surgery
26
When can ROM restrictions following post-op ulnar neuritis management be expected to be lifted?
- ~3 weeks post-op, can expect the pt to be allowed full ROM
27
What are expectations for success following surgical management of ulnar neuritis?
- usually successful. Multiple types of procedures, but none is much better or worse than the others
28
What is the most common UE nerve entrapment?
- carpal tunnel syndrome
29
T or F;
Proximal median nerve compression injuries are common.
- F; fairly unlikely that a pt will be having an elbow/forearm entrapment
30
What should be in the differential for a median nerve compression?
- cervical radiculopathy (C5-T1)
- carpal tunnel syndrome
- flexor tendon disorders
31
In an athletic population, is it more likely to see a median nerve compression at the elbow, or the wrist?
- elbow
32
What athletic activities are associated with a pronator syndrome?
- baseball
| - archery
33
What is pronator syndrome?
- compression of the median nerve associated with repeated pronation/supination, typically between the two heads of the pronator teres (elbow)
- usually insidious onset
34
What are the two potential sites of compression for a pronator syndrome?
- median nerve
- primarily between two heads of the pronator teres
- secondarily between the FDS and FDP
35
What is typical presentation for a pronator syndrome?
- vague onset, lack of MOI
- weakness of the thumb, index, and middle fingers
- reproduction of symptoms with compression at the border of the pronator muscle
36
What is the typical delay associated with a diagnosis of pronator syndrome?
- 9-12 months due to the vague presnetation
37
What two tests can help differentiate between a pronator syndrome and a carpal tunnel syndrome?
- Tinel's at the wrist
- prolonged wrist flexion provocation
- both should be negative if it's a pronator syndrome
38
What is initial nonoperative management for a pronator syndrome?
- rest/immobilization as necessary
| - avoid aggravation of symptoms
39
What are the recommended interventions for impaired muscle length for a pronator syndrome? (assuming pronator teres or FDS, as they are sites of entrapment)
- modalities or STM
| - doesn't advocate for stretching...
40
Is surgical management for a pronator syndrome common?
- nope, not common at all.
41
What is anterior interosseous nerve syndrome?
- usually thought of as entrapment of the AIN at the:
- pronator teres, accessory bicipital aponeurosis, and other ones
- current theories include it being the result of an immune mediated inflammatory response
42
What is the standard presentation for an AIN syndrome?
- 8-12 hours of deep forearm pain that resolves, recurring intermittently, and progressively more frequently
- inability to make the "OK" sign
43
How would one differentiate an AIN syndrome from a pronator syndrome?
- should be lack of sensory symptoms with AIN, as well as the specific motor involvement associated with the AIN (FPL, FDP to the middle and index fingers, and pronator quadratus)
44
What is in the differential for AIN syndrome?
- pronator syndrome
- cervical radiculopathy
- brachial neuritis
- Parsonage-Turner syndrome (UE nerve pain, sudden in onset, often involving the shoulder; may follow recent infection)
- FPL rupture
45
Is operative or nonoperative management of AIN syndrome preferred?
- nonoperative
46
What will it look like if a pt has AIN syndrome and tries to do the OK sign?
- will lack DIP flexion at the thumb and index finger; will relatively hyperextend each
47
What is the prevalence of radial n. compression?
- very uncommon
| - more associated with tennis/racquet sports
48
With a radial nerve compression, what positions/activities should be avoided?
- prolonged elbow extension, wrist flexion, and/or pronation
49
What is osteochondritis dessicans of the elbow?
- lateral compression injury of the articular surface of the elbow
- primary mechanisms of injury are repetitive microtrauma combined with vascular susceptibility
- implies bone/cartilage inflammation with potential loose bodies/separation
50
What population is osteochondritis dessicans seen in most often?
- adolescents; 90% male, usually 12-17 yo
- male baseball players
- female gymnasts
51
What bony structure is most often affected by osteochondritis dessicans?
- capitellum
52
What is the typical presentation for osteochondritis dessicans?
- vague, insidious onset lateral elbow pain, often in adolescent males that are very active
- limited ROM into extension, and to a lesser degree, flexion, pronation, and supination
- dull TTP at radiocapitellum
- potential for clicking, popping, snapping in later stages
53
What is standard nonoperative management for osteochondritis dessicans?
- rest, bracing, and avoiding aggravating activities
| - ROM and strengthening of local impairments once pain/inflammation are under control
54
How soon can pts expect to get back to prior levels of activity with an osteochondritis dessicans?
- usually ~ 3 months with return to full activity by 6 months
55
What are indications for operative management of osteochondritis dessicans?
- persistent/worsening symptoms
- symptomatic loose bodies
- articular cartilage fx
56
What is Panner's disease? What demographic is typically affected by it?
- epicondyle apophysitis; degeneration/necrosis in the immature capitellum, followed by regeneration.
- nontraumatic, self-limiting. dx'd through MRI
- children 7-10 yo
57
What does Panner's disease typically present like?
- osteochondritis dessicans.
| - management is fairly similar, but prognosis/timeline is the biggest difference
58
How long can it take for a Panner's disease to resolve? What imaging is used for diagnosis?
- can take up to 3 years
| - dx'd by MRI
59
Is Panner's disease treatable by nonoperative management?
- yes; excellent results reported with nonoperative care
60
What percentage of pts with RA have elbow involvement?
- 50%
61
What is the demographic associated with RA?
- females 35-45yo
62
What are the standard symptoms associated with RA? (4)
- pain
- joint stiffness
- overall fatigue
- weakness associated with deterioration of function
63
Loss of what elbow ROM is assocaited with RA?
- loss of elbow extension
64
T or F;
Large cysts can develop on the elbow with RA. Typically they are benign and don't need operative management.
- T; unless they're interfering with function
65
What is the focus of the acute phase of RA management? How long does it typically last?
- typically lasts 2-4 weeks
| - resolution of local joint pain; splinting, modalities, education on joint protection, gentle ROM therex
66
What are key components in the subacute (and on) phase of RA management?
- gentle stretching
- low load strengthening
- environmental adaptation
- aerobic fitness
67
What are the differences between a primary and secondary OA at the elbow? (demographics, presentation, etc)
- primary is typically male, between the ages of 40-60, with a hx of professional tasks requiring a lot of weight bearing. Onset is insidious.
- secondary should be suspected with anyone under the age of 40. Usually follows trauma or surgery.
- both are characterized by loss of terminal extension
- ulnar neuropathy is present in 26-55% of those presenting for surgical intervention
68
Total elbow arthroplasty has the best outcomes with management of what dx?
- RA
69
T or F;
Postoperative management with PT is uncommon following TEA.
- T, unless there are complications
70
What ROM can be expected following total elbow arthroplasty?
- 15-130*
71
T or F;
There are pretty significant activity limitations following total elbow arthroplasty, that last for life.
- T-ish
- weight-lifting restrictions often of 1kg for multiple lifts and 5kg for a single lift during ADLs
- typically sports and other more intense activities are not recommended by the surgeon
72
What are the 5 "Ps" associated with an acute forearm compartment syndrome?
- pain
- pallor
- passive stretch provoking pain
- paresthesia
- pulselessness
- of note, not all five may be present
73
Can forearm compartment syndrome by aggravated by a chronic condition?
- yes; often thought of as exertional
| - wheelchair athletes, motorcyclists, etc
74
What are the 3 types of olecranon bursitis?
- aseptic; trauma or sustained pressure on bursa
- septic; nearby wound/cellulitis
- chronic; prolonged or repeated pressure on bursa; multiple episodes
75
What are 3 primary outcome measures for the elbow?
- DASH (or QuickDASH)
- American Shoulder and Elbow Surgeon's Elbow Form
- Patient-rated Elbow Evaluation
76
What is a good differentiator for a radial tunnel compression syndrome?
- radial tunnel syndrome is sensory only; should be no motor involvement
77
What is Mill's Test? What should be avoided to prevent confounding findings?
- Mill's test is for a lateral epicondylitis. Pt's elbow is brought into flexion with the wrist in extension and forearm pronated. Looking for reproduction of symptoms.
- avoid shoulder extension to prevent radial n. tension
78
What should be used for test-retest after intervention for a lateral tendinopathy?
- grip strength
OCS prep
flashcards
Decks in class (25)
# Cards
-
Osteoarthritis142
-
Foot and Ankle112
-
Knee meniscal issues36
-
Lateral and anterior knee pain55
-
Knee ligamentous issues132
-
Knee ligament CPG42
-
Knee pain and mobility impairments CPG46
-
Pelvis and SIJ (APTA)85
-
Lumbar spine (APTA)104
-
Shoulder APTA (1)172
-
Shoulder APTA (2)163
-
Shoulder APTA (3)78
-
C-spine APTA109
-
C-spine APTA (2)67
-
Hip APTA104
-
Hip APTA (2)139
-
T-spine APTA69
-
T-spine APTA (2)73
-
Elbow APTA96
-
Elbow APTA (2)114
-
Elbow APTA (3)78
-
Misc Trivia83
-
Wrist and hand (OCS-A summary)53
-
TMJ (OCS-A summary)55
-
Misc Trivia 283
