Evaluation - E/W/H

Question 1

Evaluation - Diagnostic Classification:

• Patho-anatomical = ?
• Movement System = ?
• Treatment Response = ?

Evaluation - E/W/H

Answer 1

Evaluation - Diagnostic Classification:

(a) Patho-anatomical:

• Health conditions are discussed in a manner similar to a physician visit.

(b) Movement System:

• Where impairments or syndromes are listed that impact the musculoskeletal, nervous, integumentary, cardiovascular, pulmonary, or endocrine systems.

(c) Treatment Response:

• Clinical prediction rules and patterned treatments classify the patient.

(d) Notes:

• Generally, the more proximal the condition, the more apt our profession is to discuss that malady in terms of movement system and treatment-based classifications.
• The more distal we get, the more we still use pathoanatomical terms and clinical prediction rules for screening.

Question 2

Evaluation: Personnel

• Who’s envolved = ?

Evaluation - E/W/H

Answer 2

Evaluation: Personnel

(a) Who’s envolved… ?

Question 3

The Patient’s Story:

• Five components to consider = ?

Evaluation - E/W/H

Answer 3

The Patient’s Story - Five components:

(1) Positives:

• Young Age
• Healthy Lifestyle
• No Red Flags
• Decrease Comorbidities
• Decrease Severity
• Decrease Irritability

(2) Impairments:

• Strength
• Mobility
• Coordination
• Muscle Tightness
• Pain Guarding

(3) Chief Complaint:

• Patient’s description of what brought them for therapy.

(4) Treatment:

• Two or three general types of treatment to address your selected impairments.

(5) Participation:

• Patient’s Goal for Therapy

Question 4

Epicondylopathy

• Inner tendon’s three phases = ?
• The outer remains = ?
• What is usually effected more, extensors or flexors = ?

Evaluation - E/W/H

Answer 4

Epicondylopathy:

(a) Inner tendon’s three phases:

(1) Reactive

• 20’s
• Inflammatory
• Increase in proteoglycans

(2) Disrepair

• 30’s
• Separation & type-III collagen
• Neural ingrowth

(3) Degenerative

• 40’s+
• Breakdown
• Cell death

(b) Outer Remains Metabolically Active:

• Focus on the Donut, Not the hole!
• Increase tendon thickness on the outside
• Improve capacity to manage load

(c) Commonly:

• Extensors > Flexors
• Extensor Carpi Radialis Brevis

Question 5

Epicondylopathy:

• Classifications = ?
• Characteristics = ?
• Manual Therapy = ?
• Therapeutic Exercise = ?

Evaluation - E/W/H

Answer 5

Epicondylopathy:

(a) Classifications:

• Epicondylitis
• Epicondylosis
• Epicondylalgia
• Tennis Elbow (Most Common)
• Golfer’s Elbow

(b) Characteristics:

- Pain Pattern

• Localized, Distal Epicondyle

- Risk Factors

• 35-50 Years Old
• Repetitive Movements
• Women > Men

- Observation

• Avoidance of grasping or active wrist flex/ext

- Examination

• Pain: Palpation / contraction
• (+) Cozen, Maudsleys, Mills, or Medial Epicondylitis test
• (-) C Spine, nerve entrapment, & chair push-up test
• Decrease grip strength
• Patient-rated tennis elbow evaluation

(c) Manual Therapy:

- Patient Education:

• Activity reduction
• Ice ( if inflammatory )
• Orthotics
• Wrist extension
• Counterforce

- Joint Mobilization:

• Humeroradial Joint
• PRUJ
• DRUJ

- STM/MFR:

• Cross-friction Massage
• • 1 Direction
• • 2 min light, 2 min heavy
• Extensor Muscles
• • Instrument Assisted

(d) Therapeutic Exercise:

- Motor

• Scapular Strengthening
• Hand Intrinsic Strengthening

- Tendon:

• Pain should not exceed 5/10
• Isometrics
• • If pain reducing, 4-5 sets of 45 sec hold
• Eccentric Training
• • 2 sets of 15, with 2RiR
• • 48 Hour Rest
• Energy Storage
• • Rapid Eccentrics
• Energy Release
• • Rapid Concentrics

- Neurodynamics:

• Radial Nerve Glides

Question 6

Distal Biceps Tear:

• Mechanism of Injury = ?
• Often Preceded by = ?

Evaluation - E/W/H

Answer 6

Distal Biceps Tear:

(a) Mechanism of Injury

• Rapid High Force
• Eccentric Loading
• Flexed and Supinated Forearm

(b) Often Preceded by:

• Prior Degeneration
• Repetitive Pronation

Question 7

Distal Biceps Tear:

• Classification = ?
• Characteristics = ?
• Manual Therapy = ?
• Therapeutic Exercise = ?

Evaluation - E/W/H

Answer 7

Distal Biceps Tear:

(a) Classification:

• Distal biceps tear

(b) Characteristics:

- Pain Pattern

• Localized, Non-Radicular Pain over the Biceps

- Risk Factors

• > 45 Years Old
• Repetitive Pronation
• Smoking
• Heavy Eccentric Loading

- Observation

• Displaced Biceps mmBelly
• Swelling
• Ecchymosis

- Examination

• Pain: Resisted elbow flexion
• Decrease flexion/supination strength
• (+) Biceps Squeeze Test

(c) Manual Therapy

- Patient Education

• Adherence to Protocol
• Importance of Protected Phase

- Joint Mobilization

• Humeroulnar Joint
• Humeroradial Joint
• PRUJ

(d) Therapeutic Exercise:

- Protected Phase

• Orthotic Bracing
• Spot-Treat Movement System

- Progressive Motion Phase

• ROM Exercise
• Stretching

- Strengthening Phase

• Isometric
• Isotonic
• Sport/Work-Specific

Question 8

Ulnar Collateral Ligament - Injury of the Elbow:

• Common mechanisms of injury = ?
• Three bundles = ?
• Muscularly stabilized by = ?

Evaluation - E/W/H

Answer 8

Ulnar Collateral Ligament - Injury of the Elbow:

(a) Mechanism of Injury:

• Repetitive Trauma
• Overhead Athletes

(b) Three Bundles:

(i) Anterior Bundle:

• Anterior (0-60) and Posterior Band (60-120)

(ii) Posterior Bundle:

(iii) Transverse/Oblique Bundle:

(c) Muscularly Stabilized:

• UCL Fails at 260N
• Throwing Generates 290N
• • Flexor Carpi Ulnaris
• • Flexor Digitorum Superficialis

Question 9

Ulnar Collateral Ligament Injury of the Elbow:

• Classification = ?
• Characteristics = ?
• Manual Therapy = ?
• Therapeutic Exercise = ?

Evaluation - E/W/H

Answer 9

Ulnar Collateral Ligament Injury of the Elbow:

(a) Classifications:

• UCL Reconstruction
• Tommy John Surgery

(b) Characteristics:

- Pain Pattern

• Localized, distal epicondyle

- Risk Factors

• Repetitive movements

- Observation

• Decrease throwing velocity

- Examination

• Pain: Palpation
• (+) Moving Valgus Stress Test
• (-) Medial Epicondylitis Testing,

(c) Manual Therapy:

- Patient Education

• Activity Reduction

- Joint Mobilization

• Humeroulnar Joint
• Humeroradial Joint
• PRUJ
• DRUJ
• Shoulder External Rotation
• Scapula
• Thoracic Spine

- STM/MFR

• Cross-friction Massage
• • 1 Direction

(d) Therapeutic Exercise:

- Motor

• Ant Core/Subscap/Grip Strength
• Flexor/Pronator Strength

- Surgical Protocol:

(i) Immediate Motion

• Pain Control
• PROM/AAROM/AROM

(ii) Intermediate

• Resistance Training = Strength/Control
• Mobilization

(iii) Advanced Strengthening

• Progress Resistance
• Power/Endurance
• Plyometrics

(iv) Progressive Return to Activity

- Neurodynamics:

• Ulnar Nerve Glides

Question 10

Lateral Collateral Ligament Injury:

• Mechanisms of injury = ?
• The radius and ulna act as a unit, which results in = ?
• Frequency = ?

Evaluation - E/W/H

Answer 10

Lateral Collateral Ligament Injury:

(a) Mechanism of Injury

• Hyperextension force in olecranon fossa
• Levers trochlea past coronoid process

(b) Typically, Annular Ligament Remains Intact

• Radius and Ulna Act as a Unit
• Results in Posterolateral Instability

(c) Frequency

• Most Common Dislocation in < 10 yo
• 2nd Most Common > 10, After Shoulder

(d) Different From Nursemaid’s Elbow

Question 11

Lateral Collateral Ligament Injury:

• Classifications = ?
• Characteristics = ?
• Manual Therapy = ?
• Therapeutic Exercise = ?

Evaluation - E/W/H

Answer 11

Lateral Collateral Ligament Injury:

(a) Classifications:

• Posterolateral Rotary Instability
• Radial Head Subluxation

(b) Characteristics:

- Pain Pattern

• Localized, Distal Epicondyle
• Reports: Elbow “Giving way”

- Risk Factors

• Hx: Radial Dislocation
• Hx: Lateral Epicondylitis

- Observation

• Apprehension of Supination + Loading

- Examination

• Pain: Palpation
• Decrease in extension ROM
• (+) Chair Push-up Test
• (-) Lateral Epicondylitis Testing

(c) Manual Therapy:

- Patient Education

• Activity Avoidance
• Bracing

- Joint Mobilization

• Humeroradial Joint
• PRUJ
• DRUJ
• Shoulder Internal Rotation

(d) Therapeutic Exercise:

- Motor

• Grip/Extensor Strength

- Surgical Protocol:

(i) Immediate Motion

• Pain Control
• PROM/AAROM/AROM

(ii) Intermediate

• Resistance Training = Strength/Control
• Mobilization

(iii) Advanced Strengthening

• Progress Resistance
• Power/Endurance
• Plyometrics

(iv) Progressive Return to Activity

- Neurodynamics

• Radial Nerve Glides

Question 12

Annular Ligament Injury:

• Mechanisms of injury = ?
• Radial head / annular ligament configuration is more susceptible, when = ?

Evaluation - E/W/H

Answer 12

Annular Ligament Injury:

(a) Mechanism of Injury:

• Longitudinal Pull on the Radius
• Full Extension and Supination

(b) Radial Head/Annular Ligament Configuration

• Children Not as Congruent and Stable as Adults
• Looser and Even More Susceptible After Injury

Question 13

Annular Ligament Injury:

• Classification = ?
• Characteristics = ?
• Manual Therapy = ?
• Therapeutic Exercise = ?

Evaluation - E/W/H

Answer 13

Annular Ligament Injury:

(a) Classifications:

• Annular Ligament Tear
• Nursemaid’s Elbow

(b) Characteristics:

- Pain Pattern

• Localized, Distal Epicondyle

- Risk Factors

• Age 2-4

- Observation

• None

- Examination

• Pain: Palpation/ROM
• Decrease in ROM
• (+) Chair Push-up Test
• (-) Lateral Epicondylitis Testing

(c) Manual Therapy:

- Patient Education

• Referral For Imaging and Potential Relocation

(d) Therapeutic Exercise:

- Motor

• Grip Strength
• Wrist Extension Strength

Question 14

Elbow Arthropathy:

Evaluation - E/W/H

Answer 14

Elbow Arthropathy:

(a) Osteoarthritis:

• Secondary to Prior Trauma
• Chondral Degenerative Process
• Not as Common as other Large Joints

(b) Panner’s Disease:

• Disruption of Blood Supply to the Capitulum
• Repetitive Valgus Stress or Trauma (6-11)
• No Chondral Flaking
• Good Prognosis

(c) Osteochondritis Dissecans:

• Genetic Predisposition to Poor Subchondral Health / Blood Supply
• • Repetitive Valgus Stress or Trauma (10-20+)
• • Chondral Flaking
• • Guarded Prognosis

Question 15

Elbow Arthropathy:

• Classifications = ?
• Characteristics = ?
• Manual Therapy = ?
• Therapeutic Exercise = ?

Evaluation - E/W/H

Answer 15

Elbow Arthropathy:

(a) Classifications:

• Osteoarthritis (OA)
• Osteochondrosis
• Panner’s Disease
• Osteochondritis Dissecans (OCD)

(b) Characteristics:

• Pain Pattern
• Deep in Elbow Joint

- Risk Factors

• Age > 55 (OA)
• Girls > Boys (OA)
• Age 6-11 (Panner’s)
• Boys > Girls (Panner’s/OCD)
• Girls > Boys (OA)
• • Hx: Joint Trauma
• • Hx: Heavy Joint Loading

- Observation

• Swelling
• Nodules (Osteoarthritis)

- Examination

• Pain: ROM
• Decrease in ROM
• Joint Crepitus (OA)
• Loose Bodies (OCD)

(c) Manual Therapy:

- Patient Education

• Joint Protection Principles
• Rest/Immobilization (Panners)
• Anti-inflammatory Diet (OA)
• Ice – Acute | Heat Recurrent
• Referral for Medical Management

- Joint Mobilization

• Humeroulnar Joint I-II
• Humeroradial Joint I-II
• PRUJ I-II
• DRUJ I-II

(d) Therapeutic Exercise:

- Motor

• Daily AROM
• Pain-free Grip and Elbow Strengthening

- Modalities

• Ultrasound = (1 MHz; 1W/cm2 for 5 min)

Question 16

Cubital Tunnel Syndrome:

Evaluation - E/W/H

Answer 16

Cubital Tunnel Syndrome:

(a) Nerve Compression Injury

(i) Medial Intermuscular Septum

(ii) Cubital Tunnel

• Medial Epicondyle of the Humerus
• Olecranon of the Ulna
• Cubital Retinaculum & Flexor Carpi Ulnaris

(b) In Flexion, Olecranon Moves 1.5cm Away:

(i) ‘Roof Collapses’ as Space Becomes Narrow Oval

(ii) Pressure Goes Up Inside Space

• x7 in Full Flexion
• x20 in Full Flexion + Active Ulnar Deviation

(c) Prolonged Exposure:

• Thickening of Epineurium and Perineurium
• Microvascular Proliferation of the Endoneurium

Question 17

Cubital Tunnel Syndrome:

• Classification = ?
• Characteristics = ?
• Manual Therapy = ?
• Therapeutic Exercise = ?

Evaluation - E/W/H

Answer 17

Cubital Tunnel Syndrome:

(a) Classification:

• Ulnar Nerve Entrapment
• “Funny Bone”

(b) Characteristics:

- Pain Pattern

• Radicular Pain and Paresthesia from Medial Elbow to Medial Hand

- Risk Factors

• Prolonged Elbow Flexion
• Work/Sleep (7-20xmmHg)
• UCL Inflammation

- Examination

• (+) Tinel’s Sign
• (+) Elbow Flexion Test
• (-) C Spine, Medial Epicondylitis Testing
• Decrease in Grip Strength
• Wartenberg Sign (↓ Intrinsic)
• Froment Sign (↓ Add Pol)
• Claw Hand

(c) Manual Therapy:

- Patient Education

• Activity Reduction
• Heat
• Night Orthotics

- STM/MFR

• Flexor Carpi Ulnaris
• Cubital Tunnel Retinaculum

(d) Therapeutic Exercise:

- Stretch

• Flexor Carpi Ulnaris

- Neurodynamics

• Ulnar Nerve Glides

Question 18

Elbow Fracture:

• Mechanisms of Injury = ?
• What complications does surgery present = ?

Evaluation - E/W/H

Answer 18

Elbow Fracture:

(a) Mechanism of Injury:

• High-force Impact
• • Fall or Car Accident

(b) Multiple Classification Schemes

• Surgery is Most Common Treatment (ORIF)
• Stiffness is Common
• Early Mobility Helps
• Varus Deformity is Expected

(c) Difficult Surgery:

• Altered Kinematics
• Decreased ROM
• Close Proximity to Neurovascular Structures
• • Iatrogenic Nerve Involvement

Question 19

Elbow (Humerus) Fracture:

• Classification = ?
• Characteristics = ?
• Manual Therapy = ?
• Therapeutic Exercise = ?

Evaluation - E/W/H

Answer 19

Elbow (Humerus) Fracture:

(a) Classification

• Extra-articular (A)
• Articular with Shaft Continuity (B)
• Articular without Shaft Continuity (C)

(b) Characteristics:

- Pain Pattern

• Diffuse Pain

- Risk Factors

• Men aged 12-19
• Women > 80
• Fall History

- Observation

• Swelling
• Obvious Deformity

- Examination:

• (↓) ROM
• Significant Stiffness
• (↓) Grip Strength
• (+) Elbow Extension Test

(c) Manual Therapy:

- Patient Education

• Ice
• Orthotics
• Static Progressive
• Joint Active System (JAS)

- Joint Mobilization

• Humeroulnar Joint
• Humeroradial Joint
• PRUJ
• DRUJ

- STM/MFR

• Biceps
• Triceps
• Forearm Musculature

(d) Therapeutic Exercise

Protocol:
(I) Inflammatory Phase

• 0-2 Weeks
• Manage Pain/Inflammation
• Light ROM

(II) Fibroplastic Phase

• 3-8 Weeks
• Increase ROM
• Begin Light Strengthening

(III) Remodeling Phase

• 2-6 Months
• Progress Strength
• Mobilizations
• Static-Progressive Orthotics

- Neurodynamics:

• Nerve Glides (Check All)

Question 20

Carpal Tunnel Syndrome:

Evaluation - E/W/H

Answer 20

Carpal Tunnel Syndrome:

(a) Most Common UE Nerve Compression

(b) Etiology

• Fractures, Carpal Arthritis, Synovitis
• Forceful Grip with Wrist Flexion (Lumbricals)

(c) Pathogenesis

(i) Extra-neural Compression - Endoneurial Swelling

• 2+ Hours Extra-neural - 24 Hours Endoneurial

(ii) Prolonged Swelling

• Endoneurial Breakdown
• Nerve Fibrosis
• Demyelination
• Wallerian Degeneration

(d) Associated with Double Crush Phenomenon

Question 21

Carpal Tunnel Syndrome:

• Classification = ?
• Characteristics = ?
• Manual Therapy = ?
• Therapeutic Exercise = ?

Evaluation - E/W/H

Answer 21

Carpal Tunnel Syndrome:

(a) Classification:

• Median Neve Entrapment

(b) Characteristics:

- Pain Pattern

• Pain/paresthesia
• Lateral Hand
• Pain Worse at Night

- Risk Factors

• Age > 45, Women > Men
• Diabetes

- Observation

• Flick Sign - Shaking (↓) Sx
• Wrist Ratio > 0.7
• Thenar Atrophy

- Examination

• (+) Phalen’s, Tinel’s, Wainer CPR, Durkan’s (Compression)
• (-) Scaphoid Fx, Finkelstein, TOS, Cervical Spine
• (↓) Grip Strength/Sensation
• (↓) Coordination (Moberg)

(c) Manual Therapy:

- Patient Education

(i) Possible Injection Consult

(ii) Possible Surgical Consult

(iii) Heat

(iv) Activity Modulation

• (↓) Full MCP Flexion and Ulnar Deviation
• Work in 0-45° Pronation
• Work in slight Ext/Ulnar Dev.

(v) Orthotics

• 2 degrees Ext/Ulnar Deviation
• Night, During Heavy Work Activities, or Pregnant (not mouse work)

- STM/MFR

• Flexor Retinaculum
• Medial Arm

(d) Therapeutic Exercise:

- Neurodynamics

• Distal Median Nerve Glides

- Flexibility

• Flexor Retinaculum Stretch
• Hand Intrinsic Stretch
• Finger Flexor Stretch

- Post-Surgical (Only a few visits over 2-3 weeks are needed)

• Activity Avoidance Education
• Light Paper Taping Over the Incision
• Light Isometrics progressing to tendon glides
• Distal Median Nerve Glides

Question 22

Distal Radius Fracture:

• Mechanisms of Injury = ?
• Types of Fracture = ?

Evaluation - E/W/H

Answer 22

Distal Radius Fracture:

(a) Mechanism of Injury

• FOOSH
• Old Age
• Activity (Skateboarding, skiing, snowboarding…etc.,).
• Contact Sports

(b) Type of Fracture

• Extra-articular is Most Common
• Colles’ = Distal Radius Displaces Dorsally
• • Likely to be oversimplified
• • Multitude of potential fracture patterns and classifications
• Smith’s = Distal Radius with Volar Displacement

Question 23

Distal Radius Fracture:

• Classification = ?
• Characteristics = ?
• Manual Therapy = ?
• Therapeutic Exercise = ?

Evaluation - E/W/H

Answer 23

Distal Radius Fracture:

(a) Classification:

(I) Extra-Articular

• Colle’s Fracture (Dorsal)
• Smith’s Fracture (Volar)

(II) Intra-Articular

(b) Characteristics:

- Pain Pattern

• Diffuse Wrist Pain

- Risk Factors

• (>) 50 Years Old
• Fall Risk
• Women > Men

Observation

• Avoidance of grasping or active wrist flex/ext

- S/P Examination

• (↓) ROM
• (↓) Grip/Pinch Strength
• (↓) Push-off Test Strength

(c) Manual Therapy:

- Patient Education

• Ice/Heat
• Orthotics

- Joint Mobilization

• Humeroradial Joint
• PRUJ
• DRUJ
• Radiocarpal Joint
• MCP/IPs

- STM/MFR

• Forearm Musculature

(d) Therapeutic Exercise:

- Protocol

(I) Protective Phase

• 1-6 Weeks
• Wrist Immobilization
• Monitor Pain/CRPS
• Finger/Elbow/Shoulder ROM

(II) Motion Phase

• After Immobilization
• Wrist AROM (Priority: Wrist Ext/Sup/Pro and Finger Flexion)
• Tendon Gliding

(III) Function Phase

• Starts at Bone Healing
• Strength = Isometric - Isotonic
• Mobilization

- Neurodynamics:

• Nerve Glides (Check All)

Question 24

Triangular Fibrocartilage Complex (TFCC) Injury:

• Articular Disc is Mostly = ?
• Mechanisms of Injury = ?
• Causes of degeneration = ?
• Treated with = ?

Evaluation - E/W/H

Answer 24

Triangular Fibrocartilage Complex (TFCC) Injury:

(a) Articular Disc is Mostly Avascular

(b) Mechanism of Injury

• Trauma
• Fall Onto an Outstretched Hand
• Forced Rotation While Gripping

(c) Degeneration

• Wear - Chondromalacia - Puncture - Arthritis
• Secondary to Ulnar Malposition
• Prior Trauma
• Positive Ulnar Variance

(d) Treated With:

• Active Stabilization
• Bracing
• Injection

Question 25

Triangular Fibrocartilage Complex (TFCC) Injury: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*

Answer 25

Triangular Fibrocartilage Complex (TFCC) Injury: (a) **Classification**: * Acute * Degenerative (b) **Characteristics**: **- Pain Pattern** * Localized, Distal Ulna **- Risk Factors** * Hx: Distal Forearm Injury * Ulnar Variance (+)or(-) * Advancing Age * Repetitive Movements **- Observation** * Localized Swelling * Clicking/Crepitus **- Examination** * **Pain**: Palpation/ROM * (+) Ulnomeniscotriquetral Sweep * (↓) Grip Strength (c) **Manual Therapy**: **- Patient Education** * Ice * Orthotics - *Night + Vigorous Activity* * Possible Referral if Bracing/Strength are Unsuccessful - *Injection or Surgery* **- Joint Mobilization** * Humeroradial Joint * PRUJ * DRUJ **- STM/MFR** * Cross-friction Massage - *1 Direction* * ECU + FCU (d) **Therapeutic Exercise**: **- Motor** * Grip Strength * Wrist Strength **- Sensory** * Angle Reproduction - *Laser on a Bat* * Reflex Reactivation - *Lighter Perturbations* **- Neurodynamics** * Ulnar Nerve Glides

Question 26

Stenosing Tendovaginitis: * Mechanisms of Injury = **?** * Pathogenesis = **?** * Common Sites of Pathology = **?** ## Footnote *Evaluation - E/W/H*

Answer 26

Stenosing Tendovaginitis: (a) **Mechanism of Injury** * Trauma and repetitive Stress * Possible Predisposition (b) **Pathogenesis** (**i**) Metaplasia of Collagen and Extracellular Matrix * Limited to No Inflammatory Element (**ii**) Thickening of the Retinaculum * Up to 3-4x its thickness (**iii**) Adhesions Form Between Tendon and Sheath (c) **Common Sites of Pathology** (**i**) De Quervain’s Tenosynovitis * 1st Dorsal Compartment * Abd. Pollicis Longus & Extensor Pollicis Brevis (**ii**) Trigger Finger * A1 Pulley

Question 27

Stenosing Tendovaginitis: * Classifications = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*

Answer 27

Stenosing Tendovaginitis: (a) **Classifications**: * Stenosing Tenosynovitis * De Quervain’s Tenosynovitis * Trigger Finger (b) **Characteristics**: **- Pain Pattern** (**i**) Localized Pain * De Quervain’s: Radial Styloid * Trigger Finger: Pulley **- Risk Factors** * Repetitive /Forceful Jobs * Women > Men **- Observation** * Local Nodule * AROM: Catching/Crepitus **- Examination** * **Pain**: Palpation/AROM * (+) Finkelstein’s * (↓) Strength * (-) Scaphoid Fracture (c) **Manual Therapy**: **- Patient Education** * Activity Avoidance * Ergonomic Modifications * Ice * Ultrasound * Orthotics - *Rigid* * Refer for Injection - *Failing Conservative Care* **- STM/MFR** (**i**) Cross-friction Massage * 2-Direction * 2 min light (**ii**) Involved Musculature (d) **Therapeutic Exercise**: **- Motor** * Grip Strength * Gentile Tendon Glides * Stretching * Strengthen Kinematic Chain

Question 28

Scaphoid Fracture: * Mechanisms of Injury = **?** * Vascular Supply = **?** ## Footnote *Evaluation - E/W/H*

Answer 28

Scaphoid Fracture: (a) **Mechanisms of Injury**: * Most Common Carpal Fracture * Vulnerable Due to 45 Angulation * Compression in Extension & Radial Deviation - Radioscaphocapitate Ligament Fx Waist (70%) (b) **Vascular Supply**: * Most Vascularization at or Distal to Scaphoid Waist * Proximal Pole Supplied by Retrograde Intraosseous Flow/

Question 29

Scaphoid Fracture: * Classifications = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*

Answer 29

Scaphoid Fracture: (a) **Classifications**: * N/A (b) **Characteristics**: **- Pain Pattern** * Localized, Distal Radius **- Risk Factors** * 15-30 Years Old * Men > Women **- Observation** * Focal Swelling **- Examination** * **Pain**: Palpation * (+) Scaphoid Compression * (+) Snuffbox Tenderness * (-) Finkelstein’s Test * (↓) Grip Strength (c) **Manual Therapy**: **- Patient Education** * Screening and Referral * Ice * Orthotics - Thumb Spica (long/short) ***and*** Progressive Orthotics **- Joint Mobilization** * Radiocarpal Distraction * DRUJ * Light Carpal Mobilization * MCP Mobilization * IP Mobilization (d) **Therapeutic Exercise**: **- Protocol**: *Can vary greatly depending on location of fracture and surgical intervention*. (**I**) Protective Phase * 2-4 Weeks * Wrist Immobilization * Monitor Pain/CRPS * Finger/Elbow/Shoulder ROM (**II**) Motion Phase * After Immobilization * Finger/Wrist AROM * Stretching/Tendon Gliding (**III**) Function Phase * Starts at Bone Healing * Strength (Isometric - Isotonic) * Mobilization **- Neurodynamics**: * Median Nerve Glides

Question 30

Ulnar Collateral Ligament Tear of the 1st: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*

Answer 30

Ulnar Collateral Ligament Tear of the 1st: (a) **Classification**: * Skier’s Thumb - Trauma * Gamekeeper’s Thumb - Repetitive Stress (b) **Characteristics**: **- Pain Pattern** * Localized, Medial 1st MCP **- Risk Factors** * Fall Risk **- Observation** * Focal Swelling **- Examination** * **Pain**: Palpation * (+) Ulnar Collateral Ligament Test (c) **Manual Therapy**: **- Patient Education** * Screening and Referral * Ice * Orthotics - Thumb Spica (short) **- Joint Mobilization** * DRUJ * Carpal Mobilization * CMC Mobilization * IP Mobilization (d) **Therapeutic Exercise**: **- Motor** * 2-8 Weeks after Immobilization * Pinch and Grip Strength * Wrist Strength * Stretching **- Neurodynamics** * Median Nerve Glides

Question 31

Metacarpal Fractures: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*

Answer 31

Metacarpal Fractures: (a) **Classification**: * Boxer’s Fracture (b) **Characteristics**: **- Pain Pattern** * Localized, Metacarpal **- Risk Factors** * Age 22-34 * High Force Loading * Men > Women **- Observation** * Focal Swelling * Ecchymosis * Guarded Movement **- Examination** * **Pain**: Palpation/ROM * (↓) Strength (c) **Manual Therapy**: **- Patient Education** * Referral * Ice * Orthotics * + ‘Rehabilitation Ready’ Splinting (MCP Flexion *and* IP Extension) **- Joint Mobilization** * Carpal * MCP * IP **- STM/MFR** * Hand Intrinsics (d) **Therapeutic Exercise**: **- Protocol** (**I**) Protective Phase: * 3-7 Days * Hand Immobilization * Monitor Pain/CRPS * Finger/Elbow/Shoulder ROM (**II**) Motion Phase: * 7-21 Days * Tendon Gliding * Finger/Wrist AROM (**III**) Function Phase: * 4-8 Weeks * Wean from Orthotic * Strength (Isometric - Isotonic) * Aggressive Stretching and Mobilization

Question 32

Dupuytren’s Contracture: * Pathogenesis = **?** * Cord Types = **?** ## Footnote *Evaluation - E/W/H*

Answer 32

Dupuytren’s Contracture: (a) **Pathogenesis**: * Unknown Etiology * Fibromatosis of the Palmar Ligaments and Fascia * Nodule at Distal Wrist Branches Outward * Longitudinal Ligaments Limit Function * + MCP & PIP * + 4th & 5th Digits (b) **Cord Types**: (**i**) Central Cord (Pictured) * Longitudinally Runs Palmar to Flexor Tendons (**ii**) Spiral Cord (Not Pictured) * Runs Laterally and Tethers Neurovascular Bundle (**iii**) Natatory Cord (Not Pictured) * Crosses Metacarpals, Connects Digits

Question 33

Dupuytren’s Contracture: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*

Answer 33

Dupuytren’s Contracture: (a) **Classifications**: * Progressive Fibroplasia * Dupuytren’s Disease * Dupuytren’s Diathesis (More Severe) (b) **Characteristics**: **- Pain Pattern** * Localized, Palm 4th/5th Digits * Catching/Locking **- Risk Factors** * Alcoholism * Diabetes * Smoking * Men > Women * North European Ancestry **- Observation** * Dupuytren’s Nodule * Obvious Deformity **- Examination** * **ROM**: (↓) 4th/5th MCP & IP * (+) Tabletop Test (c) **Manual Therapy**: **- Patient Education** (**i**) Wound Management (**ii**) Orthotics * Extension IP (pre-surgical) * Dorsal Orthosis (I) * Volar Orthosis (II) * Static/Dynamic Ext. (III) **- Joint Mobilization** * Carpal * MCP * IP **- STM/MFR** * Forearm Musculature * Hand Intrinsics (d) **Therapeutic Exercise**: **- Protocol ** (**I**) Wound Management: * Weeks 1-2 * Orthotics * Wound Cleaning * Mid-range ROM (**II**) Motion Phase: * Weeks 2-3 * Progressive ROM * Light Mobilization * Tendon Gliding (**III**) Discharge Phase: * 4-6 * Achieve End-range ROM * Isometric Strength * Wean from Therapy

Question 34

Wrist and Hand Tendon Pathology: * Classifications = **?** * Mallet Characteristics = **?** * Complex Considerations = **?** * Mallet Considerations = **?** ## Footnote *Evaluation - E/W/H*

Answer 34

Wrist and Hand Tendon Pathology: (a) **Classifications**: * Flexor Tendon Laceration * Extensor Tendon Laceration (Mallet Finger) (b) **Mallet Characteristics**: **- Pain Pattern** * Localized, DIP **- Risk Factors** * Impact Sports or Professions **- Observation** * DIP Flexion * PIP Extension * Focal Swelling **- Examination** * **Pain**: Palpation/ROM * (↓) Grip Strength (c) **Complex Considerations**: **- Dependent on Protocol ** * Indiana Hand Protocol Manual **- Protocol Types** * Immobilization * Early Passive Motion * Early Active Motion **- Protocol Dependent on** * Flexor vs Extensor Side * Zone of Injury * Severity of Injury * Surgical Intervention Type * Strength of Suture Used * Patient: * + *Age/Health* * + *Motivation* * + *Socioeconomic Factors* (d) **Mallet Considerations**: **- Mallet Finger Protocol** * 6 weeks Mallet Splint * Light ROM Exercise **- Goal** * Strong Tendon * Glides Freely

Question 35

Complex Regional Pain Syndrome: * Pathogenesis = **?** ## Footnote *Evaluation - E/W/H*

Answer 35

Complex Regional Pain Syndrome: **Pathogenesis**: (**1**) Starts with overt or covert nerve injury (**2**) Genetic predisposition increases: * Pain/Inflammatory Mediators (**3**) Sympatho-afferent Coupling * Nociceptive Fibers Grow Adrenergic Receptors * Stress Response Triggers Pain * Worsened by an Elevated Stress Response (**4**) Decreased Regional Sympathetic Activity * Parasympathetic Dominance * Vasodilation (Red/Warm) (**5**) Upregulation of Sympathetic Receptors * Sympathetic Dominance * Vasoconstriction (Blue/Cold) (**6**) Prolonged Pain Produced Central Sensitization * Changes in Somatosensory Mapping

Question 36

Complex Regional Pain Syndrome: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*

Answer 36

Complex Regional Pain Syndrome: (a) **Classification**: * Type I (Reflex Sympathetic Dystrophy) * Type II ([Causalgia](https://www.uclahealth.org/medical-services/neurosurgery/conditions-treated/causalgia#:~:text=Causalgia%20is%20a%20rare%20pain,cases%20are%20called%20major%20causalgia.)) (b) **Characteristics**: **- Pain Pattern** * Unilateral, Non-dermatomal * Hyperalgesia = *increased pain from a stimulus that usually causes pain*. * Allodynia = *Pain caused by a stimulus that doesn't usually cause pain*. **- Risk Factors** * Advancing Age * Women>Men * Fracture or Crush Injury **- Observation** * Warm/Red - Cold/Blue * Edema/Sweating * Trophic Change **- Examination** * (↓) Range of Motion * Weakness/Dystonia * Anxiety/Depression * Budapest Criteria (3 of 4, 1 at eval) * + Hyperalgesia & Allodynia * + Edema/Sweating * + [Trophic Change](https://www.ncbi.nlm.nih.gov/medgen/866865#:~:text=Definition,from%20HPO%5D) (c) **Manual Therapy**: (**i**) Patient Education * Pain Neuroscience Ed. * Relaxation Exercises * Cardio Program * Ice or Heat (**ii**) Desensitization (**iii**) Retrograde Massage (d) **Therapeutic Exercise**: (**i**) Guided Motor Imagery * Limb Laterality Recognition * + Week 1 * Imagined Movements * + Week 2 (**ii**) Mirror Box Therapy * Active Movements (Week 3-6) * Two Point Discrimination (**iii**) Pain Free AROM (**iv**) Graded Exposure (**v**) Isometric Strengthening (**vi**) Push/Pull Stress Loading (**vii**) Return to Work

Question 37

Wrist and Hand Arthropathy – Osteoarthritis: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*

Answer 37

Wrist and Hand Arthropathy – Osteoarthritis: (a) **Classification**: * Osteoarthritis * Bouchard’s Nodes (PIP) * Heberden’s Nodes (DIP) (b) **Characteristics**: **- Pain Pattern** * Localized, DIPs & 1st CMC **- Risk Factors** * Age > 50 * Women > Men **- Observation** * Crepitus * Swelling **- Examination** * **Pain**: ROM * (↓) Grip Strength * (↓) ROM (c) **Manual Therapy**: **- Patient Education** * Joint Protection Principles * Anti-inflammatory Diet * Ice: Acute * Heat: Recurrent * Orthotics (OtC Support) **- Joint Mobilization** * Carpal I-II * CMC I-II * MCP I-II * IP I-II (d) **Therapeutic Exercise**: **- Pain-Free Motor** * Daily AROM * Hand Intrinsic Strengthening * Isometric Grip Strength * Forearm-Strength

Question 38

Auto-Immune Systemic Inflammation of the Synovium = **?** ## Footnote *Evaluation - E/W/H*

Answer 38

**Rheumatoid Arthritis**: Auto-Immune Systemic Inflammation of the Synovium (a) **Endothelial Inflammation** (b) **Synovial Hyptertrophy and Hyperplasia** * Invades Surrounding Tissue (c) **Massive Inflammatory Response** * Destroys Cartilage - Desiccation and Degradation * Destroys Bone - Elevated Osteoclastic Activity * Distends Capsular - associated Ligaments * Destroys Tendons - Matrix and Venous Disruption, Tears

Question 39

Wrist and Hand Arthropathy – Rheumatoid Arthritis: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*

Answer 39

Wrist and Hand Arthropathy – Rheumatoid Arthritis: (a) **Classification**: (**1**) Rheumatoid Arthritis * (I) Inflammatory * (II) Proliferative * (III) Destructive * (IV) Collapse & Deformity (**2**) Swan Neck Deformity (**3**) Boutonniere Deformity (b) **Characteristics**: **- Pain Pattern** * Diffuse, Fingers/Hands **- Risk Factors** * Family History * Smoking/Periodontitis * Women > Men **- Observation** * (I) Focal Swelling/Heat * (III/IV) Obvious Deformity **- Examination** * (I) Pain: Palpation/ROM * (↓) Grip Strength 2nd to: * + (I/II) Pain * + (III/IV) Deformity * + (III/IV) Tendon Rupture (c) **Manual Therapy**: **- Patient Education** (**.**) Joint Protection Principles (**..**) (I/II) Ice or (III/IV) Heat (**...**) Orthotics * Increasing Support for Each Stage * (I/II) Compression Gloves * (III/IV) Night Orthoses - * (III/IV) Swan Neck * (III/IV) Boutonniere **- STM/MFR** * Spot-treat (Contractures/Tightness) (d) **Therapeutic Exercise**: **- Motor** * Pain-free AROM * Isometric Strengthening * General Conditioning