BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND THERAPEUTIC BODYWORK Musculoskeletal Anatomy & Kinesiology UPPER EXTREMITY ASSESSMENT

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1 BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND THERAPEUTIC BODYWORK Musculoskeletal Anatomy & Kinesiology UPPER EXTREMITY ASSESSMENT MSAK201-II Session 8 LEARNING OBJECTIVES: By the end of this session, the student will be expected to: 1. Apply all review material from MSAK 101 and Identify bony landmarks and muscles around the elbow, wrist and hand 3. Measure and identify normal and abnormal elbow and wrist range of motion 4. Perform tests to identify normal and abnormal strength and length of the muscles of the elbow, wrist, and hand. 5. Demonstrate Elbow, Wrist, and Hand Orthopedic Exams and discuss their implications. 6. Critically assess the Elbow, Wrist, and Hand of a client in preparation for soft tissue treatment. 7. Palpate musculature of Upper Extremity. 8. Document assessment findings in SOAP format. 9. Discuss pathology of the Elbow, Wrist and Hand. 10. Describe the course of the three major nerves of the forearm including entrapment points. Equipment: 1. Goniometer 2. Marking pencil Procedure: 1. While your subject is sitting and the forearm and hand is prone or supine on the exam table, find and mark the following structures: Medial and lateral epicondyles of humerus Olecranon and olecranon fossa Radial head Ulnar nerve Cubital fossa Biceps tendon Coronoid process Styloid process of the ulna Styloid process of the radius Snuff box (Extensor pollicis longus and Extensor pollicis brevis) 8 carpal bones (4 proximal row, 4 distal row) 5 metacarpals 14 phalanges Determine the approximate location of the Carpal Tunnel 11/11 Blue Sky School of Professional Massage and Therapeutic Bodywork 1

2 2. Measure the range of motion of the elbow and wrist by using a goniometer: 3. Measure the carrying angle of your client. Ask your subject to pick up a heavy book bag and hold it at his/her side in anatomical position. Bisect the arm and forearm with each arm of the goniometer, and measure the angle of the mid-line of forearm with respect to the mid-line of the arm. a. Normal angle is 5-15 degrees. 4. Review and palpate the origin, insertion, and function of muscles of elbow and wrist. 5. Perform the muscle strength tests of the elbow and wrist: a. Elbow Flexion Client sits with the arm at the side, the elbow slightly flexed and the forearm supinated. Therapist stabilizes client s arm by grasping it with one hand. Client is instructed to flex elbow through its ROM against resistance applied by therapist. If biceps and brachialis are weak, the client will pronate forearm before flexing the elbow. b. Elbow Extension Seated client. Therapist fixes the patients arm as described for flexion and instructs client to move elbow through ROM while providing resistance. c. Supination The examiner stabilizes and supports the elbow at the side of the client. The thenar eminence of the examiner s resisting hand is placed on the dorsal surface of the client s hand and wrist. The client begins from a position of pronation, and as the arm is moved into supination, the resistance is gradually increased. d. Pronation Therapist s resisting hand is adjusted so that the thenar eminence presses against the palmer surface of hand. As client moves into pronation, resistance is increased. e. Wrist Flexion Client flexes wrist against resistance provided by fingertips of therapist placed on the client s palm. Flexor carpi radialis muscle is tested when examiner provides resistance on palmar side of base of second metacarpal bone in extension and ulnar deviation. Flexor carpi ulnaris is tested when examiner applies resistance on palmar side of base of fifth metacarpal bone in extension and radial deviation. f. Wrist Extension Client extends wrist against resistance applied by examiner to dorsal surface of the client s metacarpals. For testing the extensor Capri radialis longus and brevis muscles, resistance is applied by the examiner to the dorsal surface of the client s second and third metacarpal bones in the directions of flexion and ulnar deviation. For testing the extensor carpi ulnaris muscles, resistance is applied to the dorsal surface of the fifth metacarpal bone in the directions of flexion and radial deviation. 11/11 Blue Sky School of Professional Massage and Therapeutic Bodywork 1

3 NERVE ENTRAPMENT AND OTHER PATHOLOGY 1. Lateral Epicondylitis (AKA Tennis Elbow) a. Pathology: An inflammation or degeneration of the extensor tendons due to overuse or repetitive injury of wrist muscles. It can also be caused by direct injury to the lateral epicondyle. Caused by activities that stress wrist extension and supination. Most common overuse syndrome of the elbow. b. Symptoms: Inflamed, swollen, painful lateral epicondyle. Tender to the touch. Pain often worsens during wrist extension activity and slowly improves with rest. c. Treatment: RICE. Assess wrist ROM, length of wrist extensors. Cozen s or Mill s test may be positive. Palpate elbow extensors and treat as appropriate in the subacute stage. 1) Cozen s Test Assessment for Lateral Epicondylitis Client clenches a fist tightly, extends it, and maintains a pronated position. The examiner, while grasping the client s lower forearm, applies a flexing force to the client s wrist. The test is positive if it reproduces acute pain in the region of the lateral epicondyle. 2) Mill s Test Assessment for Lateral Epicondylitis The client s forearm, fingers, and wrist are passively flexed. The forearm is then pronated and extended. The test is positive if elbow pain increases. 2. Medial Epicondylitis (AKA Golfer s Elbow) a. Pathology: An inflammation or degeneration of the flexor tendons or pronator teres. Caused by activities that stress wrist flexion and pronation. Most common cause of medial elbow pain. Ulnar nerve compression occurs in up to 50% of all presentations of ME. b. Symptoms: Inflamed, swollen, painful medial epicondyle. Tender to the touch. Pain can be reproduced with resisted pronation. Elbow ROM usually within normal limits. c. Treatment: RICE. Massage is appropriate in the subacute stage. 1) Golfer s Elbow Test Assessment for Medial Epicondylitis Client s elbow is flexed slightly and the hand is supinated. The client flexes the wrist against resistance. Medial epicondyle pain suggests medial epicondylitis. This test is a reverse procedure of Cozen s test. 11/11 Blue Sky School of Professional Massage and Therapeutic Bodywork 2

4 3. Radial Nerve Entrapment a. Pathology: The Radial nerve branches from the brachial plexus, travels between the lateral and medial heads of the Triceps, and emerges from the posterior aspect of the humerus between the brachialis and brachioradialis above the elbow. It leaves the extensor compartment to travel anterior to the lateral epicondyle just under brachioradialis. It travels within supinator to emerge in distal dorsal aspect of forearm. b. Symptoms: Entrapment symptoms include pain in upper extensor forearm, tingling or numbness in the dorsum of hand and weakening of extension of fingers, thumb or wrist. c. Treatment: Assess and treat medial and lateral heads of Triceps and Supinator. Utilize Tinel s sign and if neuritis is suspected, a referral may be necessary. 1) Tinel's Sign of the Elbow - Assessment for Radial Neuropathy Therapist taps the groove between the olecranon process and lateral epicondyle. Hypersensitivity or referred pain indicates neuritis of the radial nerve and a referral may be necessary. 4. Median Nerve Entrapment a. Pathology: Median nerve branches off brachial plexus and travels lateral to brachial artery to mid humerus. At this level, the median nerve crosses over the brachial artery to lie in a more medial anatomic position. It passes between the brachialis and biceps, travels across antecubital fossa, and between the two heads of pronator teres. It then passes between flexor digitorum superficialis and profundus to enter the carpal tunnel. 1) Pronator syndrome - Entrapment between the two heads of pronator teres OR between flexor digitorum superficialis and profundus. 2) Carpal Tunnel Compression of medial nerve within the carpal tunnel. 11/11 Blue Sky School of Professional Massage and Therapeutic Bodywork 3

5 b. Symptoms: 1) Pronator syndrome symptoms include pain in anterior forearm that is exacerbated with activity and relieved by rest. Additionally, client may complain of decreased sensation in thumb, index finger, 3 rd finger, or radial side of 4 th finger. Weakness of thenar muscles and positive Tinel or Phalen sign s. 2) Carpal Tunnel symptoms include decreased sensation, tingling or numbness in median nerve distribution. Pain worse with repetitive use. CTS clients complain of night awakening with tingling or numbness, radiation of pain up forearm. c. Treatment: Assess and treat Pronator Teres, Flexor digitorum superficialis and profundus. Utilize sign s and if neuritis is suspected, a referral may be necessary. 1) Phalen s Sign Assessment for CTS The client s wrists are flexed maximally. The position is held for up to 1 minute as the dorsal surfaces of the hands are pushed together. Tingling sensations that radiate into the thumb, the index finger, and the middle and lateral half of the ring finger are a positive sign. A positive sign indicates CTS caused by median nerve compression. 2) Reverse Phalen s Sign Assessment for CTS Client s wrists are extended and the palms of the hands approximated to each other. A positive sign indicates CTS due to median nerve compression. 3) Tinel s Sign at the Wrist Assessment for Peripheral Neuropathy in the Median Nerve The carpal tunnel is percussed at the wrist. Tingling in the thumb, index finger, forefinger, and the middle and lateral half of the ring finger is a positive finding. Tingling and paresthesia must be felt distal to the point of percussion for a positive finding 5. Ulnar Nerve a. Pathology: Ulnar nerve arises from brachial plexus. Above the elbow the nerve lies on the long head and then the medial head of the triceps directly posterior to brachialis. It passes posterior to the medial epicondyle and between the two heads of the Flexor Carpi Ulnaris. As it travels down forearm wedged between FDS and FDP, it enters distal forearm with ulnar artery and FDP tendons. Nerve travels into wrist to supply hypothenar muscles. 1) Cubital tunnel syndrome entrapment between the two heads of the FCU b. Symptoms: Client complains of pain in forearm that radiates in distribution of ulnar nerve. Also, numbness, tingling in the 5 th digit and ulnar half of the 4 th digit. Wasting or weakness in the hypothenar could be noted. 11/11 Blue Sky School of Professional Massage and Therapeutic Bodywork 4

6 c. Treatment: Assess and treat Flexor Carpi Ulnaris. Utilize sign s and refer if necessary 1) Tinel's Sign of the Elbow - Assessment for Ulnar Neuropathy Therapist taps the groove between the olecranon process and the medial epicondyle. Hypersensitivity indicates neuritis of the ulnar nerve and a referral may be necessary. Palmar View Dorsal View 11/11 Blue Sky School of Professional Massage and Therapeutic Bodywork 5