CTS CTS Orthopaedic Manual Physical Therapy Series 2017-2018 - PDF document

Property of VOMPTI, LLC www.vompti.com W RIST C ASE S TUDY CTS C6-C7 Radiculopathy TOS 1 st CMC OA DM neuropathy Kristin Kelley, PT, DPT, OCS, FAAOMPT Pronator Teres Syndrome Dhinu Jayaseelan, PT, DPT, OCS, FAAOMPT Orthopaedic Manual Physical Therapy Series Charlottesville 2017-2018 Orthopaedic Manual Physical Therapy Series 2017-2018 Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com • 50 yo female computer programmer with gradual onset of night time R C6-7 facets C 6,7 nerve Upper Trap Systemic C6-7 disc hand numbness and now daytime pain CTJ/Rib 1 roots Pronator Neuropathy Transverse midcarpal Median Nerve R hand dominant Teres • Carpal Lig (DM) radiocarpal Thenar mm • Hx of chronic R neck/”upper trap” pain for years which is exacerbated 1-3 CMC , MCP, Wrist flexors during work IP Unsure of relationship of neck and hand symptoms • • Hand numbness wakes her CTS • States “clumsy” feeling lately when using her R hand • Hand pain is intermittent, but becoming more frequent C6-7 radiculopathy – Aggs: night time, typing, gardening, using push mower, prolonged TOS driving — uses L hand only to steer/turn De Quervain’s – Eases: decreased use of R hand, Intersection Syndrome 1 st CMC OA – Pain worse on work days PTS Scaphoid fracture/instability Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 1

Property of VOMPTI, LLC Sleep interruption, work ability affected • Observation: Forward head posture, rounded shoulders • Wrist ROM: (+ pain) end ROM flex, ext Can decrease symptoms with activity modification • Wrist strength 4-/5 flex and ext due to pain c/o • Cervical AROM WNL all planes except L rot 75% • UE myotomes WNL • Spurlings, cervical distraction/compression neg • Weakness with grip strength testing R vs. L None Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com CTS CTS Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 2

Property of VOMPTI, LLC Carpal Tunnel CTS • Any condition decreasing cross sectional are of CT • Tunnel contains 9 or increasing volume of its contents restricts flexor tendons and median n. perineural blood supply median nerve • Examples: • Roof is transverse – Carpal fracture/dislocation carpal ligament – Increased fluid – Tenosynovitis – Sustained wrist flex or ext – External wrist pressure – Vibration Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Carpal Palpation Wrist Anatomy/Palpation Palmar Palmar Dorsal • 3 creases on wrist – Proximal = prox end of synovial flexor tendon sheaths – Middle = prox wrist joint – Distal = prox. Fl retinaculum/transverse carpal ligament • Follow FCR to scaphoid tubercle, then trapezium • Follow FCU to pisiform, then to hook of hamate • Connect the above to show borders of CT • Between hook of hamate and triquetrum (under pisiform) is Guyon’s Canal (motor fibers exit for hypothenar eminence) Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 3

Property of VOMPTI, LLC Carpal Palpation CTS Dorsal • Most common Nerve compression in UE • Dip at proximal end of – 3 rd MC – capitate • Peak prevalence females >55 y.o. – 2 nd MC – trapezoid • Symptoms: – 4 th /5 th – hamate – pain, paresthesia or numbness in median nerve sensory distribution • At distal ulnar styloid – triquetrum – Nocturnal paresthesia — may begin as only 3 rd digit • Across distal radio-ulnar – meniscus of wrist – Sensory impairment affects object recognition, • Between ulnar styloid and triquetrum, palp on coordination, manipulation radial deviation – TFCC • NO volar wrist symptoms (supplied by palmar • 3 palpation sites for Scaphoid – distal radius, snuff cutaneous branch of median n. that does NOT box, & tubercle (palmar aspect). enter CT) Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com “New”wrist bracing for CTS CTS • Differential Diagnosis – TOS – Cervical radic – DM neuropathy – C6-7 radiculopathy – De Quervain’s – Intersection Syndrome – 1 st CMC OA – Pronator Teres Syndrome – Scaphoid fracture/instability Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 4

Property of VOMPTI, LLC Cervical Radiculopathy TOS • Disorder of Cervical Nerve Root • Onset age: 20-40 yrs • Commonly caused by disc herniation or space • Females affected> males occupying lesion • 2 types-Neurogenic (more common) and Vascular • Result in nerve root inflammation, impingement or • Typical s/s: both – Medial arm pain, numbness, paresthesia of UE, • CPR for diagnosis (90% probability with all 4 weakness criteria) – Aggs: OH activity, heavy lifting, repetitive motion – (+) Spurling disorders, postural issues, or traumatic movements of – (+)Distraction the neck or shoulder that can cause dysfunction to the – (+) ULTT (medial nerve bias) scalene musculature. – Presence of < 60 deg cervical rotation toward involved side Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com TOS TOS • Special tests • 3 Compression sites – Hyperabduction test – Interscalene triangle – Adson test – Costoclavicular space – Both have poor false (+) reliability – Subpectoralis • No true objective criteria (subcoracoid) space for diagnosis • Best diagnosis is history combined w/physical exam including palpation of entrapment sites, visual inspection, ROM of cspine and UE Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 5