CONDITIONS OF THE UPPER EXTREMITIES FREQUENTLY SEEN AND HELPED IN OUR OFFICE

Transcription

1 CONDITIONS OF THE UPPER EXTREMITIES FREQUENTLY SEEN AND HELPED IN OUR OFFICE

2 CHIROPRACTIC CENTRE 134 Main Street North Markham, Ontario, L3P 1Y3 Dr. H. Boehnke D.C.DIBAK

3 Thoracic Outlet Syndromes 1. Anterior Scalene Syndrome 2. Costoclavicular Syndrome 3. Pectoralis Minor Syndrome

4 Anterior Scalene Syndrome q This is caused by compression of the brachial plexus etc., between the anterior scalene, the medial scalene and the first rib. q Symptoms are often numbness in the hand and fingers radiating up into the forearm. It can also cause a cold hand and shoulder pain similar to Raynaud s phenomenon.

5 Anterior Scalene Syndrome 1. Patient supine with head elevated as if to test the scalene muscles 2. Test the wrist extensors or other muscles of the hand while the patient is in this position.

6 Anterior Scalene Syndrome Diagnosis and Treatment 1. Patient supine have him or her elevate the head as if to test the scalene muscles 2. Test the wrist extensors or other muscles of the hand while the patient is in the above position. If the tested muscle which was strong initially now tests weak, a scalene syndrome is present. 3. Test for the need of TP therapy or SCS

7 Anterior Scalene Syndrome Diagnosis and Treatment 4. Check for underlying problems such as weakness of the posterior neck extensors which would correlate with a sacral fixation. This could also correlate with a gluteus maximus weakness sitting which would result in a hypertonic piriformis resulting in the sacral fixation 5. Check any other factors that could be associated and correct them.

8 Costoclavicular Syndrome q This is entrapment of the brachial plexus and blood vessels as they go beneath the clavicle and over the 1 st rib. q Symptoms are usually transient and similar to the anterior scalene syndrome. The patient complains of numbness in the hand and fingers radiating up the forearm. Sometimes shoulder pain and cold hands

9 Costoclavicular Syndrome q The patient is put in a position that places the shoulder rotated posterior with the arm extended 30 q The patient is asked to inspire and finger muscles are tested for weakening

10 Costoclavicular Syndrome Diagnosis and Treatment 1. Patient is put in shoulder rotated posterior with the arm extended 30 position or the patient is instructed to elevate their arm to 140 of flexion. 2. The patient is asked to inspire fully 3. Test hand muscles, if a weakness results the syndrome is present. 4. Treat subluxations of the clavicle and or muscle weakness of the subclavius

11 Costoclavicular Syndrome Diagnosis and Treatment 5. Treatment of other factors which might contribute to this problem. Possibilities are a Category I pelvis, a Sacroiliac misalignment, dorsolumbar fixations etc.

12 Pectoralis Minor Syndrome Hyperabduction Syndrome q In this syndrome the brachial plexus and vascular structures as well as the subclavian vein can occur between the fibers of the pectoralis minor muscle, it s tendon and the head of the humerus, coracoid process and anterior rib cage. q Symptoms are transient numbness of the hands and fingers radiating into the forearm

13 Pectoralis Minor Syndrome Hyperabduction Syndrome 1. The arm muscles test weak in the neutral anatomic position or a pectoralis minor contraction position 2. The arm is then fully abducted and the former weak muscles test strong.

14 Pectoralis Minor Syndrome Hyperabduction Syndrome 1. Arm or hand muscles test weak in the neutral anatomic position and or a contracted pectoralis minor position 2. Often there will be trigger points in the belly of the pectoralis minor muscle. These will be dramatically relieved by pushing the shoulder gently inferior and posterior. If so it is likely from a weak latissimus dorsi.

15 Pectoralis Minor Syndrome Hyperabduction Syndrome 3. Test for and correct if found weakness in the ipsilateral latissimus dorsi, rhomboid, anterior serratus and posterior deltoid. 4. Look for any other factor which may contribute to the syndrome such as dural torque etc.

16 Pectoralis Minor Syndrome q This syndrome relates to neurovascular compression between the pectoralis minor muscle and the rib cage.

17 Pectoralis Minor Syndrome q Symptoms: An abnormal sensation, as of burning, prickling, throughout the arm and or hand Diminished arterial supply and venous return The insertion of the pectoralis minor on the coracoid process is usually very tender. Weakness of upper extremity muscles

18 Pectoralis Minor Syndrome q Symptoms (continued) numbness in the hand radiating up into the forearm Pain from the shoulder to the hand Cold hands Sensory symptoms on the little finger side of the hand

19 Pectoralis Minor Syndrome Hyperabduction Syndrome Brachial plexus Pectoralis Minor muscle

20 Pectoralis minor syndrome q This syndrome results from weakness of the muscles which do the opposite action of the pectoralis minor which allows the pectoralis minor to get hypertonic. q The muscles which may be weak causing this syndrome are, the rhomboids, the middle trapezius, the latissimus dorsi and or the lower trapezius.

21 Pectoralis Minor Syndrome Treatment q To treat the causes of the muscle weaknesses which allow the pectoralis minor to act unapposed and compress the nerves of the brachial plexus. q In this office we carefully examine the possible causes and correct them to give welcome relief to the symptoms of this syndrome.

22 Dorsal Scapular Nerve Syndrome q In this syndrome a nerve called the dorsal scapular nerve gets entrapped by a hypertonic (tense) scalene muscle which disturbs the function of the rhomboid and or levator scapula muscle. q This causes the shoulder blade (scapula) to drop inferior and lateral creating an unstable shoulder blade (scapula).

23 Dorsal Scapular Nerve Syndrome q This unstable shoulder blade (scapula) can result in a number of shoulder dysfunctions, such as stretching of the suprascapular nerve when the armshoulder is moved forward causing a stretch on that nerve. q That results in weakness of one or more muscles of the rotator cuff

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25 Dorsal Scapular Nerve Syndrome

26 Dorsal Scapular Nerve Syndrome q Symptoms: (according to Walther)

27 Dorsal Scapular Nerve Syndrome q Symptoms: (according to Walther) Pain along the medial border of the scapula which radiates to the lateral surface of the arm and forearm.

28 Dorsal Scapular Nerve Syndrome q Symptoms: (according to Walther) Pain along the medial border of the scapula which radiates to the lateral surface of the arm and forearm. The pain is a dull ache or generalized pain characteristic of a motor nerve.

29 Dorsal Scapular Nerve Syndrome q Symptoms: (according to Walther) Pain along the medial border of the scapula which radiates to the lateral surface of the arm and forearm. The pain is a dull ache or generalized pain characteristic of a motor nerve. If chronic, atrophy of the rhomboid muscles and possible the levator scapula muscle is present

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31 Dorsal Scapular Nerve Syndrome

32 Dorsal Scapular Nerve Syndrome q Symptoms: (according to Walther)

33 Dorsal Scapular Nerve Syndrome q Symptoms: (according to Walther) The musculature, rhomboids and levator scapula will likely be tender to deep palpation.

34 Dorsal Scapular Nerve Syndrome q Symptoms: (according to Walther) The musculature, rhomboids and levator scapula will likely be tender to deep palpation. There will be tenderness of the lower aspect of the scalenus medius muscle.

35 Dorsal Scapular Nerve Syndrome q Symptoms: (according to Walther) The musculature, rhomboids and levator scapula will likely be tender to deep palpation. There will be tenderness of the lower aspect of the scalenus medius muscle. Palpatory pressure at this area may cause increased pain in the rhomboid and levator scapula muscles and in the arm

36 Dorsal scapular nerve

37 Dorsal Scapular Nerve Syndrome Dorsal scapular nerve

38 Levator scapula Rhomboid minor Rhomboid major

39 Levator scapula Rhomboid minor Rhomboid major Dorsal Scapular Nerve Syndrome

40 Dorsal Scapular Nerve Syndrome Levator scapula Rhomboid minor Rhomboid major q Entrapment of the dorsal scapular nerve by the scalenus medius usually involves pain along the medial scapula and into the lateral surface of the arm and forearm

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42 Dorsal Scapular Nerve Syndrome

43 Dorsal Scapular Nerve Syndrome q Signs and symptoms:

44 Dorsal Scapular Nerve Syndrome q Signs and symptoms: Instability of the scapula if you watch the patient abduct both arms, the inferior angle of the scapula on the involved side will frequently move laterally into the mid axillary line. If it does not do that then having the patient extend their neck and repeating the abduction of the arms will cause execcive movement of the scapula

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46 Dorsal Scapular Nerve Syndrome

47 Dorsal Scapular Nerve Syndrome q The rhomboid on the affected side will frequently test weak in the clear, but if not, have the patient extend his neck and retest the muscle, it will now almost always test weak if the syndrome is present.

48 Dorsal Scapular Nerve Syndrome q The rhomboid on the affected side will frequently test weak in the clear, but if not, have the patient extend his neck and retest the muscle, it will now almost always test weak if the syndrome is present. q The scalenus medius muscle will most frequently palpate tense and somewhat fibrotic and will need a myofascial release

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50 Dorsal Scapular Nerve Syndrome

51 Dorsal Scapular Nerve Syndrome q It will result in an unstable scapula and will frequently be the cause of a suprascapular nerve syndrome which will be corrected when the dorsal scapular nerve syndrome is corrected.

52 Dorsal Scapular Nerve Syndrome Treatment q In this office, the cause of the over contracted medial scalene muscle is treated. The cause is one of the following: o A need for myofascial release of the medial scalene muscle on the involved side o A need to correct a weakness of one or more of the antagonist muscles

53 Dorsal Scapular Nerve Syndrome Treatment q In this office we use treatments to the muscles and spinal treatments which balance the muscles responsible for the syndrome. q The result is improved shoulder blade motion and function with reduced pain

54 Suprascapular Nerve Syndrome q The suprascapular nerve, supplies the supraspinatus and infraspinatus muscles. It also supplies sensory fibers to ligaments, bursa and the glenohumeral joint. When entrapped or stretched, it can cause shoulder dysfunction and pain which over time can cause impingement syndrome and rotator cuff tendon and muscle tears.

55 Suprascapular Nerve Syndrome q The main symptom pattern of suprascapular nerve entrapment is deep diffuse pain that is poorly localized in the posterior and lateral aspects of the shoulder that may be referred to the neck, into the arm or upper chest or localized to the acromioclavicular joint.

56 Suprascapular Nerve Syndrome q When the patient complains that shoulder motion aggravates the pain, in this case, it is scapular motion that aggravates the pain but the patient cannot differentiate it from glenohumeral motion.

57 Suprascapular Nerve Syndrome q Suprascapular nerve this nerve travels a long distance and is stretched if the shoulder blade moves excessively. It controls the following muscles

58 Suprascapular Nerve Syndrome Infraspinatus Muscle Supraspinatus Muscle

59 Suprascapular Nerve Syndrome Infraspinatus Muscle Supraspinatus Muscle

60 Suprascapular Nerve Syndrome q Symptoms: Deep diffuse pain that is poorly localized in the posterior and lateral aspects of the shoulder. The pain may be referred to the neck, the upper arm, the upper chest, or localized to the acromioclavicular joint.

61 Suprascapular Nerve Syndrome q Causes: Weakness of any of the shoulder blade stabilizing muscles o Latissimus dorsi o Anterior serratus o Rhomboid o trapezius

62 Suprascapular Nerve Syndrome q Treatment: Any treatment that corrects the muscle imbalances that lead to this syndrome. This syndrome often resolves when other treatments are made to correct for weakness of the formerly mentioned muscles.

63 Spinal Accessory Nerve Syndrome q The spinal accessory nerve (Cranial XI) can be compressed or irritated at multiple sites along its course from the base of the skull, along the lateral side of the neck, and to its termination in the region of the trapezius muscle. q Nerve compression alters the function of the sternocleidomastoid muscle and the trapezius muscle.

64 Spinal Accessory Nerve Syndrome q Signs and symptoms: Weakness or inhibition of the trapezius and sternocleidomastiod muscles. In severe cases where the trapezius is paralysed, the scapular alignment is altered. The most impressive clinical sign is a prominent inferior scapular tip. The vertebral margin of the scapula and inferior tip are no longer parallel to the --

65 Spinal Accessory Nerve Syndrome q Signs and symptoms (continued) --vertebral column but are obliquely directed toward the mid-axillary line. v D.D. This sign should not be mistaken for scapular winging as seen in long thoracic nerve palsy with loss of the anterior serratus action.

66 Spinal Accessory Nerve Syndrome q Because of the weak trapezius muscle, it can result in impingement, rotator cuff tendinitis, and or adhesive capsulitis

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68 Spinal Accessory Nerve Syndrome

69 Spinal Accessory Nerve Syndrome q Spinal accessory nerve. It originates in the spinal cord then enters the skull through the foramen magnum and then exits the skull again through the jugular foramen with other cranial nerves

70 Upper trapezius

71 Spinal Accessory Nerve Syndrome Upper trapezius

72 Spinal Accessory Nerve Syndrome Upper trapezius q Upper Trapezius

73 Spinal Accessory Nerve Syndrome Upper trapezius q Upper Trapezius Palpate to determine tension tenderness

74 Spinal Accessory Nerve Syndrome Upper trapezius q Upper Trapezius Palpate to determine tension tenderness Compare with deep inspiration

75 Spinal Accessory Nerve Syndrome Upper trapezius q Upper Trapezius Palpate to determine tension tenderness Compare with deep inspiration Compare with deep expiration

76 Spinal Accessory Nerve Syndrome Upper trapezius q Upper Trapezius Palpate to determine tension tenderness Compare with deep inspiration Compare with deep expiration Change in tension indicates a cranial motion disturbance

77 Sternocleidomastoid muscle

78 Spinal Accessory Nerve Syndrome Sternocleidomastoid muscle

79 Spinal Accessory Nerve Syndrome Sternocleidomastoid muscle q Sternocleidomastoid

80 Spinal Accessory Nerve Syndrome Sternocleidomastoid muscle q Sternocleidomastoid Palpate the SCM on the left side as the patient turns head right

81 Spinal Accessory Nerve Syndrome Sternocleidomastoid muscle q Sternocleidomastoid Palpate the SCM on the left side as the patient turns head right Palpate the SCM on the right side as the patient turns head left

82 Spinal Accessory Nerve Syndrome Sternocleidomastoid muscle q Sternocleidomastoid Palpate the SCM on the left side as the patient turns head right Palpate the SCM on the right side as the patient turns head left Note tone difference check against resp.

83 Spinal Accessory Nerve Syndrome sternocleidomastoid Upper trapezius

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85 Spinal Accessory Nerve Syndrome

86 Spinal Accessory Nerve Syndrome q Clinical signs and symptoms:

87 Spinal Accessory Nerve Syndrome q Clinical signs and symptoms: Weakness or paralysis of the trapezius and sternocleidomastoid muscles

88 Spinal Accessory Nerve Syndrome q Clinical signs and symptoms: Weakness or paralysis of the trapezius and sternocleidomastoid muscles The trapezius is an important shoulder elevator and weakness or paralysis alters scapular alignment

89 Spinal Accessory Nerve Syndrome q Clinical signs and symptoms: Weakness or paralysis of the trapezius and sternocleidomastoid muscles The trapezius is an important shoulder elevator and weakness or paralysis alters scapular alignment The most impressive clinical sign is a prominent inferior scapular tip

90 Spinal Accessory Nerve Syndrome q Impaired muscle function alters scapular alignment, resulting in a more prominent inferior scapular tip. Patients present with weak shoulder elevation, scapular instability, and a decreased ability to smoothly elevate the arm. Pecina

91 Spinal Accessory Nerve Syndrome q In spinal accessory paralysis (trapezius muscle) the vertebral margin of the scapula and the inferior scapular tip are obliquely directed toward the midaxillary line

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93 Spinal Accessory Nerve Syndrome

94 Spinal Accessory Nerve Syndrome q Signs and symptoms:

95 Spinal Accessory Nerve Syndrome q Signs and symptoms: Patient can lose the ability to shrug the shoulder on the involved side.

96 Spinal Accessory Nerve Syndrome q Signs and symptoms: Patient can lose the ability to shrug the shoulder on the involved side. Patients often complain of a dull ache in the shoulder extending down the arm

97 Spinal Accessory Nerve Syndrome q Signs and symptoms: Patient can lose the ability to shrug the shoulder on the involved side. Patients often complain of a dull ache in the shoulder extending down the arm The disturbed biomechanics can result in secondary effects such as shoulder impingement, rotator cuff tendinitis and adhesive capsulitis

98 Spinal Accessory Nerve q Treatment: Syndrome In this office we direct treatment to both the spinal aspect and the cranial aspect of this nerve by both spinal and cranial treatments as needed.

99 Spinal Accessory Nerve Syndrome q Results of treatment: Better shoulder motion and stabilization Improved neck rotation Reduced pain in the upper trapezius muscle on the involved side.

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101 Lateral Axillary Hiatus Syndrome

102 Lateral Axillary Hiatus Syndrome In this syndrome, first described by Bateman in 1955, the axillary nerve can be compressed while passing through the lateral axillary hiatus (quadrilateral foramen) in the shoulder region.

103 Lateral Axillary Hiatus Syndrome In this syndrome, first described by Bateman in 1955, the axillary nerve can be compressed while passing through the lateral axillary hiatus (quadrilateral foramen) in the shoulder region. It is also named Quadrangular or Quadrilateral Space Syndrome

104 Lateral Axillary Hiatus

105 Lateral Axillary Hiatus Quadrangular Space Syndrome Lateral Axillary Hiatus

106 Lateral Axillary Hiatus Quadrangular Space Syndrome Lateral Axillary Hiatus q The long head of the triceps divides the space created by the teres major and minor, the humerus, and the scapula into two spaces, the medial and lateral axillary hiatus

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108 Lateral Axillary Hiatus Syndrome

109 Lateral Axillary Hiatus Syndrome q The axillary nerve and the posterior circumflex artery pass through the lateral opening. It enters from its position over the subscapularis muscle and passes to the deltoid muscle

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111 Lateral Axillary Hiatus Syndrome

112 Lateral Axillary Hiatus Syndrome q When the arm is extended as in sleeping with the arm up, or abducting the arm above 90 the hiatus narrows.

113 Lateral Axillary Hiatus Syndrome q Signs and symptoms: Paresthesias or hypesthesias around the shoulder and upper arm Deltoid atrophy contour changes around the shoulder In a functional sense, the deltoid may test strong in a normal test position but tests weak when hyperabducted.

114 Lateral Axillary Hiatus Syndrome q Signs and symptoms: Compensatory activity of the supraspinatus as well as the long head of the biceps is frequently present to diminish the functional disability found with deltoid atrophy. Tenderness over the lateral axillary hiatus space Decreased shoulder abduction is frequent

115 q Treatment: Lateral Axillary Hiatus Syndrome Myofascial release of any of the involved muscles at the location of this syndrome. Release of any adhesions that may be in this location. q Result: Improved deltoid muscle strength when hyperabducted

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117 Musculocutaneous nerve syndrome

118 Musculocutaneous Nerve Coracobrachialis Muscle

119 Musculocutaneous nerve syndrome Musculocutaneous Nerve Coracobrachialis Muscle

120 Musculocutaneous nerve syndrome Musculocutaneous Nerve q Musculocutaneous nerve branches from the lateral cord close to the inferior border of the pectoralis minor Coracobrachialis Muscle

121 Musculocutaneous nerve syndrome Musculocutaneous Nerve Coracobrachialis Muscle q Musculocutaneous nerve branches from the lateral cord close to the inferior border of the pectoralis minor q Supplies the coracobrachalis muscle, often piercing it to supply the biceps and brachalis muscles

122 Musculocutaneous nerve syndrome Sensory area q Musculocutaneous nerve branches from the lateral cord close to the inferior border of the pectoralis minor q Supplies the coracobrachalis muscle, often piercing it to supply the biceps and brachalis muscles

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124 Musculocutaneous nerve syndrome

125 Musculocutaneous nerve syndrome q This syndrome is relatively rare, however several factors are consistently found:

126 Musculocutaneous nerve syndrome q This syndrome is relatively rare, however several factors are consistently found: Patients are young and active performing demanding work with flexion of the shoulder and repetitive flexion of the elbow with pronation of the arm

127 Musculocutaneous nerve syndrome q This syndrome is relatively rare, however several factors are consistently found: Patients are young and active performing demanding work with flexion of the shoulder and repetitive flexion of the elbow with pronation of the arm The majority present following repetitive high-demand activities

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129 Musculocutaneous nerve syndrome

130 Musculocutaneous nerve syndrome Some authors suggest compression occurs with hypertrophy of the coracobrachalis muscle or excessive pressure generated by the coracobrachialis muscle.

131 Musculocutaneous nerve syndrome Some authors suggest compression occurs with hypertrophy of the coracobrachalis muscle or excessive pressure generated by the coracobrachialis muscle. Some authors suggest a traction such as caused by surgical positioning in abduction and external rotation

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133 Musculocutaneous nerve syndrome

134 Musculocutaneous nerve syndrome q Symptoms and signs:

135 Musculocutaneous nerve syndrome q Symptoms and signs: Biceps muscle weakness and wasting

136 Musculocutaneous nerve syndrome q Symptoms and signs: Biceps muscle weakness and wasting Sensory complaints to the lateral side of the forearm.

137 Musculocutaneous nerve syndrome q Symptoms and signs: Biceps muscle weakness and wasting Sensory complaints to the lateral side of the forearm. Biceps brachii and brachialis muscle weakness typically follows intensive activity with a flexed arm, elbow flexionextension and a pronated forearm

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139 Musculocutaneous nerve syndrome

140 Musculocutaneous nerve syndrome q Symtoms and signs:

141 Musculocutaneous nerve syndrome q Symtoms and signs: Biceps reflex is often absent

142 Musculocutaneous nerve syndrome q Symtoms and signs: Biceps reflex is often absent Decreased biceps tone

143 Musculocutaneous nerve syndrome q Symtoms and signs: Biceps reflex is often absent Decreased biceps tone Hypesthesia and paresthesias on the lateral aspect of the forearm.

144 Musculocutaneous nerve q Treatment: syndrome If the cause is from a shortened coracobrachialis or an adhesion in the coricobrachialis, it can be helped by a specific myofascial release. If there is a more severe cause, it would need to be seen by an orthopedic surgeon

145 Ulnar sulcus syndrome q The ulnar nerve passes through a tunnel of tissue (the cubital tunnel) behind the inside of the elbow. Here you can feel the nerve through the skin. It is commonly called the " funny bone; see the figure on the left in the next slide.

146 Ulnar sulcus syndrome

147 Ulnar sulcus syndrome Compression at the elbow, ulnar sulcus syndrome also known as cubital tunnel syndrome, causes numbness in the small finger (also known as the "pinkie"), along the half (lengthwise) of the ring finger closest to the small finger, and the back half of the hand over the small finger.

148 Ulnar sulcus syndrome

149 Ulnar sulcus syndrome q The epicondylo-olecranon ligament stabilizes the ulna and the humerus. It also stabilizes the ulnar nerve at the sulcus and prevents it from moving during forearm movements. q When the ligament is hypertrophied or stretched, entrapment of the ulnar nerve occurs

150 Ulnar sulcus syndrome q When ulnar nerve entrapment happens it can cause pain and parethesia over the ulnar nerve distribution and can weaken the following muscles: Flexor carpi ulnaris Ulnar portion of flexor digitorum profundus Interossei and hyopthenar muscles Adductor pollicis

151 Ulnar sulcus syndrome q Treatment: Any chronic misalignment correction Correction of muscle imbalances such as the necessity of stretching the long head of the triceps If dislocation or avulsion are present, it is a medical orthopedic problem

152 Carpal Tunnel Syndrome

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154 Carpal Tunnel Symptoms q Pain, tingling or numbness in the thumb, index, middle or ring fingers. q A swollen or tight feeling in the hand or wrist q Hands and lower arms feel weak and you may drop objects more than normal q These symptoms are often worse at night or when first getting up in the morning

155 Carpal Tunnel Syndrome Causes q Trauma such as stopping a fall, forcing a stuck window open, holding a heavy tray over the shoulder as a waiter or waitress q Reptitive motion such as typing, using vibrating hand tools or instruments, or knitting at home. q Vitamin B-6 deficiency with resultant soft tissue swelling. q Toxic states with retention of fluid

156 Carpal Tunnel Syndrome Diagnosis q Phalen s Test q Flex both wrists and approximate them to each other. Hold for 60 seconds. Paresthesias into fingers indicates median nerve entrapment q Opponens Pollicis muscle tests weak especially in Phalen s postion q Palpable edema in the wrist

157 Opponens Pollicis Test q Ask the patient to approximate the thumb and little finger q Ask them to keep the thumb where it is and to relax the little finger q Stabilize the hand q Exert pressure against the thumb to separte it from the hand

158 Carpal Tunnel Syndrome Treatment q Adjust radius, ulna, and carpals if needed q This can be with an adjustment and or repositioning q B-6 supplementation may be necessary q Rehabilitation exercise q Bracing may be needed

159 Carpal Tunnel Syndrome Treatment q In severe cases that do not respond to conservative measures, surgery may be necessary.

160 Ulnar Tunnel Syndrome q The ulnar tunnel is bordered by the pisiform and hamate, the transverse carpal ligament and the flexor carpi ulnaris muscle q Weakness of the flexor digiti minimi and or the opponens digiti minimi muscles with normal strength of the flexor digtorum profundus of the 4 th and 5 th fingers

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162 Opponens Digiti Minimi Muscle q Patient is asked to approximate the thumb and little finger q The thumb is allowed to relax q Stabilize the hand q Pressure is applied to flatten the hand in the direction to lengthen the muscle

163 Flexor Digiti Minimi Muscle q Patient is asked to flex the little finger while the interphalangeal joints are held in extension q Stabilize the rest of the hand q Pressure is applied to extend the proximal phalanx.

164 Flexor Digitorum Profundus q Patient flexes the distal interphalangeal joint of the finger to be tested q Stabilize the proximal phalanges q Force is applied to extend the distal phalanx

165 Ulnar Tunnel Syndrome Treatment q If weakness is found in the opponens digiti minimi and or flexor digiti minimi muscle pressure against the pisiform and or hamate is done in various vectors until one vector strengthens the muscle test. q Adjustment is done to reposition the pisiform and or hamate accordingly q Stabization if necessary

166 DeQuervain s Tenosynovitis

167 DeQuervain s Tenosynovitis Diagnosis and Treatment 1. Finkelstein s test. Have the patient tuck their thumb into a closed fist and deviate the wrist ulnarward. If it creates considerable pain over the radial styloid area it is a sign of possible DeQuervain s. 2. Subluxations of the radius, ulna and or carpals especially the trapezium and or scaphoid may be involved

168 DeQuervain s Tenosynovitis Diagnosis and Treatment 3. Myofascial release of the abductor pollicis longus and extensor pollicis brevis and longus may be needed. 4. A check for stability or instability of the carpals, radius and ulna and treat accordingly with support if needed. 5. Avoidance of activities that can aggravate the carpals and tendons in the wrist

169 The Shoulder q The shoulder is the most complicated joint in the body. q It is actually a complex of joints and muscles working together. q The only direct boney connection to the skeleton is via the acromioclavicular joint (the joint between the shoulder blade and the collar bone.

170 The Shoulder q The shoulder blade attaches to the collar bone (clavicle) and the collar bone (clavicle) attaches to the breast bone (sternum), which in turn attaches to the ribs, which in turn attach to the spine. q The rest of the functional aspects of the shoulder are via muscles and tendons. q So the shoulder literally floats in a sea of muscles with one direct boney attachment

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172 Shoulder Joints Structures

173 Shoulder Joints Structures q Five functional joints

174 Shoulder Joints Structures q Five functional joints 1. Sternoclavicular

175 Shoulder Joints Structures q Five functional joints 1. Sternoclavicular 2. Acromioclavicular

176 Shoulder Joints Structures q Five functional joints 1. Sternoclavicular 2. Acromioclavicular 3. Subacromial

177 Shoulder Joints Structures q Five functional joints 1. Sternoclavicular 2. Acromioclavicular 3. Subacromial 4. Glenohumeral

178 Shoulder Joints Structures q Five functional joints 1. Sternoclavicular 2. Acromioclavicular 3. Subacromial 4. Glenohumeral 5. Scapulothoracic

179 Shoulder 5 functional joints

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181 The Sternoclavicular Joint

182 The Sternoclavicular Joint q Visual detection of a subluxation

183 The Sternoclavicular Joint q Visual detection of a subluxation 1. The examiner puts his index fingers on the sternal aspect of the clavicles

184 The Sternoclavicular Joint q Visual detection of a subluxation 1. The examiner puts his index fingers on the sternal aspect of the clavicles 2. The examiner determines if it is superior, inferior, or anterior

185 Sternoclavicular Joint misalignment-elevated clavicle

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187 The Acromioclavicular Joint

188 The Acromioclavicular Joint This is a common site of separation.

189 The Acromioclavicular Joint This is a common site of separation. The horizon sign is a frequent finding. It is a lump that shows up when the A/C joint separates with the clavicle lifting up from the acromion process

190 Horizon sign

191 Horizon sign Horizon sign overview

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193 Acromioclavicular Joint

194 Acromioclavicular Joint A space of more than 1.3 cm. Between the coracoid and clavicle is a sign of a coracoclavicular ligamentous disruption

195 Upper Trapezius Deltoid

196 Acromioclavicular Joint Upper Trapezius Deltoid

197 Acromioclavicular Joint q A/C joint separation or sprain Upper Trapezius Deltoid

198 Acromioclavicular Joint q A/C joint separation or sprain Often is associated with upper trapezius hypertonicity and trigger points Upper Trapezius Deltoid

199 Acromioclavicular Joint q A/C joint separation or sprain Often is associated with upper trapezius hypertonicity and trigger points Often associated with middle and posterior deltoid that test weak Upper Trapezius Deltoid

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201 Acromioclavicular Joint

202 Acromioclavicular Joint q A/C joint separation or sprain - continued

203 Acromioclavicular Joint q A/C joint separation or sprain - continued then hold the patients acromioclavicular joint in approximation and if it relieves the tenderness it needs adjustment.

204 Acromioclavicular Joint q A/C joint separation or sprain - continued then hold the patients acromioclavicular joint in approximation and if it relieves the tenderness it needs adjustment. v The adjustment is a controlled act, best done by a chiropractor

205 Acromioclavicular Joint q A/C joint separation or sprain - continued then hold the patients acromioclavicular joint in approximation and if it relieves the tenderness it needs adjustment. v The adjustment is a controlled act, best done by a chiropractor Follow adjustment by isometric exercise for the anterior and posterior deltoid

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207 Acromioclavicular stability excercise

208 Acromioclavicular stability excercise Anterior deltoid part

209 Acromioclavicular stability excercise Anterior deltoid part With the forearm in an elevated position with the angle such that the belly of the muscle rises push isometrically against an immovable object

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211 Acromioclavicular stability excercise

212 Acromioclavicular stability excercise Posterior deltoid part

213 Acromioclavicular stability excercise Posterior deltoid part With the patients arm in a position with the forearm pointing inferior to an angle which causes the muscle belly to rise do an isometric contraction against an immovable object

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215 Normal Shoulder Abduction

216 Normal Shoulder Abduction q In normal abduction the patient is able to bring the arms together above the head at a full 180 without pain or restriction.

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218 Slouched Shoulder Abduction

219 Slouched Shoulder Abduction q When the patient is in a slouched position with an increased kyphosis, the abduction is usually restricted.

220 Slouched Shoulder Abduction q When the patient is in a slouched position with an increased kyphosis, the abduction is usually restricted. q This is due to impingement of the greater tubercle of the humerus against the coraco-acromial lig.

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222 Shoulder Abduction with Internal Rotation

223 Shoulder Abduction with Internal Rotation q With the hands and arms in internal rotation, most patients will have restricted abduction.

224 Shoulder Abduction with Internal Rotation q With the hands and arms in internal rotation, most patients will have restricted abduction. q This is due to impingement of the greater tubercle of the humerus against the coraco-acromial lig.

225 Shoulder Muscles (anterior)

226 Shoulder Muscles Anterior

227 Shoulder Muscles posterior

228 Shoulder Muscles Posterior

229 Biceps tendon slip The biceps tendon can slip out of its groove in the humerus. In a medial slip the tendon can be palpated when the elbow is flexed to 90 degrees and the humerus is externally rotated to 30 degrees

230 Biceps Tendon Medial Slip

231 Biceps Tendon Normal

232 Biceps Tendon Medial Slip q In my personal experience, I have found that myofascial adhesions appear to occur between the pectoralis major clavicular division and the tendon of the long head of the biceps which appear to put a medial pull on the tendon. This I have often found is associated with a painful restriction of the Apley s inferior test for the shoulder. The release of the adhesions improves the ROM

233 Biceps Tendon Medial Slip Biceps Tendon Long head Pectoralis Major clavicular

234 Biceps tendon slip q Lateral Typically occurs during a throwing type motion.

235 Shoulder Impingement q This is when passive or active abduction results in an elevation of the humeral head and restriction of abduction occurs usually with discomfort or pain q This is often due to an imbalance between the muscles that pull the humerus cephalad as opposed to those that pull it caudad which results in the humeral head not being seated properly in the glenohumeral joint.

236 Shoulder Impingement q This results in a situation where the greater tubercle impinges against the hood formed by the acromion process and the coracoacromial ligaments compressing the soft tissue structures between it. These impinged structures are the supraspinatus tendon and the subacromial bursa

237 Shoulder Impingement q This patient had 1. A-C Joint separation 2. Slipped biceps tendon 3. Frozen subclavius 4. Weak external rotator muscles