ANTERIOR GLIDE OF THE RADIAL HEAD
aka "We Bad"
accessory mvt for pronation of forearm
necc w/ flexion
could impact extension
should have 180 degrees or more rotation of hand
always compare sides, and know what normal is in case of bilateral involvement
TECHNIQUE
find location of radial head
start w/ elbow flexed at 90 degrees
pt is seated in chair without arms or on edge of exam table with injured arm outside
doc usu stands posterolateral to patient
place distal interphalangeal joint of thumb on lateral epicondyle
bisect jt with thumb pointing 45 degees thru arm
thumb pad approaches radial head
when pronate loose it
when supinate it pops up into your thumb pad
keep thumb on backside of lat epicondyle
extensors may be tender
now set up support hand for max pronation of forearm,
index finger across radius and ulna at wrist, thumb underneath for support
so fingers can flex hand and rot it twd me for pronation
beware do not hyperextend elbow at any time, protective to pronate fully
don't allow or cause internal rotation of shoulder
once hand is pronated then move to extension to end of ROM
sensitize thumb at radial head, grade 2-3 wobble toward extension and feel radius
can take this to grade 5
thrust would be with elbow hand toward extension
indic: diminshed ROM in pronation, or flex-ext of elbow
GAPPING OF THE ELBOW
duke scoop = double ulnar knife edge
interlace fingers to form double knife edge
(take off any wrings except simple bands)
put knife edges in joint space
only if it has 90 degrees of flexion or more
traction the olecranon off the humerus (gap the elbow)
disengage the articular surfaces
accessory to elbow flexion
fair game for sense of fullness even with ext of elbow
real nice for any degenerative changes of elbow or foosh jam
indic: jamming, degen, articular change, muscle hypertonicity, adhesions
pt mb supine or sitting
if sitting then arm needs to be on stable surface
elbow flexed to 90 degrees
interlace fingers, grasp forarm, bury knife edges in joint crease
thumbs are lever to bring flexion back to 90 after edges engaged
scoop is pulling toward self with edges
pull slack out of shoulder
examiner can put clavicle on pts distal ulna to get more leverage
STRAIN/COUNTERSTRAIN SPECIFIC TO THE HAND
Dr Frangos teaches her patients to do this tx on themselves
ask pt before you inform potential helper: they need freedom to say y or n
if s/cs doesn't help then mb referred pain from organ, osseous restrx, etc
find tender pt, rate it, shorten muscle until pain reduces
lighten pressure, hold, passively return to neutral
be the minimalist, go as far as you need to to get the job done
THUMB
starting at thenar eminence
six movements:
flexor (median), adductor (ulnar) (windshield wiper)
opposition (opponens pollicis, median n, pain refers to wrist or thumb), reposition
abduction (radial), adduction (ulnar)
(carpal tunnel syndrome is median nerve impingement-->thenar atrophy)
TRIGGER POINTS AND RADIATING PAIN
mb intense triggers in these mm
trigger in thenar rad to wrist or thumb
hypothenar base rad to pinkie
interossei triggers rad to fingers esp index
trigger pt in forearm flexor dig superficialis-->
rad to index finger and beyond (phantom)
scalenes refer to thumb and index finger (common: stress, MVA, whiplash)
infraspinatus very common to have trigger points (ext rotator)
subscap rad to palm, thenar
here are the charts we have up in class:
**she recommends posting trigger point charts in office
helps pts understand that tension in a muscle can trigger pain far away
the two posters cost $42 at http://www.timberlakeseminars.com/catalog/product_info.php?cPath=28&products_id=34&osCsid=brjjxjffq
and are available in our bookstore
also check out:
Trigger Pt Manual by Janet Lavel in library
OPPONENS
is lateral to flexor in thenar eminence
identify tender point
have pt relax hand on own thigh or on pillow
use contralateral thumb to find tender point
use fingers on back of thumb to stabilize
flex until it doesn't hurt, hold
ok to combine flexion and opposition if near midline btw muscles
INTEROSSEI
may need to change position of hand to access btw metacarpals
may need to extend hand slightly as squeeze bones together
FLEXORS IN FOREARM
find tender pt
flexion may include wrist and fingers
some ulnar deviation may be needed
EXTENSORS
may need a little radial deviation along with extension
ABDUCTOR DIGITI MINIMI
hypothenar eminence point and hold pinkie out to side until release
BICEPS AND TRICEPS
may impact forearm
check for tender points there if forearm doesn't resolve from direct tx
PIR
to hand, arm, shoulder
stretch tense muscle
have pt isometrically submaximally contract it
(no movement dt practitioner has good hold)
extensors--basically the same as Mill's test