Upper Extremity
Rehabilitation Workshop
MBINGO BAPTIST HOSPITAL
November 29, 2014
Timothy Fanfon, PT
Kenneth Nshiom, PT/OCO
Morag Crocker, OT
Agenda
8:00 am – Anatomy review
9:00 am – Physical assessment
10:00 am – short break
10:10 am – Upper extremity conditions
12:30 pm – lunch break
1:00 pm – Splinting review & practice
Anatomy
Timothy Fanfon
Bones of the Arm
 Humerus
 Radius
– Shape of distal portion of bone allows
for rotation with pronation/supination
 Ulna
 Bony
landmarks = Radial & ulnar
styloid processes
– Potential pressure points when splinting
Bones of the hand
Carpal bones
 Metacarpals
 Phalanges

– Proximal
– Middle
– Distal
Carpal Bones
Joints of the Hand
 MCP
= Metacarpal-Phalangeal Joint
– Flexion, extension & some ulnar/radial movt.
 PIP
= Proximal Inter-Phalangeal Joint
– Flexion & extension only
 DIP
= Distal Inter-Phalangeal Joint
– Flexion & extension only
 CMC
= Carpometacarpal Joint
– Flexion, extension, adduction, abduction &
opposition
Joints of the Hand
CMC joint @ base
of thumb
Planes/directions of movement
Flexion & extension
(elbow, wrist, fingers)
 Adduction & abduction
(fingers)
 Radial & ulnar deviation
 Pronation & supinations
(forearm & hand)

Muscles of the Upper Arm

Biceps
– Flexion

Triceps
– Extension
Muscles of the (Volar) Forearm

Flexor Carpi Radialis (FCR)
– Flexes wrist
– Wrist radial deviation

Flexor Carpi Ulnaris (FCU)
– Flexes wrist
– Wrist ulnar deviation
Muscles of the (Volar) Forearm

Flexor Digitorum Superficialis
(FDS)
– Flexes wrist
– Flexes PIP joints
 Splits
at level of PIP joint to allow
Flexor digitorum profundus to pass to
distal phalanx
 Attaches on middle phalanx
Muscles of the (Volar) Forearm

Flexor Digitorum Profundus
(FDP)
– Flexes wrist
– Flexes DIP joints
 Passes
through split in FDS to
attach to distal phalanx
Muscles of the (Volar) Forearm

Flexor Pollicis Longus (FPL)
– Flexes distal phalanx of thumb

Flexor Pollicis Brevis (FPB)
– Flexes proximal phalanx of
thumb
(pollicis = relating to thumb)
Muscles of the (Dorsal) Forearm
Extensor Carpi Radialis Longus
(ECRL)
 Extensor Carpi Radialis Brevis
(ECRB)
 Both muscles

– Extend the wrist
– Radially deviate the wrist (abducts
or moves the hand in the direction
of the thumb)
Muscles of the (Dorsal) Forearm

Extensor Digitorum Communis
(EDC)
– Extends the wrist and fingers 2-5 at
the MCP & PIP joints

Attaches to the phalanges
through the extensor
mechanism and dorsal hood
Muscles of the (Dorsal) Forearm
Extensor Digiti Minimi
(EDM)
 Extensor Indicis (EI)

– Additional extensor muscles
for the index finger (EI,
indicis = index finger) and
little finger (digiti minimi =
little digit/finger)
Muscles of the (Dorsal) Forearm

Extensor Pollicis Longus (EPL)
– Extends distal phalanx of thumb
at IP joint

Extensor Pollicis Brevis (EPB)
– Extends proximal phalanx of
thumb at MCP joint

Abductor Pollicis Longus (APL)
– Extends, abducts & rotates the
thumb at the CMC joint
(pollicis = relating to thumb)
Muscles that Rotate the Forearm
 Pronators:
– Pronator teres
– Pronator quadratus
 Supinators:
– Supinator
 Bringing
the forearm to neutral:
– Brachioradialis
– Also assists with elbow flexion
– “beer drinking muscle”
Muscles of the (Volar/Palmar)
Hand

Thenar muscles = muscles
moving the thumb
–
–
–
–
Flexor Pollicis Brevis
Abductor Pollicis Brevis
Opponens Pollicis
Adductor Pollicis
Muscles of the (Volar/Palmar)
Hand

Hypothenar muscles =
muscles moving the little
finger
– Flexor Digiti Minimi
– Abductor Digiti Minimi
– Opponens Digiti Minimi
Intrinsic Muscles of the Hand

Lumbricals
– Origin on FDP tendon, inserts on
proximal phalanx of digits 2-5
– Flexes MCP joints and extends IP
joints

Dorsal Interossei
– Abducts digits 1, 2 & 4
– Flexes MCP joints and extends IP
joints

Palmar Interossei
– Abducts the fingers towards 3rd digit
– Flexes MCP joints and extends IP
joints
Brachial Plexus


Network of nerve fibers that goes through the neck,
the axilla (armpit) and into the arm and hand
Responsible for all the cutaneous (skin) and
muscular innervation of the upper limb (except the
trapezius muscle)
Radial Nerve

The radial nerve innervates the following muscles, in this
order:
–
–
–
–
–
–

Triceps
Anconeus
Brachioradialis
Extensor Carpi Radialis Longus
Extensor Carpi Radias Brevis
Supinator
Posterior Interosseous Nerve (branch
of radial nerve)
–
–
–
–
–
–
–
Extensor Digitorum (Communis)
Extensor Digiti Minimi
Extensor Carpi Ulnaris
Abductor Pollicis Longus
Extensor Pollicis Longus
Extensor Pollicis Brevis
Extensor Indicis
Median Nerve

The median nerve innervates the following muscles, in this
order:
–
–
–
–

Pronator Teres
Flexor Carpi Radialis
Palmaris Longus
Flexor Digitorum Superficialis
Anterior Interosseous Nerve (branch of
median nerve)
– Flexor Digitorum Profundus (index and middle)
– Flexor Pollicis Longus
– Pronator Quadratus

Palmar Recurrent Motor Branch (branch of
median nerve)
– Abductor Pollicis Brevis
– Opponens Pollicis
– Flexor Pollicis Brevis

Common Palmar Digital Nerve (branch of
median nerve)
– Lumbricals 1 & 2
Ulnar Nerve

The Ulnar nerve innervates the following muscles,
in this order:
– Flexor Carpi Ulnaris (FCU)
– Flexor Digitorum Profundus (ring and small
fingers)

Deep Branch of Ulnar Nerve:
–
–
–
–
–
–
–
–
Abductor Digiti Minimi
Opponens Digiti Minimi
Flexor Digiti Minimi
3rd and 4thLumbricals
Dorsal Interossei
Palmar Interossei
Flexor Pollicis Brevis
Adductor Pollicis
Physical Assessment
Kenneth Nshiom
Physical Assessment
 Inspection/Observation
 Palpation
 ROM
 Muscle
Strenght
 Neurovascular
 Special Tests
Observation
 Posture
and alignment
 Swelling/edema, ecchymosis
 Changes in skin, nails or hair (or
arm/hand)
 Contractures and other deformities
 Functional range of motion (& right vs.
left UE)
 Observe the contours and take note of
abnormal prominences, atrophy, etc
Palpation
 Palpate
the skin and feel the
temperature.
 Palpate subcutaneous landmarks
 Palpate the muscles, joints, tendons,
nerves and ligaments noting areas of
tenderness.
 Palpate and feel the pulses
Range of Motion
Shoulder
 Elbow

– Flexion = 145-150°
– Extension = 0° for men/0-15° for women

Forearm
– Pronation = 70-80°
– Supination = 80-90°

Wrist
–
–
–
–
Flexion
Extension
Ulnar deviation
Radial deviation
Range of Motion
Fingers
-flexion
-extension
-abduction/adduction

Neuromuscular
 Peripheral
nerves = all of the nerves
that lie outside of the brain and
spinal cord
– Motor nerves
– Sensory nerves
 Injury
causes loss of sensation,
movement or both
 Look for specific dermatome or
myotome patterns if you think the
injury is at the nerve root
 NB: Some cervical problems present
as UE problems, so do not forget to
assess the C-Spine
Strength

To test muscle strength, use the manual muscle
testing grading system:
– Grade 0 = no muscle contraction visible or palpable
– Grade 1 = no movement but there is a flicker (or palpable)
of muscle contraction
– Grade 2 = full range of motion with no gravity
– Grade 3 = full range of motion against gravity (no extra
resistance)
– Grade 4 = full range of motion against gravity, with
moderate resistance
– Grade 5 = full range of motion against gravity, with
maximum resistance

Remember that disuse, immobilization, and other
medical conditions can cause muscle weakness,
even when the nerve is intact.
Sensory Testing
Monofilaments (small fibres of different
sizes) or other fine pointed tools (pin, paper
clip etc.)
 Cotton ball (moving light touch)

– The patient should not look at the injured area
and then tell the therapist when they think the
therapist is touching their skin with the pointed
tool (E.g. “tell me when you feel me touch your
hand”).

Sensory testing should be done before use
of heat, ice or splinting (potential for tissue
damage)
Vascular Exam
 Peripheral
pulses
 Capillary refill
 Cynosis
Special Tests
 Apprehension
 Crank
Test
Test
 Speed Test
 Hawkins and Kennedy Test
 Neer Test
 Full can and Empty can Tests
 Finkelstein Test
 Tinel and Phalen Sign, Duran's Test
Specific Conditions
Morag Crocker
Tendonitis



Tendonitis = Inflammation, swelling and
irritation of a tendon (attaches muscle to
bone); usually used to describe more acute
tendon inflammation.
Tenosynovitis =
inflammation of the
sheath (called synovium)
that surrounds a tendon.
Tendinopathy = term to
describe problems with
either the tendon or the
tendon sheath
Tendonitis
 Cause:
– Overuse
– Direct injury to tendon
– Rheumatic disease
– Infection (very rare)
 Presentation:
– Tenderness with pressure on the tendon
– Pain with movement
– Stiffness after rest
– Visible swelling and local warmth (may or
may not be present)
Tendonitis
 Common
areas are elbow (lateral
epicondylitis), biceps, wrist & thumb
 Treatment:
– Rest (from aggravating activity)
– Ice
– NSAID’s (topical or oral)
– Changing activities (avoid repetition &
awkward positions)
– Splinting (to assist with rest)
– Gentle stretching (& muscle strengthening)
– Gradual return to activity
DeQuervain’s Tenosynovitis

Tendons affected:
– Abductor Pollicis Longus (APL)
– Extensor Pollicis Longus (EPL)
 Radial
side of wrist, over MCP & CMC joints
 move the thumb away from the plane of the hand

Tendon & sheath
affected; irritation
and thickening in
sheath
DeQuervain’s Tenosynovitis

Cause:
– repetitive movements requiring pinching or
grasping, particularly in combination with wrist
movement

Special tests:
– Finkelstein’s test = examining therapist
grasps the thumb, applies traction,
and ulnarly deviates the hand sharply.
A resulting sharp pain along the distal
radius, close to the wrist, is considered
a positive test.
– Eichoff’s test =
DeQuervain’s Tenosynovitis

Treatment:
– Rest, ice, NSAID’s etc
– Splinting:
 Splint
should prevent isolated thumb extension or
radial abduction
Trigger Finger

Tendons affected:
– Flexor Digitorum Superficialis (FDS)
– Flexor Digitorum Profundus (FDP)
– Volar (palm) surface of
the hand, where FDP &
FDS tendons enter the
flexor tendon sheath
– Most commonly affects
the ring finger, just
proximal to MCP joint
Trigger Finger

Symptoms:
– Causes clicking, catching (“triggering”) of
fingers with joint flexion
– May also cause stiffness, pain, tenderness and
swelling in the palm of the hand

Causes:
– Repetitive or forceful grasping (finger flexion)
causes thickening of the flexor tendons
(and/or narrowing of the flexor tendon sheath)
– Tendon gets stuck when gliding through the
tendon sheath
Trigger Finger

Treatment:
– Rest, ice, NSAID’s etc
– Splinting:
 Several
types but splint must prevent some degree
of finger flexion, so that the thickened part of the
tendon does not go through the sheath and catch
Safety Position

Safe position when hand must be
immobilized
– Maintains length of soft tissues to prevent
contracture
– Prevents intrinsic muscles from being
overpowered by stronger flexor & extensor
muscles
Safety Position

Used for:
–
–
–
–
–
–
–
Traumatic injury/acute condition
Burns
Crush injury
Inflammatory joint disease
Prevent contracture
Reduce pain & inflammation
Or any condition causing significant swelling,
as this can cause “clawing” (MCP extension &
IP flexion)
Safety Position

Position of joints:
–
–
–
–

Wrist position = 30° extension
MCP position = 70° flexion
IP position = full extension (if possible)
Thumb position = full abduction
Why?
– Intrinsic muscles flex MCP joints and extend IP joints
– If intrinsic muscles weakened,
they are overpowered by EDC and FDP/FDS, leading to MCP
joint hyperextension & IP joint flexion
– Will eventually cause contracture
– With crush or burn, scar tissue will
also contract as the hand heals
Nerve Injuries
 Complete
nerve laceration requires
surgical repair to restore innervation
– The body does try to repair itself by
sprouting new axons (part of the nerve)
from the injured nerve, which can
eventually bridge the gap between the
cut ends of the nerve
 Nerve
damage (not completely cut or
crushed) can be repaired/regrow
– Typically at a rate on 1-2 mm per day
Nerve Injuries

Goal of physiotherapy treatment is to
prevent problems from developing during
the time that the patient does not have
sensation or full motor control:
– For lack of sensation, they must learn to use
visual observation
– Splints and passive movement exercises are
used to maintain tissue length (in the hope that
the patient eventually regains muscle
innervation)
– Splints also used to maintain function while the
patient does not have proper muscle control

As a nerve re-grows, altered sensation can
be uncomfortable:
– Graded desensitization exercises
Carpal Tunnel Syndrome

Form of median nerve injury
– Compression of median nerve as it
passes through the carpal tunnel
(created by curve of carpal bones
and carpal ligament)

Signs & symptoms:
– Numbness and tingling of the radial
3 ½ fingers
– clumsiness, due to weakened muscles
– Pain (or altered sensation) especially at
night
– Atrophy of thenar muscles
Carpal Tunnel Syndrome

Causes:
– Repetitive movements (ex. Typing, weeding/farming)
– Vibrations (ex. tool use)
– Inflammation of the flexor tendon sheaths (ex. rheumatoid
arthritis)

Special tests:
– Durkan’s test: press with both thumbs over the
carpal tunnel for 30 seconds.
– Phalen’s test: patient flexes own wrists for
about 60 seconds.
– Tinel’s test: tap the median nerve over the volar carpal
tunnel
Carpal Tunnel Syndrome

Treatment:
– Rest (from aggravating activities)
– NSAID’s
– Splinting in neutral wrist position
 Nighttime
and for aggravating activities
– Steroid injection
– Carpal tunnel release surgery
Median Nerve Injury

Injury at distal forearm, wrist or hand:
– Affects: thenar muscles
– Lose: thumb abduction & opposition
– Potential for adduction contracture

Splinting goals:
– Maintain thumb abduction & opposition
Ulnar Nerve

The Ulnar nerve innervates the
following muscles, in this order:
– Flexor Carpi Ulnaris (FCU)
– Flexor Digitorum Profundus (ring and small
fingers)

Deep Branch of Ulnar Nerve:
–
–
–
–
–
–
–
–
Abductor Digiti Minimi
Opponens Digiti Minimi
Flexor Digiti Minimi
3rd and 4thLumbricals
Dorsal Interossei
Palmar Interossei
Flexor Pollicis Brevis
Adductor Pollicis
Ulnar Nerve Palsy

Injury at level of distal forearm, wrist or hand:
– Lose: intrinsic muscle power – dorsal interossei, palmar
interossei, lumbricals 3 & 4
– Weak intrinsic muscles are overpowered by flexors (FDS,
FDP) & extensors (EDC), causing clawing of little and ring
fingers

An injury higher up (level of humerus to proximal
forearm) results in same clawing as above but to
lesser degree
Splints for Ulnar Nerve Palsy

Splinting goals:
– Resting hand/safety position
– As wrist movement not affected, no need to
support wrist
Radial Nerve

The radial nerve innervates the following
muscles, in this order:
–
–
–
–
–
–

Triceps
Anconeus
Brachioradialis
Extensor Carpi Radialis Longus
Extensor Carpi Radias Brevis
Supinator
Posterior Interosseous Nerve (branch
of radial nerve)
–
–
–
–
–
–
–
Extensor Digitorum (Communis)
Extensor Digiti Minimi
Extensor Carpi Ulnaris
Abductor Pollicis Longus
Extensor Pollicis Longus
Extensor Pollicis Brevis
Extensor Indicis
Radial Nerve Palsy
Most commonly injured below level of
triceps muscle innervation
 Injury at level of middle humerus to middle
(to distal) forearm:

– Lose: wrist, finger & thumb extension
– Loss of wrist extension results in hand weakness
(strongest grip requires slight wrist extension)
and poor functional grasp

Splinting goals:
– Dynamic splint to use tenodesis effect OR
– Splint to maintain wrist and finger extension
Splints for Radial Nerve Palsy
Brachial Plexus Injury
Shoulder Conditions
Stroke

CNS injury
–Hemorrhagic
–Ischemic

Causes:
–Loss of sensation (and/or)
–Loss of motor control (and/or)
–Neglect
–Pain
40% of stroke patients experience pain in the
affected side, within 6 months of stroke.
Stroke

Causes of pain:
1. Complex Regional Pain Syndrome (CRPS)
– Severe shoulder and hand pain plus a swollen hand
– Usually develops approximately 1 month or more after
stroke
– Extremely sensitive hand
– Changes in nails and skin.
– Causes unknown:
 Malfunctioning pain pathways
 Autonomic nervous system
 Limited limb movement
– Treatment is difficult: neuropathic pain meds & mobilize
limb early
2. Spasticity
3. Shoulder subluxation
Spasticity
Arthritis
 Glenohumeral
 AC
joint
joint
 Thumb CMC joint
 OA of the IP joints
 RA of the MP joints
 GA of elbow and wrist
Contractures