Anne Marie C Zeller, MSc, DO
Family Medicine Resident: Year 2
Undergraduate Osteopathic Manipulative Medicine Fellow- Graduated Chief
Faculty:
Michael P. Rowane, DO, MS, FAAFP, FAAO
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Discuss common causes and diagnoses in
regards to adolescent shoulder and elbow pain
Discuss basic tenets of examination of
shoulder, elbow, and wrist
High-yield and efficient osteopathic
manipulative medicine treatments for
shoulder, elbow, and wrist
Practice , Practice, Practice!
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MUST consider the maturation of the physis
or growth plates
Weakness at the physis and decreased
resistance to shear and tensile forces compared
to the surrounding ligaments, tendons, and
muscles, PREDISPOSE this population to
injury.
•
Repetitive micro trauma or overuse mechanisms:
1. Acceleration: Athletes uses optimum load to generate
force
•
Example: racquet and pitching sports
2. Dynamic force: arm is moving against sustained
resistance
•
Example: swimming
3. Static force: action of the shoulder muscles when
then are held in a constant position with isometric
contraction
•
Example: dancer or gymnast
•
Worst position: abducted to
90⁰, externally rotated, and
extended.
– MOST tension on anterior
articular capsule and anterior
glenohumeral ligament
– Rotator Cuff and deltoid active
– Subscapularis is compromised
•
Accerate forward: pectoralis
and subscapularis are required
to quickly internally rotate the
humerus
– ANOTHER bad biomechanical
position for shoulder
1)
2)
3)
Glenohumeral Joint
Sternoclavicular and Acromioclavicular Joints
Scapulothoracic Joint
Remember: Shoulder Pain is NOT JUST Rotator
Cuff! Shoulder involves Ribs, Thoracics,
Lumbars, Cervicals, Cranial bones
Innominates, and Sacrum
Epidemiology, Pathology and OMM treatment
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Traumatic events makes up 86% of
Glenohumeral instability in adolescent athletes
16 and older.
Skeletally mature athletes with GH instability
= surgery due to 80-90% recurrence rate
Skeletally immature athletes = EXTREMELY
careful in evaluating because of the high
chance of fracture of proximal humerus.
90% of traumatic dislocation
Mechanism of Injury: high energy injury of a fall
on an outstretched hand while shoulder in
abduction and external rotation
• S/S: “dead arm”- transient loss of sensation or
numbness in involved extremity (axillary nerve),
obvious deformity, pt hold arm internally rotated,
+ anterior apprehension test
• Diagnosis: Pt history, physical exam, x-rays
• Treatment: Primary- closed reduction of
dislocation, Secondary- surgery due
to
recurrence
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rate with conservative treatment .
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Hill-Sachs Fracture
and Bankart Lesion
Hill-Sachs (Blue
Arrow): compression
fracture at the
posterolateral head of the
humerus due to
impingement against
anterior rim of glenoid
fossa when the humeral
head dislocates.
Bankart Lesion (Red
arrow): avulsion of
anteroinferior glenoid
labrum where the
inferior glenohumeral
ligament attaches
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< 5% of traumatic shoulder dislocations
MOI: Fall on an outstretched hand with shoulder
in adduction and internal rotation or direct
anterior trauma.
– Example: Offensive Linemen: forward flexed and
internally rotation of shoulder for blocking
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S/S: May not have deformity, + posterior
apprehension test, complain of shoulder pain and
have limited external rotation with <90⁰ shoulder
flexion
Treatment: rotator cuff rehab is most successful
after closed reduction
•
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Majority are bilateral, multidirectional
Hypermobility (generalized joint laxity) of joints from
sports that weaken rotator cuff from overhead motions
– Examples: gymnastics and swimming
S/S: nonspecific shoulder pain, feeling of shoulder
dislocation with overhead activities, hyperextension of
other joints of UE, + apprehension signs, + sulcus sign,
strength deficits in rotator cuff muscles and scapular
stabilizers (serratus anterior, pectoralis, and latissimus
dorsi)
• Treatment: conservative rehab with strengthening NOT
stretching exercises
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Proximal humeral epiphysiolysis
MOI: repetitive strain injury to proximal humeral
epiphysis from overtraining and improper
biomechanics seen in over-head sports. (Example:
Baseball)
• Ages: 11-15
• S/S:
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– Pt has pain in superior lateral aspect of the shoulder with
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dynamic/resisted over-head activites
palpation of proximal humeral epiphysis is tender
active ROM is full and pain free
resisted muscle testing in over-head position reproduces pain.
X-ray is BEST visualization of pathology
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Rule out: Fracture and Dislocations with
history, physical exam and X-rays or MRI
Cautions: chronic dislocations, joint
hypermobility, recent shoulder surgery
Contraindications: Septic joint, acute
dislocation, fracture, cancer
1.
2.
3.
Dr. grasps humeral shaft with
both hands and fingers
interlock on medial side
(avoiding NV bundle)
Dr. pushes with both
hypothenar eminences against
humeral shaft. Cause humeral
head to become abducted as the
humerus is adducted by pt.
Pt places his ipsilateral hand on
the opposite side of his chest
(causing internal rotation and
adduction)
4.
5.
6.
7.
Pt moves elbow forward and
backward (internal and external
rotation)
Dr. determines which direction
enhances balanced tension.
Pt is instructed to maintain arm
in the position.
Dr. fine tunes the tensions at
the GH joint to achieve
balanced tension.
1.
2.
Pt is seated and facing
Dr. Dr. places thumbs
along superior portion
of the clavicles, just
distal to the SCM
insertion
Pt. drapes arms over
Dr.’s and flexes head
and neck. Allows
fingers to sink into the
supraclavicular space
3.
4.
Pt breathes deeply.
During inhalation, the
Dr. resists the superior
movement of the
supraclavicular fasciae
During exhalation, the
pt. exaggerates flexed
posture of head and
neck as the Dr. follows
tissues as they descend
into the thoracic inlet
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According to Sutherland model, the
claviopectoral fascia has a similar role to the
interosseous membranes of the forearm and
lower leg in that it guides and limits
movement of the bone.
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Serratus anterior, rhomboid and teres major
are viewed as the functional ligaments of the
joint.
BLT treatment presented addresses Serratus
anterior, subscapularis, rhomboid, latissimus
dorsi, teres major and lower trapezius muscles.
1.
2.
3.
Pt seated. Dr. uses thumb
as a fulcrum beneath the
scapula in the axilla.
Palmar surface of thumb
is placed on the lateral
surface of the 2nd and 3rd
rib with the tip facing
posteriorly. Anterior to
the latissimus dorsi
Dr. gently slides her
thumb posteriorly along
the surface of the rib until
it rests between the
scapula and rib.
4.
5.
6.
Dorsal surface of thumb
on subscapularis. Plantar
surface of thumb contacts
the serratus anterior.
Dr. places other hand over
the posterior aspect of the
scapula. Base of hand at
Apex and finger grasp the
spine of the scapula
Dr.’s posterior hand
protract, retract, adduct,
abduct, elevate and
depress the scapula to
achieve balanced tension
in all tissues attached
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OMM Treatment of Ribs, Cranial bones,
Cervical Vertebrae, Thoracic Vertebrae,
Lumbar Vertebrae, Innominates, Sacrum with
S/CS, ME, Indirect Myofascial, Still, or FPR.
Extensive information on Throwing and other
sport mechanisms in the shoulder and its
contributions to shoulder injury and pain
ECRL: Extensor Carpi Radialis Longus
ECRB: Extensor Carpi Radialis Brevis
EDC: Extensor Digitorum Communis
ECU:Extensor Carpi Ulnaris
CET: Common Extensor Tendon
AL: Annular Ligament
RCL: Radial Collateral Ligament
LUCL: Lateral Ulnar Collateral Ligament
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Precipitated by activities that require repetitive
wrist extension, radial deviation and forearm
supination
Examples: Hammering, painting, tennis
backhand
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Patient typically reports an insidious onset but
will often relate a history of overuse without
trauma.
Pain with gripping objects (“coffee cup sign)
and shaking hands (“politician’s sign”)
Numbness or tingling: Suggest radicular
symptoms
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 Musculoskeletal and Neurologic Exam 1st!
 Tenderness with palpation at origin of Extensor
Carpi Radialis Brevis (ECRB)
 Tenderness with resisted supination
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Resisted Wrist Extension Test
 Enhanced by:
▪ Straightening elbow
▪ Making a fist
▪ Pronating the forearm
▪ Radially deviating wrist
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Middle Finger Test
 Resist the extension of the proximal
interphalangeal joint of 3rd digit
 Stresses the extensor digitorum and ECRB
 Positive if pain is over the lateral epicondyle.
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Posterior interosseous nerve entrapment (radial
tunnel syndrome)
Osteoarthritis
Cervical radiculopathy
Musculocutaneous nerve entrapment
Radiocapitellum Osteochondritis dissecans lesions
Lateral collateral ligament strain
Stress Fracture
Humeral Fracture
Synovitis of the radiohumeral joint
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PL: Planaris Longus
PT: Pronator Teres
FCR: Flexor Carpi Radialis
FDS: Flexor Digitorum Superficialis
FCU: Flexor Carpi Ulnaris
AL: Annular Ligament
MCL: Medial Collateral Ligament
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Forceful and/or
continuous flexion and
pronation at the wrist
 Activities requiring a
large amount of
stabilization applied by
the wrist
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Common Activities
Examples:
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Racquet sports
Swimming
Swinging a Golf Club
Throwing
Computer Keyboard
Playing Piano
Certain occupations
 Examples
▪ Carpenters
▪ Plumbers
▪ Meat cutter
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Pain and tenderness along medial elbow
extending into forearm
Difficulty gripping without pain
Decreased wrist strength
Tightness/stiffness when stretching elbow and
wrist
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Testing for Valgus Stability in Extension:
 MCL
 Anterior Capsule
 Bony articulations
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Fracture
Osteochondritis dissecans
Osteoarthrosis
MCL injury
Little League elbow- increased valgus angle in
adolescent throwing athletes
Flexor-Pronator Strain
Ulnar neuropathy (neuritis, entrapment)
Pediatric- avulsion fracture
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Diagnose and treat Somatic Dysfunctions in:
Cervical spine, Thoracic spine, Ribs ,
Scapula, and Clavicle
To reduce and/or correct somato-somatic
reflexes and some of the myofascial pain
referrals
To improve the venous and lymphatic
drainage
OMT Techniques Presented Address:
 Radial Head
 Humero-Radial Joint
 Humero-Ulnar Joint
 Distal Radio-Ulnar Joint
 Carpal Joints
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Patient seated with elbows flexed at 900 and forearms
at 00 of pronation and supination (thumbs up).
Then check for supination or pronation restrictions.
The radial head moves posteriorly with pronation and
anteriorly with supination.
Therefore a pronated forearm (with restricted
supination) will have a posterior radial head somatic
dysfunction.
Supinated forearm (with restricted pronation) will have
an anterior radial head somatic dysfunction.
Example: Pt is restricted in PRONATION,
Freedom of Motion is in Supination
Diagnosis: Anterior Radial Head
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Step 1
Step 2
Step 4
Step 3
*Sit next to patient as depicted to make this work
* Start in full Pronation and end in full Supination
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Step 1
Step 2
Mobilization of distal radioulnar joint
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isometric; to 4th barrier in pronation, repeat in supination
Treat restrictions of pronation/supination (proximal or distal)
*Piano key sign
Free-up the interosseous membrane*
Improve venous and lymphatic return
• (carpal tunnel syndrome)
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Patient is supine
Right arm abducted 45 degrees
Hand positioned midway between
supination and pronation (thumb
up towards ceiling).
 Both hands are placed around the
elbow and motion is medial and
lateral to produce the articulation
of the radial head with the ulna or
humerus or articulation of the
humeroulnar joint.
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**Examine for Valgus/Varus instability
before performing technique
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•Fingers should be applying lateral traction to the
thenar & hypothenar eminences and the thumbs
should be applying pressure to gently separate the ulna
and radius from the carpal bones
•Wrist Flexion, Extension, Radial and Ulnar Deviation
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Anterior Tender Points
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Elbow is flexed fully.
Forearm is pronated and arm
is internally rotated - so back
of hand approximates chest.
Forces are pronation of the
forearm and internal rotation
of the humerus until a position
of comfort is found.
Hold this position for 90
seconds and then slowly
return to neutral.
Retest for tenderness.
Coronoid TP- Same position
but external rotation of the
humerus
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ALWAYS perform a musculoskeletal and
neurologic exam FIRST
OMT learned today for shoulder and elbow
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Glenohumeral Joint
Sternoclavicular and Acromioclavicular joint
Scapulothoraic joint
Radial Head
Humero-Radial Joint
Humero-Ulnar Joint
Distal Radio-Ulnar Joint
Carpal Joints
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Wojtys E. et al. “Sports injuries in the immature athlete.” Orthop Clin North Am 1987; 18 (4):
689-708.
Ogata et al.early development and ossification of the human clavicle—an embryologic
study.1990, Vol. 61, No. 4 , Pages 330-334
Gardner E.”The embryology of the clavicle.” Clin Orthop 1968;58:9
Carreiro, Jane D.O. Pediatric Manual Medicine. (2009). Churchill Livingstone.
BRIAN L. MAHAFFEY, M.D.PATRICK A. SMITH, M.D. “Shoulder Instability in Young
Athletes.” American Family Physician
Lawton RL et al. “Pediatric shoulder instability: presentation, findings, treatment, and outcomes.”
J Pediatric Orthop 2002.; 2252-61.
Good CR et al. “Traumatic shoulder dislocation in the adolescent athlete: advances in surgical
treatment.” Curr Opin Pediatr 2005; 17:25-9.
Jakobsen BW et al. “Primary repair versus conservative treatment of first-time traumatic anterior
dislocation of the shoulder: a randomized study with 10-year follow-up.” Arthroscopy 2007; 23
(2): 118-23.
Krabak et al. “Shoulder and Elbow Injuries in the Adolescent Athlete.” Phys Med Rehabil Clin N
Am. 19 (2008) 271-285.
American Osteopathic Association. Foundations in Osteopathic Medicine. (2003)
11.
12.
13.
14.
15.
16.
Young et.al (2011) “Lateral Epicondylitis.” 5-minutle Sports
Medicine Consult. Lippincott Williams & Wilkins.
Zeisig E. et al.(2006) Extensor origin vascularity related to pain
in patients with Tennis elbow. Knee Surg Sports Traumatol
Arthrosc.14(7):659.
Walz D, et al (2010). Epicondylitis: Pathogenesis, Imaging, and
Treatment. Radiographics. 30: 167-184.
Gruchow (1979). “Epidemiologic Study of Tennis Elbow.
Incidence, recurrence, and effectiveness of prevention
strategies”. American Journal of Sports Medicine. 7(4): 234238.
Young et.al (2011) “Medial Epicondylitis.” 5-minutle Sports
Medicine Consult. Lippincott Williams & Wilkins.
Smidt, N. et al (2002). “Corticosteroid injections, physiotherapy,
or a wait-and-see policy for lateral epicondylitis: a randomized
controlled trial.” Lancet. 359: 657-662.
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17. Bisset L, et al. (2005) “A systematic review and meta-analysis
of clinical trials on physical interventions for lateral
epicondylalgia. British Journal of Sports Medicine. 39: 411-422.
18. Grewal R. (2009) “Functional outcome of arthorscopic extensor
carpi radialis brevis tendon release in chronic lateral
epicondylitis.” Journal of Hand Surgery. 34: 849-857.
19. Des Moines University OMM Department. “Treatment of
Elbow Somatic Dysfunctions Laboratory Handout.” Updated
2010.
20. Figueroa J. Professional collaboration with AOA Lateral and
Medial Epicondylitis Lecture.
21. Lewis D. Upper Extremity IV Lab and Lecture. Spring 2011.
Des Moines University.
22. Simons DG, Travell JG, Simons LS. Myofascial Pain and
Dysfunction: The Trigger Point Manual. Volume 1. Upper Half
of Body. 2nd Ed. Baltimore, Williams & Wilkins, 1999, pp. 485907
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Spencer Sequence
Step 1: Extension
Isometric
Contraction the
patient is trying to
flex shoulder is
used to lengthen
the Pectoralis
Major, Pectoralis
Minor and anterior
deltoid
Spencer Sequence
Step 2: Flexion
Isometric
contraction of
Patient extending
shoulder engages
latissimus dorsi,
teres major and
minor, posterior
deltoid
Spencer Sequence
Step 3: Circumduction
without traction
Spencer Sequence
Step 4: Circumduction
with Traction
Spencer Sequence
Step 5: Abduction
Isometric
Contraction of
patient adduction
engages Pectoralis
Minor, Teres
Minor, and
Infraspinatus
Spencer Sequence
Step 6: Adduction
Isometric
contraction of
patient pushing
elbow superior
engages
subscapularis
and teres major
Spencer Sequence
Step 7: Internal
Rotation
Isometric
contraction pt.
pushes elbow
posterior
(external
rotation)
engages the
supraspinatus
and
infraspinatus
muscles
Spencer Sequence
Step 8: Abduction with
Resisted Traction
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Structures referring to the lateral elbow
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Scalenes
Supraspinatus
Teres Minor
Deltoid
Triceps
Subclavius
Pictures of Trigger Points, Referral Patterns, and Stretches in Appendix of Powerpoint Slides
Lateral and Medial Epicondylitis- Anne Marie C. Zeller
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Structures referring to the medial elbow
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Latissimus Dorsi
Subscapularis
Triceps
Sternalis
Serratus Posterior Superior
Pictures of Trigger Points, Referral Patterns, and Stretches in Appendix of Powerpoint Slides
Lateral and Medial Epicondylitis- Anne Marie C. Zeller
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Identify the trigger points:
 Taut band
 Tender to palpation
 Recognition of Pain
 Referral of pain (“triggers pain somewhere else”)
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Treat by stretching
 May use spray and stretch
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Treat by needling
 Dry needle or infiltrate trigger point with lidocaine
Lateral and Medial Epicondylitis- Anne Marie C. Zeller
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