Condition: Adhesive Capsulitis

Description: Adhesive capsulitis, or frozen shoulder, is a progressive loss of motion of glenohumeral

range of motion in a capsular pattern. External rotation is the most limited followed by abduction and
internal rotation. The three typical stages are freezing, frozen, and thawing. Symptoms include pain
(worst in the freezing stage), loss of motion, pain with passive and resisted movements throughout ROM
(freezing stage), and pain only at the end range (frozen/thawing stage).

Evaluation/screen: Occupational profile; postural assessment; assessments with outcome measures

(DASH); ROM/MMT; occupational/functional limitations; special tests and manual palpation
Screen for full thickness RTC tear:
Maintain position while
therapist pushes inward to
create internal rotation.
Will see abduction on affected
side due to inactive RTC; deltoid
m. is taking over.

Supraspinatus tendon Infraspinatus tendon Subscapularis tendon Biceps tendon (long head)
Treatment:
Freezing Stage (Can last 2 9 months)
Characterized by pain (ADLs, sleep, at rest); ROM may appear normal but is painful
at end range; pain with palpation (see images above)
Stretch glenohumeral capsule within pain limits: pendulums and table slides hold
3 to 5 minutes as tolerated
Precaution: Excessive stretching can cause increased scarring to damaged joint capsule and
delay the healing process.
Frozen Stage (Can last up to 1 year)
Characterized by scapular motion to compensate for
decreased shoulder movement
Encourage stretching through functional activities (ex.
keep phone two feet away from you to encourage reach)
Thawing Stage (Can last up to 26 months)
Characterized by return of movement
Complete rehabilitation exercises to gain ROM and strength: dowel rod flexion, extension,
internal and external rotation
Encouraging stretch through functional activities (reaching for phone, scrapbooking, washing windows,
etc.) promotes meaningful treatment by making occupation a means and an end.
 Condition: Carpal Tunnel Syndrome
Description: Carpal tunnel syndrome is the result of compression of the median nerve within the carpal tunnel.
Other structures within the tunnel include the flexor digitorum superficialis tendons (4), flexor digitorum
profundus tendons (4), and the flexor pollicis longus tendon. The roof of the carpal tunnel is formed by the
transverse carpal ligament which attaches to the pisiform and hook of hamate on the ulnar side, and the scaphoid
and trapezium on the radial side. Symptoms include burning, tingling, numbness, edema, decreased grip strength,
and pain. There is exacerbation of symptoms at night, worsening of symptoms through repetitive hand motions,
and improvement of symptoms after straightening or shaking.

Evaluation/screen: Occupational profile; observation/palpation of involved tissues/structures; pain assessment;

Tinels sign; scratch and collapse test; Semmes-Weinstein monofilament test; Bergers test; ROM/MMT

Gentle percussion Have patient hold a full fist

along nerve produces position with wrist in neutral
a temporary tingling for 30-40 seconds (forces
sensation incursion of lumbricals).
Positive result is pain and
paresthesias, indicating
possible lumbrical contribution.

Tinels Sign Scratch and Collapse Test Bergers Test

Treatment:
Precaution: Avoid the following: sustained pinch or gripping, particularly when the wrist is in a flexed or bent
posture; repetitive overuse of the wrist in activity; positioning the wrist in a flexed or bent posture while sleeping;
holding hands in a raised position

Tip: Keep wrist in neutral positon with daily activities

Management with an orthosis: to be worn during the day in positions that

provoke symptoms and at night; 2 of flexion and 3 of ulnar deviation

** If there is suspected lumbrical involvement, block MP flexion at 20-40 **

Ergonomics:
Use larger/ergonomic grips that contour to the arches of the hand
(tools, utensils, etc.)
Avoid pressure on the palm of the hand
Avoid wearing tight items around the wrist
Work station analysis: proper wrist support for typing or writing

Median nerve mobilization: complete median nerve glides to prevent

adhesions with surrounding tissue, enhance blood flow, and enhance
axoplasmic flow

Foam handle covers that create a larger diameter on utensils, such as

knives, allow patients to complete meal preparation tasks without
gripping too tightly and aggravating median nerve compression/pain.
 Condition: Lateral Epicondylosis
Description: Lateral epicondylosis is the degeneration of the extensor carpi radialis brevis muscle tendon. It is
common in individuals who are over 35 years old, participate in highly repetitive occupational or sports activities,
use forceful and demanding hand/wrist postures, and have inadequate fitness levels. Symptoms include pain with
ROM, point tenderness over the lateral epicondyle, aching at night and stiffness in the morning, increased pain
with gripping, grasping, twisting, and pushing, and pain with resisted wrist extension, finger extension, radial
deviation, and forearm pronation.
Precaution: Lifting, especially with the forearm pronated and elbow extended, is the most painful position for many
people.

Evaluation/screen: Occupational profile/self-report of occupational performance

limitations; pain assessment; DASH; PRFE; observe edema; differential diagnoses; special
tests (Cozens test, grip strength test, handshake test, resisted middle finger test)
** Lateral epicondylosis vs. radial tunnel syndrome **
Radial tunnel syndrome (impingement of superficial branch of the radial n. by heads of
supinator m.) will present with diffuse pain 2-4 cm distal from the lateral epicondyle

Grip Strength Test:

Position patient standing or seated
Set dynamometer to 2nd handle position
Position patients affected arm with humerus adducted, elbow at 90 degrees of flexion,
forearm in neutral
Have patient squeeze dynamometer; record force exerted
Repeat with elbow extended; record force
Test is positive if there is a significant difference in force exerted between the two positions
and if there is pain with elbow extended
Treatment:
Orthoses: wrist immobilization often worn during period of acute pain; wrist is
positioned in 20-45 degrees of extension
Exercise:
After pain subsides, initiate gentle flexor and extensor forearm stretches
o Extensor: begin with elbow flexed before elbow extension; wrist
flexion with fingers to floor
Once symptoms are managed and pain is not exacerbated easily, initiate
strengthening exercises
Strengthen scapular stabilizers
Modalities: ice massage for pain management

Strengthening scapular stabilizers will help with proximal stability of the body and
can prevent compensatory postures that lead to further complications and
interfere with completion of activities, such as washing hair or dressing.
Condition: Swan Neck Deformity
Description: Swan neck deformity is a finger posture with PIP hyperextension
and DIP flexion. The MP joint tends to be flexed as well, and when viewed
from the side, the finger appears to zig-zag. Swan neck can result from injury
at the DIP, PIP, or MP joints. These injuries include mallet finger,
hyperextension of the VP/capsule at the joint, and volar subluxation and
ulnar drift, respectively. Symptoms include pain, swelling, and decreased
function of the affected hand.

Evaluation/screen: Occupational profile/self-report of occupational

performance limitations; pain assessment; ROM; observe for hypermobility
of uninjured fingers; determine if PIP hyperextension is passively correctable;
distinguish between primary injury to the DIP or PIP

Distinguishing between primary injury: Stabilize PIP in neutral

position. If patient cannot actively extend DIP, injury is primarily DIP
extensor issue. If patient can actively extend DIP, injury is primarily a
volar PIP issue.

Treatment:
Non-operative treatment: orthosis that positions PIP in slight flexion purpose is to prevent PIP
hyperextension and promote active PIP flexion
Dorsal blocking
SIRIS orthosis

Exercises:
Avoid extending PIP joint beyond corrected position until given permission from physician
o Use a dorsal blocking orthosis
When given the okay to begin exercise, practice gentle bending movements at PIP joint in a
comfortable range
Observe quality of active flexion and promote practice of motions that do not cause snapping

SIRIS orthoses prevent PIP hyperextension while promoting flexion which allows patients to regain
functionality of the fingers in order to grasp doorknobs or a steering wheel.
Condition: Osteoarthritis (Hand)
Description: Osteoarthritis (OA) is referred to as the wear-and-tear disease there is breakdown in the
articular cartilage due to mechanical and chemical factors as well as changes in the underlying bone.
Risk factors include age and genetic susceptibility. Symptoms include pain and joint motion limitations
due to osteophytosis, overall decreased ROM, inflammation, and fatigue. Osteophytes can cause
triggering, locking, and the development of Bouchards (PIP) or Heberdens (DIP) nodules. Common
deformities that results from OA include mallet finger and crepitus.

Evaluation/screen: Occupational profile/self-report of occupational performance limitations; assess

pain; ROM; ability to perform ADLs (AIMS, COPM); observe hands side by side; observe stability (tip
pinch), inflammation; palpation; dynamometer (be mindful of deformities, pain, fatigue); pinch meter
(be mindful of deformities, pain, fatigue); 9 Hole Peg Test (dexterity); Moberg Pick Up Test
(sensory/manipulation); Grind Test; Eaton Radiographic Classification
Grind Test: Compression at the CMC
joint while gently rotating the head
of the metacarpal on the trapezium.
A positive test results in pain and
crepitus.

Treatment:
No available cure for OA treatment is designed to manage symptoms
Conservation methods (non-operative):
Joint protection principles: see Figure 33-2 (Chapter 33, page 459) Cooper text
o Principles include: respect pain; balance rest and activity; exercise in a pain free range; avoid
positions of deformity; reduce the effort and force; use larger/stronger joints
Modalities:
o At home: warm bath/shower; hot packs
o In the clinic: non-thermal ultrasound; fluidotherapy; electrotherapy; cryotherapy
Exercise: avoid painful active and passive ROM
o Gentle AROM six pack exercises (tendon glides)
o Stretch and massage first web space to prevent contracture
o Thumb hollowing or abduction
o Isometrics
o Strengthen first dorsal interosseous
Orthoses: assess degree of thumb deformity; stabilize MCP of thumb; wrist vs
hand-based: consider daytime wear for I/ADLs allow function and stability
o Thumb cool neoprene orthosis
o Thumb spica custom fit
o Finger oval-8 splints/rings
For nighttime positions: resting hand orthosis custom fit will reduce risk of further
deformities
Adaptive Equipment: large foam handles; non-slip material; adaptive cutting board; electric can
openers; flip top containers; pump soap bottles; adaptive utensils

Shampoo bottles with a pump top decrease arthritic pain while increasing independence in bathing.