3/23/2010

Section Outline
POST--REHAB WORKSHOP PART TWO
POST
 Shoulder:
UPPER QUADRANT ◦ Anatomical structures (bones, joints, muscles, nerves),
biomechanics
◦ Injuries: Separations, dislocations, rotator cuff injuries, frozen
shoulder, bursitis, impingement, tendonitis
 Elbow:
◦ Anatomical structures (bones, joints, muscles, nerves),
biomechanics
◦ Injuries: Golfers/tennis elbow
 Wrist and Hand:
◦ Anatomical structures (bones, joints, muscles, nerves),
biomechanics
◦ Injuries: carpal Tunnel syndrome, scaphoid fracture,
• Assessment, kinetic chain activation, PNF patterns,
Stabilization requirements

Shoulder – Chapter 8 (p. 135)

 Major ligaments
Functional Anatomy
◦ coracoacromial,
◦ coracoclavicular,
◦ acromioclavicular,
 Rotator cuff – infraspinatus, supraspinatus,
◦ sternoclavicular, teres minor, subscapularis
◦ glenohumeral capsule
 4 main joints:  Primary muscles – pectoralis major/minor,
◦ Glenohumeral
◦ Acromioclavicular latissimus dorsi, trapezius, rhomboid
◦ Sternoclavicular major/minor, deltoid, scalenes, levator
◦ Scapulothoracic
 3 degrees of freedom scapulae, biceps brachii, triceps brachii
◦ Mobility = stability normal
◦ Mobility < stability inflexible
◦ Mobility > stability hypermobile

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Functional Anatomy Functional Anatomy

Functional Anatomy
Functional Anatomy

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Functional Anatomy
 Majority of innervation & blood flow is
found in subclavian anterior humeral
spaces
 Brachial plexus (neural and vascular
structures) can be compressed between
clavicle, 1st rib, scalenes – thoracic outlet
syndrome, results in numbness, tingling
cramping in hands (Adsons test for pulse)
 Trauma to anterior structures typically
results in reduced innervation & blood
supply with swelling
Functional Anatomy
Anterior distal dislocation of glenohumeral joint
3/23/2010
Functional Anatomy
 Glenohumeral jt is a shallow ball-and-socket jt that
allows a high degree of mobility.
 Glenoid fossa is deepened by a ring of cartilage called
glenoid labrum, that cradles humerus into glenoid
 3 GH ligaments form a “Z” shape to protect the joint
from multiple angles
 Supported by infraspinatus, supraspinatus and teres
minor, minimal support to jt anteriorly (large amount
of anterior dlc’s)
 GH rhythm is when the humerus abducts 2 degrees
for every degree of scapular rotation
Functional Anatomy
 Coracoid process provides a
“fixed point” for all shoulder
stability
 GH connects a number of
ligaments to it, as does the AC
jt.
 Irritation of coracoacromial
ligaments can lead to adhesive
capsulitis (frozen shoulder) Glenohumeral ligaments
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Functional Anatomy
 AC joint connects scapula to the clavicle (then to
rest of body via sternoclavicular jt)
 Highly unstable when compared with sternoclavicular
jt, has a high incidence of separations
 AC jt is a point of attachment for a number of
muscles, and has to be mobile enough to allow
overhead movements as well as pressing and pulling
movements
Functional Anatomy
 On initiation of abduction, scapula
rotates upwards, then stabilizes against
ribs, then raises humerus
 Rotation moves acromion process out
of the way, stabilization allows for high
force movements, humerus raises
without impacting greater tubercle
onto acromion process
 Deltoid pulls humerus up, RC pulls
humerus down and into glenoid fossa
clears subacromail space
3/23/2010
Functional Anatomy
 Scapulothoracic jt is a
physiological jt, it has no
ligamentous attachments, only
supported by muscles and fascia
 Allows for elevation, depression,
protraction & retraction – gliding
movements
 Provides stability for the
shoulder to perform pressing
movements – must rotate to
allow humerus to be positioned
properly without banging into
acromion
Functional Anatomy
 Biceps tendon joins into the
shoulder on anterior lesser tubercle,
as well as coracoid process running
through bicipetal groove in humerus
 Held in place by transverse humeral
ligament. If damaged, biceps tendon
will pop out of bicipetal groove
 Serratus muscles stabilize scapula to
ribs, and protract and retract scapula
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Functional Anatomy Functional Anatomy

Static & Dynamic Stabilizers of the Scapula & GH Joint (Table 17.1)
 Scapula supported by Description
trapezius, thoracocervical Scapula: weight of upper extremity
creates downward rotation &
fascia, and rhomoids forward tipping on scapula
GH joint: In dependent position: if
 Postural difficulties can alter scapula is in normal allignment,
weight of arm creates adduction on
the mechanics of scapular humerus
mobility, leading to
Static Stabilizers Dynamic Stabilizers
Cohesive forces of scapular bursa Upper trapezius, serratus anterior,
middle trapezius & rhomboids
Superior capsule & suprahumeral Rotator cuff, deltoid, long head of
ligament are taut biceps brachii
Adhesive and cohesive forces of
synovial fluid and negative joint
pressure
Glenoid labrum

dysfunctional movements When humerus is elevating and

scapula is rotating upwards
Tension placed on static restraints
by rotator cuff
RC & deltoid; elbow adduction
brings in 2-joint muscle support

from the shoulder GH ligaments provide inferior

translation of humeral head
Long head of biceps stabilizes
against humeral elevation
Long head of triceps stabilizes
againt inferior translation
“Therapeutic Exercise, 5th edition” Kisner & Colby, 2002

MOVEMENT CAPABILITIES MOVEMENT CAPABILITIES

 Normative values
 Flexion – 150-180˚  Adduction – 180 ˚ NOTE QUALITY OF MOVEMENT

 Extension – 50-60 ˚ Note: new research shows people over 50 years old  Abduction – 0 ˚
have significantly lower active and passive ROM
(Gill et al. Br. J. Occ. Ther 2006)

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MOVEMENT CAPABILITIES MOVEMENT CAPABILITIES

 Scapular mobility
 Elevation – 35-40 ˚
 Internal Rotation – 70-90 ˚
 Depression – 10 ˚
 External Rotation –90 ˚
 Protraction –
 Athletes typically do NOT exhibit normal ROMs for
any movement path  Retraction –
Range of Motion data from the American Academy of Orthopaedic Surgeons (Greene and Heckman 1994)
Rang

Movement Capabilities Movement Capabilities - Grading

 With age, the shoulder will lose its’ ROM in
external rotation, then abduction, horizontal
adduction, and internal rotation
 Highest incidence of reduction on aging racket
sport players and golfers.
 Decreased tissue density leads to decreased
tensile strength, increased likelihood of injuries
 0 – Zero – No evidence of contractility
 1 – Trace – Evidence of Contractility, no joint motion
produced
 2 – Poor – Complete ROM with gravity eliminated
 3 – Fair – Complete ROM against Gravity
 4 – Good – Complete ROM against gravity with
some resistance
 5 – Normal – Complete ROM against gravity with full
resistance

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Shoulder injuries
 Extremely mobile, minimal bone support. Collection of hanging jts
ROTATOR CUFF TEAR
◦ Sternoclavicular  Page 138, 179
◦ Acromioclavicular
 What is the main role of the rotator cuff?
◦ Coracoacromial
◦ Coracoclavicular  Does the rotator cuff contract to cause
◦ Glenohumeral movement, or prevent excessive movement?
◦ Scapulothoracic
 How does the rotator cuff become injured?
 What can we do to prevent or rehabilitate
 Only sternoclavicular jt binds shoulder to rest of the body
 Chapter 17: pages 555-644 rotator cuff injuries?
 Chapter 18: pages 645-742

Rotator Cuff Tear

Rotator Cuff Tear
 Typically, rotatorcuff tears result in
 The RC deteriorates with age
supraspinatus tendon
◦ RC tendons decrease elasticity, decrease concentration
 Repetitive movements where tendon of strong collagen fibres, decreased density of collagen
is compressed & rubbed between  meaning most people will develop some form of
acromion process & greater tubercle RC problem over time
can cause fraying or complete tear
 Someone with signs of impingement has a high
 Other common injuries from sports chance of developing rotator cuff tears
are rapid force application of the
muscle while stretched that causes an
internal rupture

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ROTATOR CUFF TEAR
 Subacromial space is typically
only 9-11 mm, and has to
accomodate the supraspinatus
and sub-acromial bursa
 The supraspinatus causes
shoulder abduction for the
first 20 degrees. Many sports
& recreational activities
perform arm movements like
this repetitively
ROTATOR CUFF TEAR
 Commonly injured in swimmers and
baseball players during the recovery phase
in swimming and the acceleration phase in
throwing
 Typical compensation involves using the
supporting musculature to create
movements
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ROTATOR CUFF TEAR
 The rotator cuff acts like suspension
cables holding up a tent. They don’t
cause a lot of movement but they
resist excessive movement of humerus
in the glenoid fossa in all directions
 Blend together at humerus to form a
common tendon (RC tendon)
 RC injuries occur when there is either
too much force applied, or not enough
force applied in one or more directions
to cause an imbalance
Rotator Cuff Tear
 With a high incidence of injury in sports, the
rotator cuff function is vitally important to
athletes
 Most injuries come down to technique faults,
muscle imbalances (postural or non-postural)
and less frequently to acute injury
 Conditioning for the rotator cuff is most often
excessive, resulting in hypertrophy of
supraspinatus muscle, ligament stiffness and
accompanied tendonitis
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Rotator Cuff Tear

 RC tears will present pain with
abduction past 30˚, flexion past 30˚,
resisted internal or external rotation; as
well as loss of function in any/all these
movements
 Minor tears (stage 1, also called
“impingement”) will not present much
functional limitation but highly painful
(nerve irritation), while advanced tears
(stage 3-5) will present loss of function,
swelling, and minimal pain in the arm
during movement – no nerve irritation
Rotator Cuff Tear
 Non-athletes tear RCs through repetitive
occupational (reaching for high shelves, mechanics,
drivers) or recreational activities (gardening,
shovelling, fishing, etc)
 May or may not lose ability to do activities, or may
create compensation patterns to avoid pain while still
performing movements (shoulder shrug)
 Typically only seek treatment after problem
eliminates the chance of performing a movement

Rotator Cuff Tear Rotator Cuff Tear – Non

Non--surgical
Stage of Program Goals Indications Contra-indication
 STEP ONE: Refer to a HCP to get a Weeks 1-2 Increase RC strength, Rubber tubing, post. Overhead movements,
proper diagnosis and course of action. If endurance & flexibility Shoulder, seated pushups, pressing with arms higher
isometrics, pendulum than 20˚ below
the injury is unstable, training WILL make horizontal, heavy loading,
it worse. pain, swelling numbness

 Perform an active assessment on the Weeks 3-4 Increase global

endurance, quadrant
Pressing movements
below shoulder height,
Same as weeks 1-2,
reduce intensity &
region to determine level of function and flexibility, strength rowing, PNF patterns, low volume with presence of
limitations, refer back to HCP with findings loading, continue rubber
tubing
DOMS

if necessary Weeks 4-8 Strengthen fast twitch Job-specific strengthening, Same as weeks 3-4,
 Refer to Practical Workbook for Sample fibres, increased loading, loading that causes
maintain/strengthen increase from 2 sets to 3 fatigue, fast movements
Program designs posture, strengthen for sets, begin overhead
occupation & recreation movements with low
 Once cleared to exercise, the progression loads
will be as follows:
Program Specifics found in the “Active Post-Rehab Specialist” Workbook

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Rotator Cuff Tear – Surgical

Rotator Cuff Tear - Surgical
Type of Surgery Indications Outcomes Red Flags

 Follow surgeons/physiotherapists recommendations

Arthroscopy Small (<1 cm) tears,
presence or tear limits
Sling 1-2 weeks, followed
by GH mobilization,
Swelling, radiating pain,
sudden loss of function,
based on type of surgery performed
function, but does not supraspinatus less than full ROM, loss of  Ensure full ROM, no swelling, no radiating pain prior
impede function strengthening, Active- mobility in peripheral jts,
assisted stretching, loss of stability to beginning, or receive medical clearance with
therapeutic modalities
Mini-open Arthroscopy Moderate (1.5-3.5 cm) Sling 3-6 weeks, return to Same as above
indications and contraindications
tears, or multiple sites, full ROM, strength &
requires splitting the flexibility slowly (atrophy,
deltoid, noticeably deinervation)
impedes function http://video.google.ca/videosearch?sourceid=navclient&rlz=1T4SNCA_en
Traditional Open, Large (>5 cm) tear, Deltoid is detatched from Same as above CA289CA311&q=rotator%20cuff%20surgery&um=1&ie=UTF-
acromion resection multiple sites,
subacromial
acromion, arm is slinged
in abduction 4-8 weeks,
Stretch & strengthen
deltoid, trapezius,
8&sa=N&hl=en&tab=wv#sourceid=navclient&rlz=1T4SNCA_enCA289C
decompression is highly same goals as above adduction muscles A311&q=rotator+cuff+surgery&um=1&ie=UTF-
involved
8&sa=N&hl=en&tab=wv&start=10

AC joint Injury AC joint Injury

 Page 157, 174
 Typically happens with impact on the hands (during a fall),
direct loading from above (contact with another object
onto the AC joint area), or repetitive strain through
overhead extension
 Degree of sprain/separation is determined by damaged
structures (tear to coracoacromial ligament separates
grade 2 & 3)
 Commonly presents with anterior superior displacement
of clavicle and looks like a bump on the shoulder, night
pain, pain with activities where arm moves from body

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AC Joint Injury
 The Rockwood classification is as follows:
 Type I - Minor sprain of AC ligament, intact capsule, intact CC ligament,
intact deltoid and trapezius
 Type II - Rupture of AC ligament & joint capsule, sprain of CC ligament
but CC interspace intact, minimal detachment of deltoid and trapezius
 Type III - Rupture of AC ligament, joint capsule, & CC ligament; clavicle
elevated (~100% displacement); detachment of deltoid and trapezius
 Type IV - Rupture of AC ligament, joint capsule, & CC ligament; clavicle
displaced posteriorly into trapezius; detachment of deltoid and
trapezius
 Type V - Rupture of AC ligament, joint capsule, and CC ligament;
clavicle elevated (>100% displacement); detachment of deltoid &
trapezius
AC joint injury
 Joint is typically 1-3 mm wide in young adults, but
shrinks to 0.5 mm in older adults – less room for
error
 Joint is covered by a thin joint capsule and 4 small
ligaments
 Provides strength to joint in anterior and posterior
translation – not protected in proximal translation!!
 Test: adduct the arm across the body. May present pain
with posterior capsule tightness and impingement
syndrome, but will be a dull type pain. Sharp pain at the
site of the AC indicates an AC sprain
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AC joint Injury
 Presents with painful arc, horizontal
adduction; limited ability to perform
repetitive movements, lack of overhead
mobility
 Damaged AC ligament, as well as potential
bone spur formation. Compression of joint
leads to pain in 71-120˚ range of abduction
 Gliding of AC joint (compression of
Kenny-Howard harness
acromion distally from clavicle) would cause
pain – stretching damaged ligaments
AC Joint injury
 Reduction in strength is typically found in abduction,
flexion and terminal internal rotation
 Movements that suffer are throwing, pressing, and
diagonal movements requiring D1 PNF patterns
(compression of acromion into clavicle)
 Movements that need to be strengthened are pulling
movements, adduction, and external rotation
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AC Joint Injury AC Joint Injury

Stage of Program Goals Indications Contraindications
 STEP ONE: Refer to a HCP to get a proper diagnosis Stage 1: Weeks 1-4 Rotator cuff Increase strength of RC through Pain/inflammation with
and course of action. If the injury is unstable, training strengthening int & ext rot, maintain flexibility mov’t, mov’ts where they
through int & ext rot, ext, some can’t see hand, night pain,
WILL make it worse. flex & abd neuralgia, visible
 Perform an active assessment on the region to deformation of joint

determine level of function and limitations, refer back Stage 2: Weeks 4-8 Scapular stabilization Increase mobility and stability of
scapula against minor/mod
Overhead mov’t, adduct
mov’t, abduct above
to HCP with findings if necessary resistance horizontal, pain with
mov’t night pain
 Refer to Practical Workbook for Sample Program
Stage 3 :weeks 6-12 Trunk stabilization Increase global mov’t capability, Mov’ts where they can’t
designs pressing strength, pulling see hand, adduct with
strength, PNF patterns resistance, pain,
 Once cleared to exercise, the progression will be as
Stage 4: Weeks 12-16 Increasing loads Submaximal RT for pulling and Pain, RT to failure or
follows: scap depression mov’ts, 50% load fatigue,
for pressing mov’ts, limited
overhead

AC Joint Injury – Surgical Repair Adhesive capsulitis

 Page 175
 Typically called Frozen Shoulder, the movement of the
 http://www.youtube.com/watch?v=JmSpqj4tj5I&feature=related glenohumeral joint is limited, and movement of the
shoulder is accomplished almost primarily through the
movement of the scapula.
 Scapulothoracic rhythm is typically 2:1,
but in this case is 1:1
 Thickened and scarred coracoacriomial
ligament, leads to other ligamental
thickening and scarring to take up slack

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Adhesive Capsulitis
Adhesive Capsulitis
 1st stage – freezing - (10-36 weeks), very sore, achy
and troublesome: joint capsule is tight and minimal
mobility without pain
 2nd stage – frozen - (4-12 months), highly restricted
movements, minimal pain unless at terminal ROM
 3rd stage – thawing - (6 months up to a year),
spontaneous recovery. No known reason why.
 May take 1-4 years to fully recover. Can only
vigorously stretch to manage condition (stretching
shoulder capsule)
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Adhesive Capsulitis
 Decreased synovial fluid in GH jt, restriction of “slack”
in joint capsule, decreased water content of collagen
fibres (also present in diabetics),
shortened/thickened/inflammed stabilizing muscles,
decreased blood supply to RC (specifically
supraspinatus), degenerative changes to GH jt.
 One or more of these may lead to development of
reduced ROM in GH jt, and present as frozen shoulder
Adhesive Capsulitis
 Females affected more than males, common in middle
age/early geriatrics, no differentiation in race, more
common with diabetics
 Loss of ROM is most commonly found in ex rot,
abduction, flexion (involves stretching of anterior
capsule)
 Majority of movements will be performed with hand
below the navel
 Include more passive stretching than active (pulley
systems, partner assisted, gravity assisted)
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Adhesive Capsulitis Shoulder Dislocation

 As spontaneous resolution does occur (but takes a  Page 176
long time), main function is to maintain or gain as much  Humerus forced anteriorly and
passive ROM in the shoulder as possible, and maintain distally out of glenoid fossa – typically
fitness through entire body during this process. falling onto back onto an
 Function may return to full, or may be somewhat outstretched hyperextended arm,
reduced afterwards, so manage function as movement direct impact to shoulder while ext
returns. rot & abducted
 Contraindications: condition gets worse, other  Sudden impact, immediate loss of
comorbities get worse (acute injury, diabetes, etc), function, intense pain, and noticeable
swelling in area, loss of function in opposing limb deformation to the shoulder

Shoulder Dislocation Shoulder Dislocation

 Bankart lesion – injury to
anterior labrum due to
dislocation
 Hill-Sachs lesion –
compression fracture to
posterolateral surface of
humerus
 DLC commonly results in
humerus in the subcoracoid
region, rarely in intrathoracic
region
 As ligamental and capsular structure is
compromised, recurrent dislocations are
common, especially in activities involving
overhead movements or impact
 Proximity to blood and neural vessels make
reduction very important, and must be handled
properly to prevent further damage
 Commonly results in RC tear (partial or
complete)
 SLAP tear – Superior Labrum, Anterior to
Posterior
 TUBS – Traumatic, Unilateral, Bankarts lesion,
Surgery required

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Shoulder Dislocation Shoulder Dislocation

Stage of Program Goals Indications Contraindications
 Commonly isolated for a period of time determined
Stage 1: 1-4 weeks Stabilization of GH Isometric exercises, Abd & ext rot mov’ts,
by surgery requirements (more time if no surgery), passive stretching of post pressing, secondary dlc’s,
typically 2-4 weeks, up to 6-8 weeks depending on capsule, small ROM
ecc/conc exercises, high
ant capsule stretching, D2
PNF patterns
age and activity volume low resistance, D1
PNF patterns
 Frozen shoulder can develop in older clients if Stage 2: 4-12 weeks Strengthen and stabilize Continue to stabilize GH, Abd & ext rot mov’ts,
GH strengthen RC through pressing below 45˚,
isolated for extended periods short ROMs, add short secondary dlc’s, ant
ROM pressing mov’ts, capsule stretching, D2
 Exercises focus on RC strengthening in small ROMs keep hands in front of PNF patterns
eyes
or isometrics, minimal/no stretching of anterior Stage 3: 12-36 weeks Strengthen GH & scapula Increase ROM slowly, Abd & ext rot move’t
capsule, gentle passive stretching of posterior capsule keeping hands in view of beyond 45˚, pressing
eyes, increase resistance below 45˚, secondsary
before increasing ROM dlc’s, resisted D2 Patterns

Elbow & Wrist Functional Anatomy Elbow & Wrist

Functional Anatomy

Median nerve , radial

nerve, brachial artery
Chapter 9, Chapter 10,
& branches
Page 181 Page 207

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Elbow & Wrist Functional Anatomy

Elbow Functional Anatomy
 Elbow is a collection of joints between the distal
humerus, and proximal radius and ulna:
◦ Radioulnar
◦ Radiohumeral
◦ Ulnohumeral
 Primary movements of the elbow include
flexion/extension, and pronation/supination
 Elbow is a synovial joint, and is contained in a joint
capsule

Elbow Functional Anatomy Elbow Functional Anatomy

 Proximal ulna has protrusion called
olecranon process that “locks” it onto
humerus
 This makes elbow a very strong joint,
resilient to shear and compressive forces
 Common ROM measurements:
◦ Flexion: 0-150˚
◦ Extension: 0 to -10˚ (slight hyperextend)
◦ Pronation & supination - 80˚ each way
◦ Error is +10˚
 Elbow is supported on the medial side by
the ulnar collateral ligament, on the lateral
side by the radial collateral ligament, joint
capsule and bony structures
 23 muscles are associated with the elbow
joint, and give it tremendous stability and
strength
 Stability = mobility!!

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Elbow Functional Anatomy Elbow Functional Anatomy

 Medial epicondyle (proximal ulna) is common  Pronator muscle and flexor muscles
attachment for the flexor muscles of the forearm can compress median nerve
 Lateral epicondyle (proximal radius) is common  Postures that require prolonged
attachment for the extensor muscles of the forearm pronation (use of a keyboard) can
 Pronation occurs through the pronator teres, while cause pronator to become hypertonic,
supination occurs through the biceps brachii and the thus pinching the nerve and causing
supinator (minimally) pain down the arm
 Radioulnar jt is a pivot joint, allowing rotation while  Highly linked to carpal tunnel
maintaining strength through axial loading syndrome

Golfer’s Elbow Golfer’s Elbow

 Page 203
 Ulnar nerve is in close
 Golfer’s elbow (medial
epicondylitis) results from proximity to the medial
inflammation of the origin of the epicondyle, so if
flexor muscles due to excessive inflammation leads to
force production in transverse swelling, the unlar nerve can
internal rotation (golf swing, racket
sport forehand) be compressed
 Typically a result of technique  This can result in numbness
faults, improper conditioning or tingling in 4th & 5th fingers
(tournaments), and long duration (pinkie & ring)
of play

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Tennis Elbow
 Tennis elbow (lateral
epicondylitis) occurs with
inflammation of the common
origin of the extensor
muscles of the forearm
 Common in racket sports
requiring backhand
movements, as well as office
settings
Tennis Elbow/Golfer’s Elbow
Stage Goals Indications
Stage 1: Weeks 1-6 Manage inflammation,
increase pain-free
Active mov’ts against
direction of injury, passive
flexibility mov’t with direction of injury,
active anti-inflammation
modalities
Stage 2: Weeks 6-12 Increase active mobility,
strength and endurance
Active mov’ts in direction of
injury, passive and active
stretching in direction of
injury, low-load/low-volume
RT
Stage 3: Weeks 12-26 Return to activity Activity-specific mov’ts, low-
mod load, low volume, active
& passive stretching and
antiinflammation modalities
3/23/2010
Tennis Elbow/Golfer’s Elbow
 Commonly use counter-force braces
to reduce the expansion of tissues
due to inflammation, and reduce the
force at the site of the common
tendon origins
 Shown to be effective at allowing
individual to continue playing, but
doesn’t cure injury
 Only cure is rest
Contraindications
Carpal Tunnel Syndrome
Contraction in direction of
injury, high-load/high-volume
 Page 249
activities, activity without
using counter-force brace,
 Collection of neurovascular and
swelling, numbness, or pain tendinous structures enter the hand
under a broad band of thick, dense
Hihg-load/high-volume
activities, activity without
connective tissue called the flexor
using counter-force brace, retinaculum
swelling, numbness or pain
 Carpal tunnel formed under the
flexor retinaculum, above the carpal
Pain, swelling, numbness
inflammation, activity
bones, and between the flexor
without counter-force brace tendons of the hand
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Carpal Tunnel Syndrome Carpal Tunnel Syndrome

 Common in occupational settings that require
continuous use of the hands (office work,
construction, massage therapy)
 Can be mild to debilitating levels of pain
 Results from tendons and flexor retinaculum
becoming inflamed, thus shrinking the space for the
median nerve to pass through the carpal tunnel
 Compression of the nerve results in painful sensation
in the thumb, index, middle and medial half of ring
fingers

Carpal Tunnel Syndrome Carpal Tunnel Syndrome

 Surgical interventions invole splitting
the flexor retinaculum to release the
median nerve without cutting the
superficial fascia
 This increases the space for the
median nerve to move through, but
in many cases can result in a relapse
 Heavy gripping or pinching
movements, or activities that use the
hands for extended periods of time
should be avoided
 Tinel’s sign – compression of the median
nerve at the site of the carpal tunnel, as
well as at the medial epicondyle, will elicit
pain, numbness or reflex contraction in
the hand
 Phalen’s Sign – holding maximal flexion
for 30-60 seconds increases the pressure
in the carpal tunnel, and produces carpal
tunnel symptoms
 Grip strength – have client squeeze your
index & middle fingers, try to pull fingers
out.

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 3/23/2010

Carpal Tunnel Syndrome

Stage Goals Indications
Stage 1: weeks 1-6 Maintain anti- Maintain neutral wrist, may
inflammatory regimen need splinting, ice as
needed
Stage 2: Weeks 6-16 Return to specific Include functional training
activities methodologies to return
to work/activity, maintain
neutral wrist, strengthen
scapular stabilizers
Contraindications
Large wrist ROM, high grip
strength exercises, high
volume activities, leaning on
handlebars, small diameter
grips
End of Upper Quadrant
Large wrist ROM, repetitive
mov’ts, vibrations through
hand, high grip strength
exercises, loading through
wrist exttension (bench
press)

Stage 3: Weeks 16-36 Manage symptoms, Increase loads & volume High grip strength exercises,
increase functional slowly, continue to repetitive mov’ts, vibrations,
capabilities increase overall fitness loading through wrist
extensions

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