A.

Soft tissue injuries of the elbow

1. Lateral epicondylitis (Tennis Elbow)– Called lateral epicondylitis not because of
inflammation, misnomer or faulty naming (Lateral epicondylosis) Degeneration of the lat.
Epicondyle, secondary caused by the inflammation of the tendons that originate on the lateral
epicondyle
- Most common lateral elbow pain
- Also known as tennis elbow – mostly tennis player experience this (when they perform
back hand stroke)
- during the backhand swing tennis players tend to produce a faulty mechanism, excessive
extension of the wrist causing pain in the lateral epicondyle or the tendons that attached
to the lat. Epicondyle.
Etiology
- Secondary to repetitive UE motions, excessive wrist extension, gripping and lifting
- Vibrations common on drivers
- Raquet sports – because of faulty backhand stroke, excessive contraction of the wrist
extensors irritating the origin at lateral epicondyle.
Epidemiology
- Common in male than female because in the population of tennis players
- 35 above
- Work-related – repetitive micro trauma, severely damaged needs surgery.
Special Test
(Method 1) Cozen’s test - resistance
- Ask the patient to flex the elbow, extend and radially deviate the wrist
- You must resist the motion by pushing the hand into flexion and ulnar deviation
(+) pain in the lateral epicondyle
(Method 2) Mill’s test - stretching
- Ask the patient to flex the elbow
- You are to passively stretch the wrist by flexion and ulnar deviation
(+) pain in the lateral epicondyle
(Method 3) Maudsleys – dirty finger
- Ask the patient to rest their hand on the table and ask to lift the middle finger
- You must resist the lift
(+) pain in the lateral epicondyle

PT management
- Icing (direct 3-5mins) (CBAN) cold, burn, aching, numbness.
- Splint (cock up – slight extension)
- Stretching – wrist flexion
- Medicine – corticosteroid injection

2. Medial epicondylitis (Golfer’s Elbow) – Called medial epicondylosis not because of

inflammation, misnomer or faulty naming (Medial epicondylosis) Degeneration of the medial
epicondyle, secondary caused by the inflammation of the tendons that originate on the medial
epicondyle.
 - Overused of the forearm flexors and pronators
- Common in Golfer’s excessively flex their wrist when hitting the ball
- During the stroke of the golf club when the golfer tend to produce a faulty mechanism,
excessive flexion of the wrist causing pain in the medial epicondyle or the tendons that
attached to the medial epi.

Clinical manifestation
- Localized pain in the medial elbow occasional radiation into the forearm
- Symptoms would be painful when the patient is resisting wrist flexion and forearm
pronation and passive wrist extension and FA supination, tight fist.

Special test
Medial epicondylitis (Golfer’s elbow test)
- Ask the patient to flex the elbow and pronate the forearm
- You are to passively extend the wrist and supinate the forearm to stretch the muscles that
originate on the medial epicondyle
(+) pain in the medial epicondyle

PT management
- (Pain control) ask the patient to discontinue any aggravating activities
- Modalities – cryo therapy
- Splint – neutral wrist splint
- Sport modification - Improve trunk rotation for the golfer
- Medicine – analgesics

3. Olecranon bursitis. (Miner’s elbow) Inflammation of the bursa that is directly on the
olecranon process or elbow point

- It is called miner’s elbow because miners they are always asked to crawl underground.
- crawling produces impact on the olecranon that causes olecranon bursitis/ repetitive trauma
- most commonly seen in wrestler’s, weightlifter’s, gymnasts, skateboarders/rollerbladers that
do not wear an elbow pad

Etiology
- (Septic) result of a localized or systemic infection
- There is inflammation, redness and warming of the olecranon
- Limited elbow ROM
- (Aseptic) traumatic injury
- Chronic bursitis – repetitive microtrauma/ small abrasion or laceration
- Seen in athletes of football and hockey

Clinical manifestation
- Pain and swelling
- Chronic – not painful, thickened and boggy (small liquid pouch)
PT Assessment
- ROM – flexion, extension
- MMT -
- LGM – limb girt measurement if there is swelling, take note and measure the small liquid
pouch to have a baseline if the swelling has subsided
PT management
- Icing
- Elbow pad to protect the olecranon
- Bandaging to reduce the swelling of the olecranon bursa
- ICP – intermittent compression pump – sleeve like device will compress and pump to
drain the edema.
- Medicine – sterile aspiration ff by compressive dressing to avoid refilling of the liquid
into the bursa
- NSAID, corticosteroid injection

4. Triceps tendinitis – inflammation of the triceps tendon, tendon that inserts in the olecranon
fossa

- Repetitive overuse or extension overload at the elbow

- Most commonly seen in boxers, pitchers, weightlifters, bowlers and gymnasts.
- Pain is reproduced in resisted elbow extension and passive elbow flexion and shoulder
Forward flexion
- Snapping sensation – not common but may occur by subluxation of the medial head of
triceps over the medial epicondyle.
PT Assessment
- MMT
- ROM
- LGM
PT management
- Activity modification with the limitation of full elbow extension
- Modalities if acute cryo, if subacute to chronic heating
- Orthosis – limit full extension (triceps tendinitis pad)

5. Ulnar collateral ligament sprain – Valgus stress in the elbow, traumatic and repetitive
microtrauma which is throwing
Clinical Manifestation
- Medial elbow pain caused by the late cocking and acceleration of throwing. In late
cocking there is external rotation of the shoulder, it produces a valgus stress or lateral
stress of the elbow. Making it susceptible to injury
- Audible pop – tearing of the UCL
- Often an overuse type because it develops over time
- Decrease in throwing velocity
PT Assessment
Lateral Pivot shift test
- Ask the patient to position the elbow into full elevation and flexion
 - You will apply an axial load on the ulna, at the same time you will supinate the forearm
and use the other hand to apply a valgus stress
(+) pain on the UCL
(+) audible pop if acute

Ligamentous Valgus instability test

- Patient is standing, ask to position elbow into full elevation and flexion
- Apply supination force and a valgus stress on the elbow
PT management
- Discontinue throwing activities for 3-6weeks
- Hinged elbow brace – to limit full elbow extension and valgus stress
- Taping – anchor straps on the upper arm and forearm, then x tape on the medial elbow to
act as counterforce
- Proper throwing mechanism – avoid full extension
- Med/surgical – ligament reconstruction if there is full thickness tear

B. Peripheral nerve syndromes of the Elbow and Forearm

1. Ulnar Neuropathy (CTS) – as nerve emerges to the cubital tunnel, it is susceptible to trauma
and repetitive overuse
Cubital Tunnel Syndrome – tight with elbow flexion, with constant elbow flexion it produces a
nerve irritation and injury – manifested with vague elbow pain.
Weakness in adductor pollicis
(+) Fromen’s sign/ okay sign – ask the patient to pinch the paper, the patient can’t hold onto the
paper and the distal phalanx of the thumb tends to flex
(+) Jean’s sign - the distal phalanx of the thumb tends to extend upon pulling the paper

Special test
Tinnel sign – direct tapping of the nerve, to induce the sensory or the neurologic symptoms of
the patient.
(+) numbness and tingling sensation
Elbow flexion – ask the patient to flex the elbow and extend the wrist for 5 mins
(+) numbness and tingling sensation

PT management
- Medication – anti-inflammatory meds
- Elbow pads
- Surgical decompression and transposition
2. Radial Neuropathy (RTS)
Compression at radial groove is called Saturday night palsy because for example you went out
on a party on a Saturday night and you slept on one arm and had a tingling and numbing
sensation when you woke up. Also called honeymoon palsy
 - Compression of (PIN) Posterior interosseous nerve
- Nerve enters through fibrous band bet. 2 heads of supinator mm (Arcade of Frosche)
- Repetitive motion disorder – elbow extension and pronation
- Tenderness on supinator mm
- Pain elicited with resisted FA supination
- NO SENSORY DEFICIT
- Weak wrist & finger extension – chronic
- Surgical exploration and decompression – severe cases

3. Median Neuropathy (PTS)

- uncommonly injured in the upper arm
- susceptible in cases of blunt trauma or fracture
- As the nerve emerges along the distal medial humerus, it passes under the ligament of Struthers
site of compression
- Pain at medial elbow
- Distal sensory disruption
- Weakness – incl pronator teres
Pronator Teres Syndrome
- median nerve entrapment between 2 heads of pronator teres
Anterior Interosseous Nerve (AIN)
- NO SENSORY SX
- preservation of forearm pronation strength
- weakness in Flexor pollicis longus, flexor digitorum profundo’s 1 & 2, and pronator
quadratus
- loss of tip-tip (Pinch Grip Test / Kiloh-Nevin Sign) ask the px to pinch the index and the
thumb in a tip to tip manner

C. Common conditions of the wrist and hand

1. Common wrist fractures

Scaphoid - is the most fractured bone followed by lunate
Lunate – dislocate
Scaphoid - fracture
Colles fracture – presents a volar displacement of the radius, radius went to the side of the palm
(outward)
Smith’s fracture – presents a dorsal displacement (inward)

D. Soft tissue injury of the wrist and hand

1. Dupuytren’s Disease
a. Contracture thickening of palmar fascia
b. Benign hypertrophy of the fascia
 c. Epidemiology:
i. Men 7-5 x > than W
ii. Prevalence increases with age
d. Etiology:
- Autosomal dominant
- Progresses ulnarly to radially
- Result to flexion deformities of the MCP, PIP, and DIP (oc)

Clinical Manifestation:

- begins insidiously as small imperceptible nodules

- progress to thick cords
- underlying tendons, synovial sheaths, and skin layers are not affected
- Tenderness near nodules and cords c gripping & pressure
- Hallmark: palpable nodules and cords

PT Management
- Splinting
- IRR
- US
- Post-op Rehab
• ROME
• Gentle stretching
- Med/Surg - Disulfides
Surgical Fasciectomy – no longer perform “tabletop test”
Percutaneous or enzymatic fasciotomies

2. De quervain syndrome – Washer woman’s hand

- Inflammation of the synovium of the tendon
- Happens when there is forceful gripping with ulnar deviation of the wrist, Repetitive use
of the thumb.
Clinical Manifestation
- Repetitive microtrauma
- Crepitus – tiny popping sounds when moving the thumb
- Mild edema and there is tenderness over the dorsal compartment

Special test
Finklestein’s Test
- Ask the patient to grab or grip on the thumb and deviate it ulnarly
(+) pain on the first dorsal compartment of the wrist

PT Management
- Rest
- Analgesics
- Thumb spica splint
 3. Scapholunate instability
- Fall on outstretched hand, pronated forearm, wrist extended and ulnar deviation
- Scaphoid moves volar to the side of the palm, lunate and triquetrum moves dorsally –
dorsal intercalated segment instability
Clinical manifestation
- Wrist edema or inflammation, bruising to the palm, restricted ROM
- Tenderness over the scapholunate joint (Dorsum)
Special Test
Watson’s test (scaphoid shift)
- Apply a dorsally directed force on the distal scaphoid
- The px will apply radial deviation
Murphy’s sign
- Ask the px to make a fist
Med/Surg

- Should be treated surgically. 

- Chronic scapholunate injuries - more difficult to treat -> surgical intervention. 
- Partial wrist arthrodesis can

PT Management

- Pain & Inflammation reduction

- Increase ROM 
- Strengthening
- Functional Exercises

4. Triangular fibrocartilage complex injuries (TFCC)

- primary stabilizer of the distal radioulnar joint
- acute traumatic - FOOSH
- repetitive microtrauma – gymnastics

Clinical Manifestations:

- wrist catching 
- locking
- tenderness to palpation

Special test
Supination Lift Test

- ask the px to put the hand below the table and ask to put resistance on the table
- if there is no table, simply push down on the hand of the patient and ask to resist it.

(+) pain on the ulnar side

Treatment:
-surgical debridement - treatment of choice – removes any damage to create a better mesh of
reproduction of new fibrocartilage

5. First MCP joint ulnar collateral ligament sprain

 - Radially directed forces on 1st (MCP) joint -> UCL injury.
- Game keeper’s thumb, most common in skiers

Grad Signs
e
1 Tenderness to palpation
without joint laxity
2 Tenderness to palpation with
joint laxity but a good end point
3 Tenderness to palpation with
significant joint laxity and no
end point

Stener lesion - interposition of the adductor pollicis aponeurosis between the base of the first
proximal phalanx and the ruptured end of the UCL
-Prevent adequate healing -> chronic joint pain and instability.

Clinical Manifestation:
- “pop”
- feeling of instability in the joint
- tenderness
- If a Stener lesion is present -> a palpable mass on the ulnar side of the first MCP joint
(representing the avulsed UCL)
- Lack of end point during stress examination also suggests complete UCL disruption

PT Management

- Modalities
- Analgesics
- Immobilization
- Thumb spica cast (10 - 14 days)
- Followed by a wrist-hand-thumb spica orthosis (2 weeks)
- Hand-based thumb spica orthosis (2 to 4 more weeks)
- Participate in contact sports - continue to wear a thumb spica splint during competition
for the remainder of the season.
- Local taping after splinting is completed
- Gentle progressive ROM exercises

Med/Surg

- Early surgical repair -complete ruptures/Stener lesion

- Also indicated for individuals with an avulsion fracture of the base of the proximal
phalanx with angulation and displacement greater than 3 mm, or with chronic recurrent
instability

6. Injuries to the digits

1. Coach’s Finger
- jammed finger
- PIP dislocation reduced by the coach or athletic trainer
- most common dorsally directed dislocation
- If stable, it can be treated nonoperatively with splinting
- Often self-reduced, but it can become stiff and painful if not treated appropriately.

2. Mallet Finger
- rupture of the terminal extensor tendon of the distal phalanx -> loss of active extension.
Etiology:

- usually caused by forced flexion of the distal phalangeal joint

- being hit on the end of the finger with a ball, such as a baseball or basketball.

3. Jersey Finger
- Avulsion of the FDP from the distal phalanx.
- Occurs most commonly in the fourth finger
- Usually, an athlete finger is caught in the jersey, and forced extension occurs against the
contracting long flexor

PT Assessment:

- Active flexion of the digit should be evaluated

- Retraction of the tendon into the hand usually occurs unless stopped by an attached bone
fragment.
ST:
Sweater Finger Sign – flexing DIP and PIP

4. Trigger Finger
- Thickening of the proximal portion of the flexor tendon sheath
Etiology:

- Chronic irritation of the palmar surface of the MCP joint

- Thickened sheath becomes hung up at the A-1 pulley.

Clinical Manifestation

- Digit may become “stuck” and fixed in flexion until passively maneuvered

PT Assessment:

- Have the patient actively flex the digit and while palpating the volar MCP region,
passively extend the digit.
- Feel a nodule, which “pops” during extension.