Manual Therapy for the Elbow/Forearm/Wrist/Hand

Clinical Application Worksheet

Course Objectives Covered: 2, 3, 5, 9, 12, 13.

Associated CAPTE Standards:
- 7D20: Evaluate data from the examination to make clinical judgments.
- 7D27: Competently perform physical therapy interventions to achieve patient/client goals and outcomes.
- 7D30: Monitor and adjust the POC in response to patient/client status.
Instructions:

 Impairment/limitation is provided.
 Select 3 varying manual interventions (mobs, STM, stretching, MWM, PNF, etc.) that would be most
appropriate to address the impairment or functional limitation.
o Prescribe manual interventions not only from this course but also techniques learned in PTH646 or during
your clinical experience.
o Must provide a VARIETY of techniques/ideologies (Don’t use all Maitland mobs in one impairment)
 Provide intent and details/dosage for chosen techniques.
o Intent = to create change within a particular structure (joint capsule, connective tissue, soft tissue, neural
tissues) that will contribute to reducing/eliminating the dysfunction/impairment. (e.g. applying a sustained
inferior glide to the GH joint during active shoulder abduction allows for improved clearance of greater
tuberosity under acromion.)
o Details/Dosage = rate/rhythm, amplitude, relationship to barrier, frequency/duration, reps/sets as it relates to
the general purpose (e.g. joint decompression, reduce pain, improve mobility) and based on the
methodology/school of thought (e.g.. Maitland, Kaltenborn, Mulligan, etc.). Link the joint mobilization
grading descriptions to this.
 Practice hands-on techniques with your partner.
 Scoring: .25 pts. per item (technique = .25, intent for technique = .25, dosage/details = .25, multiplied x 3 for
each impairment/limitation).

Elbow/Forearm:

1. Limited elbow extension ROM with firm end feel - you identify Radiohumeral joint restrictions
Technique Intent Dosage/Details
1. Humeroradial Providing a long Patient supine with arm at side and elbow in the open-packed position of
traction axis traction force at full extension and supination
the joint will Kaltenborn Grade II: PT stabilizes the humerus with one hand applying a
increase synovial long-axis traction force on the radius holding for 5 seconds between R1
fluid and blood flow and R2 10 times moving closer to extension restriction each time
and correct any
positional faults of
the radius
articulating with the
humerus
2. Mulligan Providing Patient supine with fist clenched
MWM for medial/lateral slides PT will provide a medially directed force on the humerus while applying a
extension at the humeroradial laterally directed force on the radius and ulna as the patient actively flexes
and humeroulnar and extends their elbows for 15 repetitions or until ROM deficits are
joint will attempt to corrected
correct any
positional defaults
that may be limiting
mobility of the joint
3. A-P Providing a Patient supine with towel under humerus with joint in full extension and
humeroradial posteriorly directed supination

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 glide glide to the joint Maitland Grade III: PT will apply repeated large amplitude oscillations in
will improve the posterior direction of the radial head on the humerus between R1 and
athrokinematic R2 for 30 seconds 3 times
extensibility and
will improve
extension ROM

2. Painful elbow flexion ROM

Technique Intent Dosage/Details
1. Mulligan Providing Patient supine with fist clenched
MWM for medial/lateral slides PT will provide a medially directed force on the humerus while using a
flexion at the humeroradial belt with hips/glutes to provide a laterally directed force on the proximal
and humeroulnar forearm as the patient actively flexes and extends elbow for 15 repetitions
joint will attempt to or until ROM deficits are corrected
correct any
positional defaults
that may be limiting
mobility of the joint
2. Humeroulnar Providing a Patient sidelying with joint in the open packed position 70° flexion and 10°
joint traction distraction force at supination resting on PT shoulder
the joint will PT will stabilize the humerus and apply an inferior glide of the ulna on the
improve blood flow humerus and hold for 3 seconds and repeats 10 times or until pain with
and synovial fluid ROM has decreased
flow to decrease
pain with ROM
3. Muscle Providing Patient supine with elbow flexed to their midrange
energy progressive Patient will perform an isotonic concentric contraction of their elbow
technique- resistance to the flexors as the PT applies force into elbow extension for 5 seconds and will
isotonic biceps brachii will be repeated 3 times
contraction strengthen the
for biceps muscle and improve
brachii pain-free elbow
flexion if the muscle
is limiting the ROM
using reciprocal
inhibition to also
inhibit the elbow
extensors

3. Lateral elbow tendinopathy (chronic) and decreased extensor mm mass extensibility

Technique Intent Dosage/Details
1. Direct pin Providing a direct Patient supine with forearm pronated
and stretch to technique to the PT will apply pressure to a tender spot at the common extensor tendon
common extensor tendon will with one hand and will use the other hand to extend the wrist to lengthen
extensor lengthen the tissue the muscles for 3 minutes
tendon and increase
extensibility of the
extensor muscles
2. Muscle energy Using autogenic Patient seated with elbow extended
technique- isometric inhibition principles Patient will perform a light isometric contraction of their wrist extensors
contraction to relax the into the PTs hand for 5 seconds and will relax for 5 seconds, repeated 5
antagonist muscle times
mass will increase
resting length of the
muscle fibers and
improve
extensibility
2. Indirect Providing an Patient supine with elbow in a neutral position
common indirect technique to PT will apply pressure at a tender point of the common extensor tendon
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 extensor the extensors will and will use the other hand to passively move the wrist and fingers into
release provide a positional extension and will hold for 60 seconds
release and relax the
shortened muscle
fibers

4. Limited supination ROM

Technique Intent Dosage/Details
1.
2.
3. Radial head
HVLAT

5. Decreased elbow ROM with functional difficulties including holding phone to ear and eating (bringing fork to mouth)
Technique Intent Dosage/Details
1. MET
2. Mulligan
MWM
3.

Wrist and Hand:

1. Hand stiffness with difficulty forming cylindrical grip/opposition

Technique Intent Dosage/Details
1.
2.
3.

2. Limited wrist radial deviation

Technique Intent Dosage/Details
1.
2.
3.

3. Limited wrist extension ROM due to adaptive shortening of joint capsule and long digital flexor muscles
Technique Intent Dosage/Details
1.
2.
3.

4. 2nd MCP ROM loss in frontal and sagittal planes

Technique Intent Dosage/Details
1.
2.
3.

5. Hypomobility of CMC and IP joints of digits 4 & 5

Technique Intent Dosage/Details
1.
2.
3.

BONUS (not required, but +2 point overall if all scenarios listed below are completed per the following instructions):
For each listed dysfunction above, consider a therapeutic exercise to correspond and build off your manual therapy
intervention. Must consider:

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- purpose and dosing (dosing specific for joint or soft tissue extensibility to improve ROM, improving strength, or
increasing endurance)
- a potential progression and regression of your chosen exercise based on patient capabilities and symptoms. This might
mean considering additional causes or contributions to the dysfunction listed: (e.g., soft tissue extensibility or muscle
recruitment limitations contributing to ACJ pain and limitations with OH reaching). Be creative!!

1. Limited elbow extension ROM with firm end feel - you identify Radiohumeral joint restrictions.

2. Painful elbow flexion ROM

3. Lateral elbow tendinopathy (chronic) and decreased extensor mm mass extensibility.

4. Limited supination ROM

5. Decreased elbow ROM with functional difficulties including holding phone to ear and eating (bringing fork to mouth)

6. Hand stiffness with difficulty forming cylindrical grip/opposition.

7. Limited wrist radial deviation.

8. Limited wrist extension ROM due to adaptive shortening of joint capsule and long digital flexor muscles

9. 2nd MCP ROM loss in frontal and sagittal planes.

10. Hypomobility of CMC and IP joints of digits 4 and 5.