An Illustrated Guide To Taping Techniques Principles and Practice Second Edition

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh 6 Apply 2 circumferential anchors of 10 cm 7 Place a strip of 7.5 cm elastic adhesive Tip: elastic adhesive bandage, using only bandage starting from the p­ osteromedial slight tension, to the midthigh and midcalf aspect of the distal anchor, spiralling The last 7.5 cm of the strip must be applied regions, covering the skin well beyond the around the lateral side of the tibia, directly to the anchor strip and must not edge of the underwrap. ­anteriorly. Cross medially below the patella be applied under tension. (The tape end with moderate tension and pull proximally will peel back if tension has not been Note: with strong tension over the medial joint released.) Re-check the athlete’s position. line to the proximal anchor. Note: This strip helps to medially rotate the tibia as well as approximate the medial joint. 138

Knee and Thigh 7 Knee sprain (MCL) 8 Place the second strip of 7.5 cm e­ lastic 9a Begin the lateral X with a strip of 7.5 cm 9b Place the next strip of 7.5 cm elastic adhesive bandage also starting at the elastic adhesive bandage from the ­adhesive bandage from the ­anterolateral p­ osteromedial aspect of the distal anchor, ­posteromedial aspect, winding behind the aspect of the distal anchor, pulling this time heading anteriorly on the medial tibia (reinforcing internal rotation of the ­proximally with some tension over the side. Pull proximately with strong tension tibia) with some tension upwards on the la­ teral joint line, to the proximal anchor. over the medial joint line to the proximal lateral aspect of the knee above the patella anchor anteriorly, releasing the tension only to the proximal anchor anteriorly. when adhering the end of the strip. Note: Note: These last two strips form an X directly on the lateral joint line, with less tension. The ends interlock with These two strips form an X directly on the the medial X over the anchors, reinforcing stability. medial joint line over the site of the medial collateral ligament. 139

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh 10 With the knee still flexed, apply a vertical 11 Apply an X of 7.5 cm elastic adhesive 12 Re-anchor the tape proximally and distally. strip of 7.5 cm elastic adhesive bandage b­ andage (fully stretched) on the posterior from the centre of the posterior of the distal knee. Note: anchor to the centre of the proximal anchor This completed butterfly must be tight to prevent hyperextension. enough to limit the last 10–15° of knee extension. 140

Knee and Thigh 7 Knee sprain (MCL) 13 Apply an oblique vertical strip of 5 cm Tip: Note: n­ on-elastic tape from the ­posteromedial When applying this strip, hold the distal The knee must remain relaxed while the aspect of the distal anchor to the end firmly against the distal anchor while athlete’s weight is borne mainly on the ­anteromedial aspect of the proximal pressing the knee into extreme varus and uninjured leg. anchor. pull up with maximal force. 141 Tip: Note: The athlete will need to hold on to the Fold the edges of the tape back on taper’s shoulder or a nearby wall for stability themselves to reinforce its strength, making at this stage. the portion crossing the ligament virtually untearable.

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh 14 Apply a second vertical strip of non-­elastic 15 Repeat the non-elastic tape X, overlapping 16 Using light tension, re-anchor the tape job tape, this time from the anterior aspect slightly anteriorly to the first tape. with two circumferential strips of 10 cm of the distal anchor to the posteromedial elastic adhesive bandage over the midthigh aspect of the proximal anchor using the and midcalf anchors. same principles as outlined in step 12. Note: The X formed by these two strips must lie on the medial line over the site of the MCL. 142

Knee and Thigh 7 Knee sprain (MCL) 17 Cover the end of the elastic tape with two 19 Wrap the entire tape job with an elastic 20 Tape the elastic wrap in place with short strips of non-elastic tape to keep the wrap prior to allowing the athlete to resume n­ on-elastic tape. elastic tape securely in place. activity. This gives the tape the time and heat necessary to set. Notes: 18 Test the degree of restriction. • For acute sprains, leave elastic wrap on a. Extension must be limited by 10°. b. There must be no medial laxity. for at least the first 48 hours. c. There must be no pain on medial stress • For back-to-sport taping, leave the testing, external rotation of the tibia elastic wrap on for 15 minutes and then under the femur or extension. remove for full activity. 143

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh Anatomical Area: Knee and Thigh T REATMENT Early Injury: Knee Sprain Medial Collateral Ligament • R.I.C.E.S. • Taping: MCL sprain, p. 136 (plus elastic wrap for first 48 hours) T ERMINOLOGY • therapeutic modalities • medial collateral ligament sprain: 1st–3rd degree of severity (see Sprains Later • continued therapy including: chart, p. 36) • internal collateral ligament sprain: 1st–3rd degree of severity Note: • pulled knee Surgery may be indicated for 3rd-degree sprain. E TIOLOGY a. therapeutic modalities • excessive inward pressure forcing the knee medially into valgus (inwardly b. transverse friction massage c. mobilizations if stiff following immobilization bent ‘knock-kneed’ position). Example: a football player tackled at the d. flexibility exercises for quadriceps, hamstrings and gastrocnemii knees from the left side may sustain a medial sprain of the left knee and • strengthening exercises (isometric at first) for quadriceps and hamstrings potentially a lateral sprain of the right knee • gradual reintegration programme with pain-free taped support: for MCL • sudden impact forcing body laterally on a fixed foot sprain, see p. 136 • often associated with other injured structures (medial meniscus, medial • total rehabilitation programme for range of motion, flexibility, strength and collateral ligament and anterior cruciate ligament: ‘the unhappy triad’) proprioception • bracing may be recommended for return to activity or for continued athletic S YMPTOMS performance if chronically unstable • local pain and tenderness on the medial side (inside) of the knee • swelling, possible bruising S EQUELAE • active movement testing: medial pain on end-range extension • medial (valgus) laxity • resistance testing (neutral position): no pain on moderate resistance • chronic instability • stress testing: • weakness of quadriceps • degeneration of medial meniscus a. 1st- and 2nd-degree sprain: medial pain with or without instability when • osteoarthritic changes tested at 30° knee flexion b. 3rd degree of severity: complete ligament rupture ‘opens up’ at 30°, can be less pain than with 2nd degree c. instability at 0° extension is indicative of a severe injury with posterior capsule involvement R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support. 144

Knee and Thigh 7 Taping for Lateral Collateral Ligament Sprains of the Knee Materials Knee sprain (MCL) Purpose Razor • supports the lateral collateral ligament (LCL) by tightening the lateral aspect of the joint line Skin toughener spray/adhesive spray • prevents the last 15° of knee extension and restricts end-range flexion slightly Underwrap • allows functional flexion and extension of the knee Lubricant Heel and lace pads Indications for use 10 cm (4 in) elastic adhesive bandage • lateral collateral ligament sprains: 1st and 2nd degree 7.5 cm (3 in) elastic adhesive bandage • post immobilization of 3rd-degree LCL sprains 5 cm (2 in) non-elastic white bandage • can be combined effectively with taping techniques MCL or for multiple knee ligament injuries 15.2 cm (6 in) elastic wrap Notes: To determine degree of injury, be certain that a competent sports medicine specialist examines the athlete. a. lateral stability should be tested at 30° knee flexion and at 0°. b. if the knee is also unstable medially at 0° extension, a serious injury is indicated. c. X-rays should be taken. • Be certain to check both medial and lateral sides of both knees for damage resulting from lateral impact. • Watch for peroneal nerve damage, weakness of eversion (outward pushing) of foot and decreased sensation – lateral side of injured leg. • Keep tabs on any necessary medical follow-up. • Ensure that anchor tightness does not compromise circulation. For additional details regarding an injury example see T.E.S.T.S. chart, p. 149. 145

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh Positioning Standing upright. Place a roll of tape under the heel of the foot of the injured knee, so that the knee is slightly flexed. The foot is turned inwards to medially rotate the tibia under the femur (releasing the tension from the MCL); 80% of the body weight should be supported by the uninjured side. Procedure 1 Make sure the area to be taped is clean 3 Begin the lateral 7.5 cm elastic adhesive NOTE: and relatively hair free. Check skin for cuts, bandage X with a strip starting anteriorly on blisters or areas of irritation before spraying the distal anchor, pulling up strongly around Be sure to maintain the knee in as much with skin toughener or spray adhesive. the tibia, and lateral to the patella, finishing valgus as possible in order to keep the on the proximal anchor posteriorly. lateral aspect shortened. 2 Apply skin toughener/adhesive spray, skin lubricant pads, underwrap and anchors as Tip: illustrated in previous technique. For more detail, see steps 2–5 of MCL Taping. For stability, have the athlete place a hand on the taper’s shoulder or use a nearby wall Tip: or other stable structure for support during the taping procedure, particularly during Apply lubricant and padding on both application of the lateral support arrows. hamstring tendons to protect tender skin from irritations, blisters and tape cuts. 146

Knee and Thigh 7 Knee sprain (MCL) 4 Complete the lateral X with a strip from 5 Repeat anchor X on the medial aspect 6 Use a vertical strip of 5 cm non-elastic the posterolateral distal anchor, pulling without causing internal rotation of the tibia tape with the edges folded in for extra up strongly to the anterolateral proximal or varus (outward) stress on the knee. strength, to reinforce the lateral ligament. anchor, with the X over the lateral joint line. Start anteriorly on the inferior anchor and Note: pull up strongly on the lateral side, ­keeping Avoid compressing the patella when the knee in maximum varus, and adhere taping. the tape securely to the proximal anchor posteriorly. 147

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh 7 Complete this laterally reinforcing X with 8 Apply the second white tape X slightly 9 Remember to anchor the tape job. a second vertical strip starting p­ osteriorly ­posterior to the first, with the X at the joint on the distal anchor, and crossing the line. 10 Before applying elastic wrap, test for p­ revious strip at the joint line. Maintain degree of restriction: m­ aximal varus while adhering the end to the ­proximal anchor anteriorly. a. extension must be restricted by 10° b. there must be no lateral laxity and Note: c. there must be no pain on lateral stress It is important to place these crosses over the lateral joint line well behind the patella. testing (bending outwards) or extension. 11 Continue with steps 16, 18 and 19 in the previous (MCL) taping, pp. 142-143. Note: • For sprains: leave elastic wrap on for at least the first 48 hours. • For back-to-sport taping, leave elastic wrap on for at least 15 minutes and remove for full activity. 148

Knee and Thigh 7 Anatomical Area: Knee and Thigh T REATMENT Knee sprain (LCL) Early Injury: Knee Sprain: Lateral Collateral Ligament • R.I.C.E.S. • therapeutic modalities T ERMINOLOGY • taping for LCL sprain taping (p. 145) (plus elastic wrap for first 48 hours) • lateral collateral ligament sprain Later • external collateral ligament sprain • continued therapy including: • fibular collateral ligament sprain • torsion injury a. therapeutic modalities • see sprains chart, p. 36, for description of 1st to 3rd degree of severity b. transverse friction massage c. mobilizations if stiff after immobilization E TIOLOGY • flexibility exercises for quadriceps, hamstrings and gastrocnemius • excessive outward pressure forcing the knee laterally into varus (outwardly • strengthening of quadriceps, hamstrings and gastrocnemius • strengthening of quadriceps (isometric at first) bent or ‘bow-legged’ position) • gradual reintegration programme with pain-free taped support: LCL sprain • sudden impact forcing body medially on fixed lower leg taping, p. 145 • direct blow to side of knee • total rehabilitation programme for range of motion, flexibility, strength and • isolated tears are uncommon proprioception • bracing may be recommended for return to activity or for continued S YMPTOMS athletics if chronically unstable • pain, tenderness on lateral side (outside) of the knee • swelling, possible bruising S EQUELAE • active movement testing: lateral pain on end-range extension • lateral (varus) laxity • passive movement testing: lateral pain on end-range extension • rotational instability • resistance testing (neutral position): no pain on moderate resistance • predisposition to lateral meniscal tears • stress testing at 0° and 30° knee flexion • weakness of quadriceps • inability to ‘cut’ when running a. 1st- and 2nd-degree sprains: pain with or without instability • possible peroneal nerve damage b. 3rd degree of severity: complete ligament rupture (‘opens up’); can be • degenerative arthritic changes less pain than with 2nd-degree sprain. See notes re degree of injury testing (p. 36) c. instability at 0° extension is indicative of a severe injury with posterior capsule involvement Note: Surgery may be indicated for 3rd-degree sprain. R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support. 149

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh Taping for Patello-Femoral Pain Materials Purpose Razor • compresses the patellar tendon, thereby changing lines of stress and thus altering the biomechanics of Quick-drying adhesive spray 2.5 cm (1 in) semi-elastic tape (preferable) or ­ the patello-femoral joint non-elastic tape (semi-elastic tape has a minimal • reduces upward mobility of patella amount of elasticity and is not a conventional elastic • allows full movement at the knee joint adhesive tape) Indications for use • patellar tendinitis • patello-femoral joint syndrome • Osgood–Schlatter’s disease • medial knee pain associated with flat feet (seek advice from podiatrist on foot orthotics) • ‘jumper’s knee’ Notes: • Evaluate pain using a visual analogue score (VAS) prior to taping, by having the athlete perform a half- squat. Re-evaluate this movement throughout the taping procedure, monitoring any change in pain. Use only the taping strips which alleviate the pain. • Avoid compressing the patella against the femur, as this may aggravate pain. • There should be no pain during activity. If the athlete cannot function pain free, a patella strap may be indicated (jumper’s knee strap). • The semi-elastic adhesive tape used in this procedure is minimally elastic and maximally adherent. Should it not be a­ vailable, use non-elastic adhesive tape instead (do not use elastic adhesive bandage). For additional details regarding an injury see T.E.S.T.S. chart, p. 154. 150

Knee and Thigh 7 Positioning Patello-femoral pain Relaxed, supported long sitting position or supine, with the knee aligned in a neutral position and supported on a roll or cushion. Procedure 1 Make sure the area to be taped is clean 3 Perform the test position: a half-squat. 4 Starting posteriorly on the lateral and relatively hair free; shave if necessary side, apply a horizontal strip of 2.5 cm Note: s­ emi-elastic adhesive tape. Using 2 Check skin for cuts, blisters or areas Assess the intensity of pain with a VAS, ­moderate firm pressure, this strip should of ­irritation before spraying with skin and the angle of the knee at pain onset. compress the patellar tendon just above ­toughener or spray adhesive. the tibial tubercle. 151

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh Note: 5 Re-evaluate the level of pain. 6 Apply a diagonal strip of tape from the upper lateral aspect of the knee beside the • Do not encircle the leg completely patella, pulling distally across the patellar tendon and ending medially. • Make sure that the tape ends adhere well to the skin. 152

Knee and Thigh 7 Patello-femoral pain 7 Re-evaluate the level of pain. 8 Apply a diagonal strip of tape from the 9 Re-evaluate the level of pain. lower lateral aspect of the knee beside a. 40 ° of full weight-bearing flexion should the patella, pulling proximally across the p­ atellar tendon and ending medially. be possible. b. If pain is not eliminated with this taping, try a patellar tendon strap (jumper’s knee strap). Note: Active therapy should precede returning to activity. 153

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh Anatomical Area: Knee and Thigh T REATMENT Early Condition: Patello-Femoral Joint Syndrome (if acutely inflamed) • ice T ERMINOLOGY • therapeutic modalities • patellar malalignment syndrome • lateral retinacular stretching • retro-patellar inflammation • taping: for Patellar Tendon, see p. 150 • pre-chondromalacia Later E TIOLOGY • continued therapy including: • quadriceps weakness • poor tracking of patella a. therapeutic modalities to control pain • subluxing or dislocating patella b. quadriceps re-education: particularly vastus medialis obliquus (VMO) • poor biomechanics of adjacent joints • posttraumatic blow to knee utilizing muscle stimulation or biofeedback • secondary to patellar tendinitis c. flexibility exercises, hamstring and tensor fascia lata (TFL) • jumping as in plyometric training • gradually progressive negative weight training with corrected biomechanics • common in basketball and volleyball (proper patellar tracking) and taping • orthotics may help if faulty alignment is caused by poor foot biomechanics S YMPTOMS • peripatellar pain may be experienced in various locations: S EQUELAE • chronic pain of quadriceps a. diffuse around the patella • weakness of quadriceps and tensor fascia lata (TFL) b. at the inferior tip of the patella • inflexibility c. anterior or posterior to the patellar tendon • inability to participate in sports d. at the tibial tubercle (insertion of the tendon) • chondromalacia • pain is often felt following sitting or resting • active movement testing: may have pain on extension; pain when climbing or particularly when descending stairs • passive movement testing: muscle tightness or imbalance involving quadriceps, hamstrings and tensor fascia lata (TFL) • resistance testing (neutral position): weakness of quadriceps (specifically vastus medialis obliquus –VMO) with or without pain • stress testing: patello-femoral grinding test causes pain 154

Knee and Thigh 7 Taping for Quadriceps (Thigh) Contusion or Strain Materials Patello-femoral joint syndrome Purpose Razor • applies localized specific compression to the bruised or torn tissue Skin toughener spray/adhesive spray • prevents subsequent swelling, bleeding or muscle fibre tearing in the area 10 cm (4 in) elastic adhesive tape • allows full function and flexibility 7.5 cm (3 in) elastic adhesive tape Indications for use 3.8 cm (1½ in) non-elastic white tape • quadriceps contusion 15.2 cm (6 in) elastic wrap • quadriceps strain • for hamstring strains tape is applied to posterior thigh Notes: • The exact site of the contusion or strain must be localized. • Underwrap is not recommended, as it significantly lessens the effectiveness of the tape technique. • The pressure of tape strips must be localized to the injured area and not too tight circumferentially. If constricted, hamstring and calf muscles may cramp; also, the athlete may feel that the leg is weak, stiff or heavy. • Any massage is strictly contraindicated in the early stages due to the high risk of further internal bleeding and the potential development of myositis ossificans. For additional details regarding an injury example see T.E.S.T.S. chart, p. 161. 155

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh Positioning Lying on a bench with the knee flexed over the edge and the heel resting on the ground or the floor. Procedure 1 Make sure the area to be taped is clean 2 Localize and mark the exact site of the 4 Beginning 7.5 cm below the lower aspect and relatively hair free; shave if n­ ecessary. contusion or muscle strain. of the injury, wrap 10 cm elastic a­ dhesive Check skin for cuts, blisters or areas b­ andage around the limb using light of i­rritation before spraying with skin 3 Spray quick-drying adhesive ­tension. Repeat this strip, overlapping the ­toughener or spray adhesive. ­circumferentially to the thigh and let dry previous one by approximately 1.5 cm (1⁄2 in) completely. until the entire injured area is ­covered and surpassed by 7.5 cm. Note: This layer of tape forms a foundation for the compression strips to avoid excessive tension on the skin. 156

Knee and Thigh 7 5b Stretch the tape fully, hold it horizontally 5c Apply strong pressure equally with both Patello-femoral joint syndrome across the limb and keep it stretched hands while maintaining lateral stretch Note: laterally. until the tape reaches three-quarters of the way around the limb. Wrap the tape For large thighs or large contusions, 10 cm ends towards the back and let the roll hang tape can be used for these strips if the down on the medial side. taper has wide enough hands to maintain pressure across the entire tape width. Note: This pressure can cause some discomfort. 5 Prepare to apply the first pressure strip directly below the centre of the site of Tip: injury. The taper can better stabilize and control counter-pressure by gripping and a. Fold back 12 cm (5 in) at the end of the squeezing the athlete’s knee with their roll of 7.5 cm elastic adhesive bandage in own knees to gain better support during one hand and hold the remainder of the the application of the pressure strips. roll in the other. (Technique not illustrated.) 157

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh 5d Be careful to keep the strip from d­ etaching 5e Complete encircling the limb by 6 Repeat the pressure strip, overlapping by and release the tension before adhering o­ verlapping the tape ends well at the back half the tape width above the first strip. the lateral tape end posteriorly. without tension. 7 Repeat again over the injury, always with Tip: maximal pressure anteriorly. Ensure the medial side does not detach while cutting the tape from the roll. 158

Knee and Thigh 7 Patello-femoral joint syndrome 8 Continue repeating the pressure strips, Tip: 9 Finish the ends of this taping with overlapping by half proximally until the short strips of non-elastic tape to avoid entire tape base is covered. Ensure the tape job extends at least one ­detachment of the elastic tape during full tape width above and below the area activity. of injury. 159

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh 10 Wrap the entire tape job with an elastic 11 Affix the elastic wrap with non-elastic tape. wrap prior to activity, to give the adhesive in the tape the time and heat necessary in 12 Re-assess the degree of pain – isometrically, order to set (remove prior to activity). isotonically and in full dynamic motion. 160

Knee and Thigh 7 Anatomical Area: Knee and Thigh • therapeutic modalities Quadriceps contusion • gentle activity with taped compression Condition: Quadriceps Contusion Later • continued therapy including: T ERMINOLOGY • contusion of one of the quadriceps muscles 1st to 3rd degree severity (see a. therapeutic modalities b. strengthening exercises: pain free contusion chart, p. 38) c. flexibility exercises • gradual return to full pain-free activity with taped support; see Compression E TIOLOGY taping, p. 49 • direct blow on thigh; for example, a direct blow from a tackle to the thigh in • dynamic proprioceptive programme rugby or football) S EQUELAE • haematoma S YMPTOMS • myositis ossificans if massaged early • pain, tenderness over site of injury • complete rupture of muscle if used too early • swelling and haematoma if not treated immediately • weakness • active movement testing: pain on active contraction of quadriceps • scarring and inflexibility • passive movement testing: • predisposition to recurrent strains a. pain on knee flexion b. worse with hip extension • resistance testing (neutral position): pain and/or weakness of quadriceps • palpable localized deformity possible T REATMENT Early • ice • taping: Compression, see p. 49 • early flexibility exercises enhanced by active contraction of hamstrings only; no overpressure 161

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh Anatomical Area: Knee and Thigh Materials Taping for Adductor (Groin) Strain Razor Skin toughener spray/adhesive spray Purpose 10 cm (4 in) elastic adhesive bandage • applies localized support and compression over the injured muscles 7.5 cm (3 in) elastic adhesive bandage • allows full flexion and extension 3.8 cm (1½ in) non-elastic tape • applies local pressure while permitting full flexibility 15.2 cm (6 in) elastic wrap • can also be adapted to restrict abduction Indications for use • acute adductor (groin) strain • chronic adductor (groin) strain • adductor tendinitis Notes: • The exact site of injury must be localized. • Be certain that groin injuries of the muscle attachments to the pubic bone are properly evaluated; if in doubt, refer. • If necessary, X-ray to rule out avulsion or stress fractures (scans may be necessary in the early stages of a stress fracture as they may not show, initially, on X-ray) or osteitis pubis which refers pain to the adductor region. • The skin near the groin is extremely tender and prone to irritation: careful preparation of this area is essential (a full explanation of the technique should be given to the patient prior to taping and consent sought due to the intimate nature of the groin region). • Once taped, the usual pretraining/event stretches should be carried out with the utmost care. Proper warm-up and flexibility will reduce the risk of re-injury or an exacerbation of the current injury. For additional details regarding an injury example see T.E.S.T.S. charts, p. 166. 162

Knee and Thigh 7 Positioning Adductor (groin) strain Standing with the knee slightly flexed, the heel on a roll of tape and the foot turned inwards (this decreases the stretch of the groin muscles). Re-check the position frequently during the course of the taping. Procedure 1 Make sure the area to be taped is clean 2 Localize and mark the exact site of the 4 Apply one layer of 4 cm elastic adhesive and relatively hair free; shave if n­ ecessary injury. bandage with light tension around the limb. (in cases of upper thigh and groin injury, you may want to ask the patient to do 3 Spray skin toughener or quick-drying 5 Continue additional foundation strips this). Check skin for cuts, blisters or areas a­ dhesive circumferentially to the thigh and ­overlapping by 2 cm until the tape covers of ­irritation before spraying with skin let dry completely (care must be taken an area of at least 7.5 cm above and below ­toughener or spray adhesive. when spraying close to sensitive body the injury site. areas). 163

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh 6 Apply the first pressure strip slightly below 6b Apply the remainder of the strip ends, 7 Apply subsequent strips of tape proximally, the site of the injury. encircling the limb with little or no tension, overlapping by one half the width of the being careful not to allow these to peel tape above this first strip, as in the previous a. First stretch the tape fully and apply back and consequently lose the localized technique. it with strong pressure equally with both pressure. hands. Release the pressure only when Note: the tape strip reaches three-quarters of the The finished tape job should have no way around the limb. creases or folds. 164

Knee and Thigh 7 Adductor (groin) strain 8 Cover the ends of this taping job with short 9b Then around the hip and waist. 10 Affix the end of the wrap with non-elastic strips of non-elastic tape as in the previous tape. technique. Tip: Maintain correct positioning in slight internal 11 Test the degree of pain reduction – 9 Wrap the entire tape job with an elastic rotation. ­isometrically, isotonically and in full wrap prior to activity, to give the adhesive dynamic motion. in the tape the time and heat necessary in order to set, in the following fashion (hip Note. spica technique). This ‘spica’ elastic wrap can be reinforced with a second wrap pulled tightly enough a. Wrap the tensor in a modified figure of to assist adduction and resist abduction. eight medially around the upper thigh. 165

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh Anatomical Area: Knee and Thigh T REATMENT Early Injury: Adductor Strain • R.I.C.E.S. • taping: for adductor strain taping, see p. 162 T ERMINOLOGY • therapeutic modalities • strain of one of the adductor muscle or tendons, severity 1st to 3rd degree Later • ‘pulled’ groin muscle • continued therapy including: E TIOLOGY a. transverse friction massage • explosive contraction of adductor muscles b. progressive, graduated exercises to regain strength (isometric and ­ • excessive stretch of adductor muscles • more susceptible when muscles are not warmed up non-weight bearing at first) • overuse due to unaccustomed repetitive action • gradual reintegration to activities programme with pain-free taped support • common in goal tending, soccer, hockey, football and some track and field S EQUELAE sports • persistent pain • weakness S YMPTOMS • scarring and inflexibility • slight to severe pain varying with degree and location of injury • chronic reinjury • pain may be diffuse or localized and may reach as high as pubic bone • imbalance may lead to pelvic and lumbar spine compensatory problems • haematoma not always present • bone spurs may develop • active movement testing: • ossification of haematoma possible a. some pain on hip adduction b. pain also possible on active abduction due to muscle stretch • passive movement testing: pain on hip adduction • resistance testing (neutral position: pain and/or weakness on hip adduction) R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support. 166

Chapter 8 Shoulder and Elbow 2Section The gleno-humeral (shoulder) joint is one of the most mobile of all the joints in the body. It is this mobility that predisposes the shoulder joint to injury, both acute and chronic, and heightens the joint’s dependency on muscular and capsular support. By contrast, the acromio-clavicular (AC) joint is less mobile and depends solely on ligaments for support. At the elbow, the humero-ulnar joint (the true elbow joint) is a hinge joint similar to the knee. It sustains similar injuries, requiring the application of taping principles presented in the knee/thigh section. The main purpose and value of taping an elbow is the prevention of full extension of the joint, with or without lateral reinforcement. Because the associated radio-ulnar (forearm) joint allows a great degree of pronation and supination (rotation), the overall effectiveness of taping for lateral ligaments is compromised. 167

8 Section 2: Practice B978-0-7234-3482-5.00008-3, 00008 Shoulder and Elbow 2 13 16 14 1 Muscles 11 15 18 7   1. Trapezius 8 19 5   2. Deltoid 3   3. Anterior margin of deltoid 4   4. Pectoralis major 9 17   5. Upper margin pectoralis 12 major 6 20   6. Lower margin pectoralis The right axilla or armpit is the hollow below the ­shoulder. 7 10 21 major Its a­ nterior wall is made up mainly of the fibres of pecto-   7. Biceps short head ralis major (4) with pectoralis minor behind. The posterior Right shoulder from the front.   8. Coracobrachialis wall consists of teres major (9) with the tendon of latissimus The arm is slightly abducted   9. Teres major dorsi (12) ­immediately in front. Close to pectoralis major a • The nipple in the male (21) normally lies at the 10. Serratus anterior bundle of muscle made up of the short head of biceps (7) 11. Triceps and coracobrachialis (8) runs down the arm with the cords level of fourth intercostal space. of the brachial plexus s­ urrounding the axillary artery imme- • The deltopectoral groove ­containing the Tendons diately behind. The axilla is also a very important site for lymph glands draining lymphatics from the arm and, most cephalic vein is formed by the adjacent 12. Latissimus dorsi importantly, the breast. b­ orders of deltoid (2) and pectoralis major (5). • The lower border of pectoralis major (6) forms Bones the anterior fold. 13. Acromion of scapula 14. Acromial end of clavicles 15. Greater tuberosity of humerus Joints 16. Acromioclavicular Hollows 17. Deltopectoral groove 18. Supraclavicular fossa 19. Infraclavicular fossa Miscellaneous 20. Areola 21. Nipple 168

Shoulder and Elbow 8 1 Muscles 4 Shoulder and Elbow 16 1815   1. Trapezius – upper fibres 2 12 4   2. Trapezius – middle fibres 1 13 17   3. Trapezius – lower fibres 2 7   4. Deltoid 3 9 11   5. Rhomboid major 6   6. Supraspinatus 12 14   7. Infraspinatus 10   8. Teres minor 3   9. Teres major 10. Latissimus dorsi 5 11. Triceps Right shoulder, arm elevated. Bones While maintaining good postural control of the trunk, the right arm has been abducted through 12. Spine of scapula some 180 °. The left scapula remains in a nor- 13. Vertebral border of scapula mal resting ­position but with firm muscle control, 14. Inferior angle of scapula the g­ lenoid pointing laterally. The right s­ capula 15. Acromion of scapula has been rotated through some 70–75° under 16. Acromial end of clavicle the activity of t­rapezius with the remaining arm m­ ovement occurring at the shoulder joint. Activity Nerves is obvious in deltoid (4), the major abductor at the shoulder joint, and no doubt in s­ upraspinatus (6), 17. Axillary nerves posterior to though this muscle is masked by trapezius (2). humerus Joints 18. Acromioclavicular Right shoulder, from behind. The arm is slightly abducted and the inferior angle of the scapula (14) has been made to project ­backwards by attempting to flex the shoulder joint against resistance. • The inferior angle of the scapula (14) usually lies at the level of the seventh i­ntercostal space. It is overlapped by the upper margin of the latissimus dorsi (10). • The axillary nerve (17) runs transversely under cover of the deltoid (4) behind the shaft of the humerus at a level 5–6 cm below the acromion (15). • Latissimus dorsi (10) and teres major (9) form the lower boundary of the p­ osterior wall of the axilla. 169

8 Section 2: Practice B978-0-7234-3482-5.00008-3, 00008 Shoulder and Elbow 9 3 4 56 2 1 7 9 12 6 10 10 1 13 27 11 15 8 8 5 16 12 18 13 17 14 3 9 4 11 Shoulder joint: anterior aspect. Posterior aspect of the shoulder and upper arm: bones 1 Costoclavicular ligament. 2 Conoid ligament. 3 Trapezoid and muscles of the shoulder girdle. Right, superficial ligament. 4 Coracohumeral l­igament. 5 Short head of biceps. ­muscles; left, deep muscles. 1 Acromion. 2 Spine of ­scapula. 6 Coracobrachialis. 7 Pectoralis minor. 8 Long head of 3 Medial border of ­scapula. 4 Inferior angle of scapula. biceps. 9 Subscapularis. 10 Anterior capsule of shoulder 5 Medial angle of scapula. 6 Superior angle of scapula. joint with opening of subscapular bursa. 11 Long head of 7 Glenoid fossa. 8 Humerus. 9 Trapezius. 10 Deltoid. biceps. 12 Latissimus dorsi. 13 Pectoralis major. 11 Latissimus dorsi. 12 Levator scapulae. 13 Rhomboideus minor. 14 Rhomboideus major. 15 Supraspinatus. 170 16 Infraspinatus. 17 Teres major. 18 Teres minor.

Shoulder and Elbow 8 9 1 Shoulder and Elbow  4 15 7 2 8 3 8 6 13 4 10 5 2 14 9 3 8 Forearm from the front. 12 a. Left elbow from the front. There is an Muscles VEINS M-shaped pattern of superficial veins. Cephalic (9) and basilic (8) veins are joined by a median   1. Biceps   8. Basilic cubital vein into which drain two small median   2. Brachio Radialis   9. Cephalic Vein forearm veins. The order of the s­ tructures in the   3. Pronator Teres 10. Median Cephalic Vein cubital fossa from lateral to medial is biceps ten-   4. Biceps 11. Median Basilic Vein don (4), brachial artery (13) and median nerve (6).   5. Flexor carpi Radialis 12. Median Forearm Vein Nerves Arteries   6. Median 13. Brachial FASCIA BONES   7. Bicipital Aponeurosis 14. Medial Epicondyle of Humerus 15. Lateral Epicondyle of Humerus 171

8 Section 2: Practice B978-0-7234-3482-5.00008-3, 00008 Shoulder and Elbow 5 1 1 4 4 2 11 63 3 3 5 71 6 4 2 2 12 5 67 Elbow joint: anterior aspect. 1 Anterior band Cubital fossa: soft tissues. 1 Biceps. 2 Bicipital 8 of medial ligament. 2 Oblique band of medial aponeurosis. 3 Brachialis. 4 Brachioradialis. 5 9 ­ligament. 3, 4 Anterior capsule. 5 Lateral l­igament. Pronator teres. 6 Common flexor origin. 10 6 Annular ligament. 7 Tendon of biceps. Posterior aspect of the elbow and fore- arm: ­superficial muscles. 1 Brachioradialis. 2 Extensor carpi radialis longus. 3 Anconeus. 4 Extensor carpi radialis brevis. 5 Extensor ­digitorum. 6 Extensor carpi ulnaris. 7 Extensor digiti minimi. 8 Abductor pollicis longus. 9 Exten- sor pollicis brevis. 10 Extensor pollicis longus. 11 Ulnar nerve. 12 Flexor carpi ulnaris. 172

Shoulder and Elbow 8 w The back of the forearm Shoulder and Elbow The superficial extensor muscles take a ­common 1 10 1 o­ rigin from the lateral epicondyle and the 2 2 s­ upracondylar ridge. Brachioradialis (1), the mus- 9 3 cle coming from higher up the ridge, has been 4 described with the anterior muscles in view of its 11 12 15 role as a flexor muscle. Extensor carpi ­radialis 14 16 5 l­ongus (2) also comes from the supracondylar ridge below brachioradialis and below that, the exten- 8 7 sor carpi radialis brevis (3) which arises from the epicondyle. These muscles can be identified quite 2 easily running down the radial side of the back of 3 13 the forearm. 4 5 Muscles   1. Brachioradialis   2. Extensor carpi radialis longus   3. Extensor carpi radialis brevis   4. Extensor digitorum   5. Extensor carpi ulnaris   6. Triceps   7. Flexor carpi ulnaris   8. Anconeus Left elbow from behind Bones With the elbow fully extended, the extensor muscles form a bulge in the lateral side. In the adjacent hollow can be felt the head of the radius (14) and the capitulum of the humerus (11) which indicates   9. Lateral epicondyle of humerus the line of the radio-humeral part of the elbow joint. The lateral and medial epicondyles (9, 10) of the 10. Medial epicondyle of humerus humerus are palpable on either side. Wrinkled skin lies at the back of the prominent olecranon of the 11. Capitulum of humerus ulna (12). In this arm the margin of the olecranon bursa (16) is outlined. A very important structure in this 12. Olecranon of ulna region is the ulnar nerve (15) which is palpable as it lies in contact with the humerus behind the medial 13. Posterior border of ulna epicondyle (10). The posterior border of the ulna (13) is subcutaneous throughout its whole length. 14. Head of radius • With the elbow extended, the medial and lateral epicondyles and the olecranon are on the same level Nerves but with flexion of the elbow, the olecranon moves to a lower level. • The subcutaneous position of the ulnar nerve behind the medial epicondyle makes it easily palpable. 15. Ulna Here it can be easily injured, causing paraesthesia (tingling) in the distribution of the ulnar side of the Bursa hand. This area is commonly referred to as the ‘funny bone’. 16. Margin of the olecranon bursa 173

8 Section 2: Practice B978-0-7234-3482-5.00008-3, 00008 Shoulder and Elbow Taping for Acromioclavicular (AC) Sprain: Shoulder Separation Materials Purpose Rectangular piece of felt or very dense foam • compresses and stabilizes the acromioclavicular (AC) joint approximately 5 × 3.6 cm (2 × 11⁄2 in) and 1 cm • keeps the distal end of the clavicle down while allowing almost full gleno-humeral function (1⁄2 in) thick to cover AC joint • elastic support assists abduction Square of gauze, thin felt or folded underwrap approximately 3.6 × 3.6 cm (2 in sq) to cover nipple Indications for use: Razor • acute AC sprain Skin toughener spray/adhesive spray • sub-acute shoulder separation 3.8 cm (11⁄2 in) non-elastic tape • chronic shoulder separation 7.5 cm (3 in) elastic adhesive bandage • chronic step deformity accompanied by pain at the AC joint 5 cm (2 in) elastic adhesive bandage TIP: Ensure that step deformity is corrected/ reduced by proper positioning. NOTES: • Acutely injured athletes should not return to competition without proper investigation (high risk of advancing severity of the injury). • Ensure correct diagnosis by following up with a sports medicine specialist. • Be certain that a radiological evaluation is done, particularly if any deformity is present. • This taping can be used for a female athlete by applying the chest anchors below the breasts and the anterior end of the vertical anchor angled more towards the midline. • Monitor limb sensation, strength of pulse and venous return prior to, during and after taping to ensure that there is no neurovascular compromise. • Tender skin at the axilla (armpit) needs special attention and protection. For additional details regarding an injury example see T.E.S.T.S. chart, p. 181. 174

Shoulder and Elbow 8 Positioning Acromioclavicular (AC) sprain: Shoulder separation Sitting comfortably with the elbow and forearm well supported across the lap with a solid cushion. Procedure 1 Make sure the area to be taped is clean 3 Spray the area well with tape adherent to 4 Wrap an anchor with light tension around and relatively hair free; shave if necessary. maximize adhesiveness, thus stabilizing mid-humerus with 7.5 cm (3 in) elastic anchors. a­ dhesive bandage. 2 Check skin for cuts, blisters or areas of ­irritation before spraying with skin TIP: TIP: t­oughener or spray adhesive Turn athlete’s face away and protect nipple Ensure that the last 7.5 cm (3 in) ends of the when spraying. anchors are applied without tension and Note: pressed firmly to avoid ‘peeling back’ of the Sensation, pulse, temperature and colour tape. must be checked before starting to tape. 5 Apply two anchors of 7.5 cm elastic Note: ­adhesive bandage horizontally to the chest with light pressure, from anterior to Alternatively, fixation tape can be used in conjunction with adhesive spray and fixed halfway round the p­ osterior at the level of the 5th rib (covering mid-humerus from front to back, instead of encircling the upper arm. the nipple with gauze, underwrap or felt, especially in men). 175

8 Section 2: Practice B978-0-7234-3482-5.00008-3, 00008 Shoulder and Elbow 6 Cut a piece of felt or dense foam p­ adding 8 Apply a compression strip of tape directly 9 Repeat this strip, moving laterally to cover large enough to cover the p­ rominence of downwards over the distal end of the one half of the first strip. the AC joint (approx. 3.5 × 5 cm and at least ­clavicle. Extend the elastic tape horizontally 1 cm thick). as much as possible and apply through the NOTE: padding with strong pressure downwards Recheck sensation, pulse, temperature, 7 Using 7.5 cm elastic adhesive bandage and while maintaining the horizontal tension. colour. moderate tension, apply rectangle directly Release the tension only when the ends of on the upper end of the AC joint (outer tip the strip reach the chest anchor anteriorly of the clavicle and adjacent acromion). and posteriorly (front and back). TIP: TIP: Be sure the athlete is still sitting well Ensure that the last 7.5  cm of tape is positioned with the forearm supported. completely without tension when being affixed. 176

Shoulder and Elbow 8 10 Reinforce stability by applying a strip of b. Ensure that these strips cross the anchor 11 Apply a second downwards strip of  Acromilavu (AC)sprain:Shoulde spartin Acromioclav 3.8 cm non-elastic tape. completely. n­ on-elastic tape more laterally. a. Maintain strong horizontal tension while TIP: NOTE: applying strong pressure downwards on Do not release tension until the anchors are These strips further stabilize the distal end the superior (upper) aspect of the AC reached. of the clavicle and approximate the normal padding. anatomical position of the joint. 177

8 Section 2: Practice B978-0-7234-3482-5.00008-3, 00008 Shoulder and Elbow 12 a. Re-anchor over the chest anchor to hold 13 Repeat this strip, starting posterolaterally 14 Anchor the top of these strips with a strip strips in place. on the arm and pulling up on the posterior of elastic adhesive bandage. aspect of the deltoid muscle. b. With arm at approximately 45° angle of abduction (ask the patient to put their hand NOTE: on their hip), place a strip of 7.5 cm elastic When properly placed, the combination of adhesive bandage, s­ tarting l­aterally from these two strips assists abduction. the arm anchor, going ­anteriorly across the top of the padding and pulling up with firm tension to take the weight of the arm off the distal part of the joint. 178

Shoulder and Elbow 8 15 Reapply the humeral (arm) anchor strip (if 16a Finish with a strip of elastic adhesive 16b Lateral view of finished taping.  Acromilavu (AC)sprain:Shoulde spartin Acromioclav using fixation tape go just beyond the ends tape, applied as a horizontal anchor to of the tape front and back so skin contact the chest, to fix the lower ends of the 17 Assess the degree of pain reduction post is made). v­ ertical strips of tape. taping – static and with unassisted arm flexion and abduction. NOTE: TIP: Re-test sensation, pulse, temperature During the acute phase a sling or collar and and colour, ensuring that taping has not cuff may be used to support the weight of compromised circulation. the arm. NOTE: The arm section of the tape job becomes optional as the AC responds to treatment and becomes less problematic. 179

8 Section 2: Practice B978-0-7234-3482-5.00008-3, 00008 Shoulder and Elbow Anatomical Area: Shoulder and Elbow NOTE: Severe 3rd-degree shoulder sprains may require surgery. Injury: Shoulder Sprain Acromioclavicular (AC) Separation Later • continued therapy including: T erminology • sprain of acromioclavicular joint: 1st to 3rd degree of severity a. therapeutic modalities b. range of motion and flexibility exercises E TIOLOGY c. strengthening: isometric at first • direct impact to the point of the shoulder d. carefully guided progressive functional strengthening as tolerated • a fall, landing on the tip of the shoulder • gradual return to pain-free sports activity with taped support • a severe fall on the outstretched arm • a felt doughnut over the joint can further protect it from impact in contact sports • common in hockey, rugby, football, horse riding and martial arts NOTEs: S YMPTOMS Premature return to activity risks further injury, escalating a 2nd-degree • pain and tenderness over the top of the AC joint sprain to a 3rd-degree sprain (complete rupture). • local swelling and bruising No muscles directly cross the AC joint, therefore muscle strengthening • active movement testing: pain on all movements, particularly on flexion and does not specifically reinforce it. horizontal adduction S EQUELAE • resistance testing: pain on all movements • instability • passive movement testing: pain on horizontal adduction • chronic pain • stress testing: varying degrees of pain and step deformity between the • associated strain of deltoid or trapezius muscles can cause residual weakness • arthritic changes: osteophyte formations clavicle and the acromion in 2nd and 3rd degrees of sprain severity • ‘clicking’ T REATMENT Early • R.I.C.E.S. • taped support: a sling can offer additional support during first 48 hours • therapeutic modalities • 2nd- and 3rd-degree sprains should have at least 3 weeks of inactivity and support before dynamic treatment is started R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support 180

Shoulder and Elbow 8 Anatomical Area: Shoulder and Elbow Materials Anatomical area: shoulder and elbow Taping for Elbow Hyperextension Sprain Razor Skin toughener spray/adhesive spray Purpose Underwrap • supports the elbow laterally 5 cm (2 in) elastic adhesive bandage • limits the last 30° of extension and end-range pronation of the forearm 7.5 cm (3 in) elastic adhesive bandage • allows full flexion and almost full supination 3.8 cm (11⁄2 in) non-elastic adhesive tape 7.5 cm (3 in) elastic wrap bandage Indications for use • acute, sub-acute or chronic hyperextension sprains of the elbow • posterior impingement syndrome • medial sprains of the elbow, supported by reinforcing the medial X strips • lateral sprains of the elbow, supported by reinforcing the lateral X strips • combination ligament sprains • chronic instability following fracture, dislocation of the elbow NOTES: • Ensure a proper diagnosis by a sports medicine specialist. • X-rays should be taken to rule out possibility of fracture. • Pain or laxity on lateral stress testing with the elbow at 15° flexion will indicate the need for added medial or lateral support. • Easily irritated structures include the biceps tendon, soft skin in elbow crease and the ulnar nerve or ‘funny bone’, found posteromedially in the groove. • If forearm anchor is too tight, circulation of the forearm will be constricted. For additional details regarding an injury example see T.E.S.T.S. chart, p. 187. 181

8 Section 2: Practice B978-0-7234-3482-5.00008-3, 00008 Shoulder and Elbow Positioning Sitting, with the elbow held in 40° flexion. The forearm should be in a neutral position between pronation and supination with the hand in a functional position. Procedure 1 Make sure the area to be taped is clean 3 Apply underwrap from the proximal (upper) 4 Apply two circumferential anchors of 5 cm and relatively hair free; shave if necessary. one-third of the forearm to the distal (lower) elastic adhesive bandage with minimal one-third of the humerus. tension to the mid-humerus half-covering 2 Check skin for cuts, blisters or areas the underwrap and half-covering the skin of i­rritation before spraying with skin NOTE: directly. ­toughener or spray adhesive. Padding and lubricant may be applied on the anterior aspect of the elbow to protect 5 Repeat two similar anchors mid to lower NOTE: the biceps tendon and the soft skin when forearm. Sensation, pulse, temperature and colour returning to sports with significant repetitive of hand must be checked prior to taping. elbow motion. 182

Shoulder and Elbow 8 Anatomical area: shoulder and elbow 6 To form a check-rein, place the elbow in 7 Repeat this strip, overlapped by half the 8 Anchor these strips at both ends. 45° of flexion and apply a vertical strip of tape width more laterally. 5 cm elastic adhesive bandage from the Tip: lower anchor with tension to the upper Remember to keep the hand in a functional anchor, directly over the anterior aspect of position. the elbow joint. TIP: Be certain to apply these strips with enough tension to block the last 30° of extension when the elbow is fully stretched. 183

8 Section 2: Practice B978-0-7234-3482-5.00008-3, 00008 Shoulder and Elbow 9 For medial stability, hold the elbow bent 10 Apply a second strip to form an X across 11 Repeat the white tape X on the lateral at 35° of flexion and apply a vertical strip the medial joint line of the elbow, also with aspect to cross at the lateral joint line. of 3.8 cm non-elastic tape from the distal strong tension. anchor to the upper anchor with strong tension. NOTE: NOTE: For medial sprains ensure a varus (inwardly For lateral sprains ensure a more valgus bent) position and apply a second white (outwardly bent) position and apply a tape X on the medial side with great second white X on the lateral side with tension. great tension. 184

Section 2: Practice Shoulder and Elbow 8 12a Apply two anchors distally and ­proximally 12b Anterior view of finishing taping. Anatomical area: shoulder and elbow using 7.5 cm elastic adhesive bandage. NOTE: NOTE: Hand sensation, pulse, temperature and In closing up, a space is left at the anterior colour must be reassessed to ensure that elbow, to avoid undue irritation to the taping has not compromised circulation. sensitive underlying structures. 13 Test the degree of restriction: a. extension should be limited by 30 ° or more b. there should be no pain on passive extension or lateral stress testing. TIP: Wrap the tape job with a 7.5 cm (3 in) tensor bandage for 10 minutes to ensure good adherence. 185

8 Section 2: Practice B978-0-7234-3482-5.00008-3, 00008 Shoulder and Elbow Anatomical Area: Shoulder and Elbow NOTE: NOTE: Any suspicion of deformity requires immediate medical attention Injury: Elbow Sprain: Hyperextension and X-rays. T ERMINOLOGY Later • sprain of medial or lateral collateral ligaments • continued therapy including: • tearing of anterior joint capsule a. therapeutic modalities E TIOLOGY b. taping for limited activity • fall on outstretched hand c. gentle traction and mobilization • forced hyperextension of the elbow (anterior capsule with/without medial • progressive resistance rehabilitation programme for humero-ulnar as well as radio-ulnar joints and/or lateral ligament sprain) • gradual return to activities with taped support as above • forced valgus (inward) stress causes damage to the medial collateral SEQUELAE ligament (more vulnerable and more common) • chronic instability • forced varus (outward) stress causes damage to the medial collateral • ulnar nerve paraesthesia • adhesions causing reduced range of motion ligament • arthritic changes • chronic medial sprains are common in pitchers and javelin throwers • calcification of ligaments S YMPTOMS • pain on anterior capsule – medial and/or lateral joint line – implies localized injury site • swelling • active movement testing: pain on end-range extension • resistance testing (neutral position): a. no significant pain on moderate resistance b. pain on flexion if biceps simultaneously injured • stress testing: varying degrees of pain and laxity on stress testing (done at 15° flexion). Amount of laxity indicates degree of injury TREATMENT Early • R.I.C.E.S. • sling • therapeutic modalities R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support. 186

Chapter 9 Wrist and Hand 2Section The wrist is a flexible osseo-ligamentous complex forming a connective link between the forearm and the hand. Multidirectional mobility results from the numerous multiarticular carpal bones which, along with the radio-ulnar joints, allow the hand to be positioned functionally at any angle. Stability is derived from the complex array of ligaments often injured when falling on an outstretched hand. The hand, while being the most active and intricate joint complex in the body, is the least protected. Constructed as a series of complex, delicately balanced joints, it offers manipulating ability, dexterity and precision. This highly sensitive structure, used to hold, catch and manipulate, is particularly vulnerable to trauma when subjected to repetitive stresses or impact of falls. Providing adequate support while maintaining functional movement is the prime consideration when taping the hand and or wrist. 187