Diagnosis and Treatment of the Upper Extremities Nonoperative Orthopaedic and Manual Therapy - DOS WINKEL

Neur-opathies oj the Shoulder k'o,r<o r,.-y) 195 Rowe CR Anterior subluxation in the throwing shoulder. Stanley D, Trowbridge EA, l\\orris SH. The mechanism o f c lavicular fracture: a clinical a n d biomecharilcal analy­ In: Zarins B, Andrews ,JR, Carson WG, eds. lnjurws to sis. J Bone Joint Surg {Br}. 1 988;7046 1-464, the Throwing A nn Philadelphia: Saunders; Stenvers JD, Overbeek WJ . Bestaat bij de frozen shoulder toch ook e e n b e nige beper king? Ned Tijdschr 1985 : 1 44 1 5 1 . Geneeskd. 1978; 1 22 : 1 08 1 - 1 087. Rowe CR. Recurrent transient subluxation o f the shoul­ Strizak AlIi, Danzig TL, D, Stap l e T. der: the \"dead arm\" syndrome. Clin Or/hop. S ubacromial 1987;223 1 1-19. study. J Bone Joint Rowe CR, Zarins B. Recurrent transient subluxation o f the shoulder. J Berne Joint {Am/. 1 9 8 1 ;63:863- 87 1 . Thetter 0, Steckmeier E, SchmbLder A, Rolle A. Das Tho­ racic-Outiet-Syndrom. Orthopade. 1 98 7 ; 1 6 :4 4 1 -447. Rmve CR, Zarins B , Ciullo Recurrent anterior d i sloca- Thompson WAL, Kopell H P . Peripheral entrapment neu· tion of the shoulder after repair: apparent ropathies o f the u pp e r extremity. N Engl J Med. 1 959;260 : 1 2 6 1 - 1 265. causes o f failure and Joint Surg {AmI 1 984;66159-168. Russe 0, Gerhardt J,J , King of Examina- Tyson RR, Kaplan GF. Modern concepts o f diagnostics and treatment of the thoracic outlet syndrome. tion, SUm.rim'a w,'f':u.su r f': ,·/lR'fM..' and Diagnosis in Orthop Clin North Am. 1 975;6:507-5 1 9. Orthopaedics and Bern: Hans H uber Verlag; 1972. Uhthoff HK, Piscopo M. Anterior capsular redundancy o f the shoulder: congenital traumatic? An embryologi­ Sahlstrand T , Save-Sbderbergh J. Subacromial bursitis cal study. J Bone Joint Surg fBrl 1 985;67'363-366. \\vith loose bodies a cause of refractory painful arc syndrome: a case report. J Bone Joint Surg {AmI Varriale PL, A d l e r ML. Occu l t fracture of the glenoid 1 980;62: 1 1 94-1 1 96 . without dislocation: a case repolt. J Bone Joint Surg {Arn}. 1 983;65:688-689. Sain J , A n d rews J R . Proper p i tching techniques. I n : Zarins B , Andrews JR, Carson WG, eds. lnjtbries t o the Verhoef J, Verplanke L. uniek Throwing A nn. Philadelphia: Saunders; 1 985:30-37. fenomeen? Ned TiJdschr !Vlfl.f/'IJ.l-iI.f1 1 98 5;851 5 , 3 : 4 6-£5. Samilson RL, Prieto V Dislocation arthropathy of the shoulder. J Bone Joint Surg {Am}. 1983;65:456-460. Visser JD, Korungs J G . s c h o u d e rgewricht. Ned Scavenius M , Iversen BF, S tiirup J. Re�)ecl:ion of the lat- 1 98 1 ; 125,26: 1 035-1038. eral end of the clavicle following with em- phas i s on non-traumatic of the acromial end Vleeming A, Stoeckart R, Klein HW, Volkers ACW M isverstanden betreffen d e bursae van de schouder of th e clavicle in 1 987; 1 8:261 -263. Ned T�Jdschr Geneeskd. 1987; 1 3 1 ,4 1 : 1807-1809. Wadsworth CT. Frozen s h o u l d e r . Phys Ther. 1 986;66: 1878-1883. Schneider A. Beitrag zur physikalische-therapeutischen Warren-Smith CD, Ward MW . Operation for acrorniocla­ Behandlung d es Sch u l te r -Arm-Schmerz-Synd roms. vicular dislocation: a review of 29 cases treated by one Zeitschr Krankengymnastik. 1 976;28:4 J 2-4 J 3. method. J Bone Joint Surg {Br}. 1987;69:7 1 5-71 8. Selesnick FJ , Jablon M , Frank Post M, Retrosternal Weisman JA von, Matison JA. Z u r Ron tgendiagnostik del' dislocation of the c lavicle: report of four cases. J Bom habituellen Luxation des Oberarmgelenks. Fortschr Joint Smg fAm! 1 984 ;66:287-2 9 1 . Rontgens!. 1 977; 1 26:29-35. Serratrice G. De piJrilijke schouder. Tempo !v1ed Ned. Wells R. Suprascapular nerve entrapment In: Zarins B, 1981 ;647-62. Andrews JR, Carson WO, eds. injwies to Thro'W- ing A rm. Philadelphia: Saunders; 1985. Simeone FA. Neurological complications o f closed shoul­ der injuries. Orthop Clin North Am. 1 97 5 ; 6: 499· 505. Welter H f, Thetter 0 , Schwe i b e re r L Kom p ressionssyndrome der o b eren Simon ViH. Soft tissue disorders of the shoulder: frozen !v1tm.hc. ener ll,fed Wochenschr 1 984 ; 1 26: 1 shoulder, calclflc tendinitis, and t e n d i ni t i s . Or!hop Clin North A m. 1 975 6:52 1-539. Skllt]a M, Morilux J H . Case studies: ,he s uprascapular laris insertion in a child: a case Surg lAm}. 1 985;67:63 5 636. nerve and s houlder dysfunction. J Sports W i l h elm A. U n klare Schmerzzustande an Phys Ther. 1 985;6 2 54-257. Extremitat. Orthopade. 1 987; 1 6:458-464. oberen 36th ed. Sobotta J , Becher PH. A tlas of Hzmum 1, Williams PL, Wap;\\�ck R, eds. Gray's & Edinburgh: Longman; 1 980. 2 and 3. 9th Berlin Schwarzenberg; 1 975. Copyrighted Material

1 96 DIAGNOSIS AND TREATMENT OF THE UPPER EXTRElVlITIES W inkel D, Fisher S. Schematisch handboek voor Wyke B. Morphological and functional features of the in­ ondeTzoek en behandeling van weke delen nervation of the costovertebral jOints. Polia Morphol. aandoeningen van het bewegingsapparaat. 6th ed. 1 9 7 5 ; 2 3 : 296--305. Delft: Nederlandse Akademie voor Orthopedische Geneesklmde; 1 982. Wyke B. The neurological basis of thoracic spinal pain. Rhe-umatol Phys Med. 1 970; 1 0 356-367. Copyrighted Material

Part II The Elbow 9. Functional Anatomy of the Palpation of the Muscles at the Elbow . . . . . 200. . . . . . . . . . . . . . . Dorsoradial Aspect of the Forearm . \" ....,.,., ..,.215 Joint Morphology ,..... , 200 Brachioradialis ., ,215 Humeroulnar Joint . . .. ,.,200 \" \"\" ,,.. , 215 Humeroradial Joint .. . ,,200 Extensor Radialis Proximal Radioulnar Joint 200 \"\"\" ,,,,217 Distal Radioulnar Joint . ,. . 202 Extensor Radialis Joint ' .,.,. .,\" ,.202 Brevis , ,, , . . , ,217 Musculature ' , ,., \" .. .,202 Extensor Digitorum Other ' , , , , ' , \" ,. 202 Communis ,., . ..., \" .217 Extensor Minimi , 218 Attachment of the Extensors Extensor Ulnaris , '\" 218 Radialis Longus and Brevis . . ... , .,.,., ,.,202 Abductor Polllcis Longus Nerves in the Cubital . ,204 and Extensor Poilicis BiomechaniCS , \" .. \" .. ,. 204 Brevis .. , ,,218 10. Surface Anatomy of the Arm, Extensor Pollicis Longus \" \" 218 Elbow, and Forearm .. . .. . . . 207 Palpation of the Flexors of the Forearm . . . . ,.,.. ,....,..,218 Cubital Fossa .,.,..,., 218 Palpation of Bony and Teres . ,....,..,.,.219 Structures , , . \" 208 Palpation of Muscles and Other Radialis .. \" \" .,,219 . ,,..., ' , .,,219 Soft Tissue Structures of the , ..,220 Arm , \" .. .,......, , , 208 , , , ,..,208 220 Brachialis .... ,, , .. , , .,.,,,., ., .210 Flexor Digitorum Profundus 220 Coracobrachialis \" . \" ,. , ., 210 Flexor Pollicis Longus .,.,.., 220 \" ,.211 Anconeus ,211 11. Examination of the Elbow . . ..221 Elbow Joint Medial Bicipital Sulcus ,212 Lateral Sulcus 212 221 Palpation of the Bony and ,. ., Zero Position 221 Structures , . . ,212 Maximal Loose-Packed Cubital JOint Position . \". . .,\" \" ,.\" .221 \" .212 Maximal Close-Packed Radial Head (Caput Radii) 214 Position , ,.. 221 197 Copyrighted Material

198 DIAGNOSIS AND TREATMENT OF THE UPPER EXTREMITIES Capsular Pattern ... .. . . ... . .221 12.2 Pathology of the Bursae 242. . . . Subcutaneous Olecranon 242 Forearm (Antebrachii) ... ...221 Bursitis .. , . , Zero Position . .. . .....221 Maximal Loose-Packed Position . .. . . . . . . . ... . .222 12.3 Pathology of the Muscle- Maximal Close-Packed Tendon Unit . . 243. . .... . . .. Position ... .. . . . ... 222 Strains or Overuse of the Pattern ..... . ..222 Brachialis ,., .. ,243 Overview of the Functional Myositis Ossificans 244 Examination , .. .222 Lesions of the ,244 General Inspection ........222 Lesions of the . ,,245 History .. ..... . . , .222 Golfer's Elbow (Medial Specific ......223 Humeral Epicondylitis) ,245 ......., . ,223 Tennis Elbow (Lateral Functional Examination ,.,...224 Humeral 246 Palpation ..... ,... ... \" .224 13. Treatment Techniques in Examinations in Lesions of the Elbow . .. . 251 Limitations of Motion .... , ,224 .. Other Examinations . \" .... ,224 Cubital Joint Arthritis \" ' .. , .251 Description of the Functional Intra-articular Injection ,, 251 Examination .,.... \" . .224 Loose Bodies ... , , , ,,.,. 251 Active Motions .,...225 Manipulation , .. , 252 Passive Motions . .. . . .226 Subluxation/Dislocation of the Resisted Motions . , .... \" ..229 Radial Head (Sunday Afternoon Arm) , , , ,259 12. Pathology of the Elbow . .. .. . . 234 259 of the Brachialis 12.1. Elbow Joint Pathology .. .. . 234 Muscle Belly . ... . . . , .. , \" .260 Transverse Friction . . ,260 Pathology with Limited Strain/Overuse of the Muscle Motions in a Pattern .. , .2 3 4 , ,..26'1 Arthritis ..... . , .....,...234 Transverse . . . , ,... , . 261 Pathology with Limited Insertion Tendopathy of the Motions in a l\\Joncapsular ..... , ,.. \" .. , ,..261 Pattern .. , . 235 Transverse Friction . , ,.262 Osteochondrosis Stretch ... . ,..263 Dissecans ,...235 Injection . . ..... ... \" ., ,263 Panner's Disease 237 Subtendinous Bursitis of the Loose Bodies in Adults , ...238 265 Synovial ,266 osteochondromatosis .238 Insertion Tendopathy of the Pathology of the ,266 Capsuloligamentous Transverse Friction 266 Complex ....239 Stretch .,., 268 ....... , .....,.239 Injection , .. , ,268 Copyrighted Material

The Elbow 199 Golfer's Elbow (Tendopathy of Transverse Friction . .... . . . ..287 the Wrist . ... . . . ....268 I . . ..... . . . .... . .. . 289 Transverse Friction Type 1: Tennis Elbow 5 (Insertion Insertion at the of the Extensor Medial Humeral .......... . . ...289 .269 Transverse Friction ..........289 Transverse Friction Type 2: Tennis All Types . . . .. .290 Lesion of the ....... .290 Musculotendinous Subcutaneous Olecranon Junction . ..............270 Bursitis . ...........291 Strekh ........ . . . . 272 .................29 3 .............274 Tennis Elbow of the Extensor Neuropathies in the Elbow Carpi Radialis Longus) .......275 Region 294. . . . . . . . . . . . . . . . . . . Transverse Friction . . .. . . ..275 Functional ... . . . . ....294 Tennis Elbow 2 (Insertion Radial Nerve .. . .294 of the Extensor of the Radial Radialis . . ......278 NeNe ............. ...295 Transverse Friction .. . . . .278 Ulnar Nerve . ............296 Stretch . ... . .279 Cubital Tunnel Syndrome .. . ..298 Stretch . ... . .280 Median Nerve ................299 ......28 3 Pronator Teres Syndrome . .. 301 Tennis Elbow 3 (Tendinitis of Radialis .... 286 Part II-Elbow Review Questions . . 302 Transverse Friction ....286 Tennis Elbow 4 (Strain Part II-Elbow Review Answers 303. . . Part II-References 304. . . . . . . . . . . . . . of the Musculotendinous Part II-Suggested Reading 304. . . . . . . Junction and/or Proximal Muscle of the Extensor Carpi Radialis Brevis .... . . . . . . . . .. . . . . 286 Copyrighted Material

9 Functional Anatomy of the Elbow The trochlear notch of the ulna is also ante­ riorly 45°. A ridge is found between Within the joint the medial and lateral parts of the notch. It of the humerus, radial and proxi- ends in the of the coronoid process at its mal part of the ulna. In a sense, the elbow anterior aspect. A part of the joint surface of­ consists of three the ten is not covered \\vith joint This humeroulnar, the absence of can be seen between the radioulnar. These three jOints are part of the trochlear notch that forms the an- enclosed the of the cubital articu- terior of the olecranon and the lation. that, in the anatomical Movements in the elbow are related to those in the wrist. This is lady true for the pronation and Hurneroradial Joint movement in both proximal and distal radi­ The capitulum of the humerus forms the oulnar connections. Numerous muscles in the head of the humeroradial joint. The concave forearm have a flllction both in the elbow and surface on the radial head forms the socket. in the wrist One can see it as a ball and socket joint ticulatio Because of the radius' JOINT MORPHOLOGY \\vith the ulna (the radi- oulnarjoint) and the humeroulnar joint, how­ Hurneroulnar Joint ever, there is a much smaller functional range The head of the humeroulnar is of motion than in other ball and formed by the trochlea of the humerus. The Proximal Radioulnar Joint socket is formed the trochlear notch of the ulna. These joint surfaces are not completely The articular circumference of the radius congruent. In full extension the trochlear articulates \\vith the radial notch of the ulna as notch does not have contact \"vith the medial well as \\vith the annular The annu- of the and in full flexion it does lar encloses the radial circumfer­ not have contact \\vith the lateral ence. Its fimction is to maintain contact be­ The trochlea is angulated approximately tween the ulna and radius. At its inner 45° anteriorly in relation to the longitudinal the is covered \\vith It is axis of the ulna. This results in an increased funnel \\vith the \"vide possibility of flexion range of motion. nel and the small 200 Copyrighted Material

Functional Anatomy oj the Elbow 201 10 �/-'I;:-2- a c B Figure 9-1 Different aspects of the elbow. A, Right humerus, anterior view; B, right ulna, radial view; C, right radius, anterior view; D, right humerus, posterior view; 1, humeral trochlea; 2, trochlear notch; 2a, part of the notch that is often not covered with cartilage; 3, humeral capitulum; 4, fovea (facet) of the head of the radius; 5, circumference of the head of the radius; 6, radial notch of the ulna; 7, radial fossa; 8, coronoid fossa; 9, olecranon fossa; 10, lateral humeral epicondyle; 11, medial humeral epi­ condyle; 12, neck of the radius; 13, coronoid process. Copyrighted Material

202 DlAGNOSIS AND TREATMENT OF THE UPPER EXTREMITIES The radial collateral is a triangular band that rilllS from the Jat­ nected to the radius. toward the radius and annu- lar This also is very closely Distal Radioulnar Joint connected to the insertions of the and extensor radialis brevis muscles. The movements in the proximal radioulnar cannot take independently from MUSCULATURE motions in the distal radioulnar Func- both form a kinematic lmit. Flexion and pronation and The head of the distal radioulnar is nation are the active movements in the elbow formed the ulnar articular circumference joint (Figure . The muscles that are in­ and the socket is formed the ulnar notch of volved in each active motion are as follows: the radius. Because of the intimate connec­ .. for flexion tion with the 1, brachialis seen to have an articular disc. The 2, the is thickened at its dorsal and volar 3. brachioradialis however, one cannot of real 4. teres here, 5. to a lesser extensors ra- dialis and brevis Radius and ulna are also connected to each other by means of a fibrous joint, the interos­ .. for extension seus membrane. This membrane forms the L site for the attachment of numerous forearm muscles, 2. anconeus .. for pronation Joint Capsule 1, quadratus 2. pronator teres the joint of the elbow 3, with fast movements and re- above the radial and coronoid sistance: flexor radialis below the radial articular cir­ .. for supination cumference and coronoid process of the ulna, At the of the elbow, the cap­ 1. supinator border of the ole­ 2. 900 flexion of the elbow its is cranon fossa to below the radial articular cir­ cumference with a fold, to the olecranon. 3. with fast movements and re- fold unfolds in flexion,) Both humeral sistance: extensors radialis lon- are extra-articular. gus and has a thin fibrous membrane . Within the capsule, two collat- OTHER STRUCTURES are found. The ulnar (medial) Attachment of the Extensors Carpi runs from the medial Radialis and Brevis condyle, in three toward the ulna. The anterior and posterior bands are the stron- Only a very small part of the extensor The oblique band often is not well devel- radialis originates from the lat- The anterior band is the re- 9-6). Its main straint of extension. Copyrighted Material

Functional Anatomy oj the Elbow 203 Figure 9-2 Joint capsule, medial view. 1, Anterior band of the ulnar collateral ligament; 2, posterior band of the ulnar collateral ligament; 3, oblique band of the ulnar collateral ligament; 4, tendon of the biceps; 5, fibrous capsule; 6, interosseus membrane; 7, oblique cord. Figure 9-3 Joint capsule, lateral view. 1, Radial collateral ligament; 2, annular ligament. proximal to the lateral epicondyle. The The extensor carpi radialis brevis also has an muscle also has an attachment to the lateral origin at the radial collateral ligament as well intermuscular septum. as to a thickening in the fascia that covers this muscle. In particular, this last connec­ The extensor carpi radialis brevis attaches tion could play an important role in the to the lateral epicondyle through a tendon transfer of loads generated by the extensor that is shared with the extensor digitorum. Copyrighted Material