486 CLI N I CA L A P P LICAT I O N OF N E U R O M USCU LAR TECH N I Q U E S : T H E U P P E R B O DY HUMEROULNAR JOINT Figure 1 3.87 1 . Medial epicondyle. 2. Olecranon. 3. Lateral e picondyle. Horizo n ta l bony a lignment becom es equilatera l tria ngle This joint is formed where the trochlea of the humerus, a d uring elbow flexion. spoon-shaped surface, is met by the trochlear notch of the ulna. The longitudinal ridge of the ulnar head fits into the • When elbow is fully extended the three contacts should channel of the trochlea while the concave surfaces on either form a straight line. side of the ridge correspond to the lips of the trochlea. The ulnar head's anterior edge, the coronoid process, and its • When the elbow is flexed to 90° they should form an posterior edge, the olecranon process, slide within the chan inverted triangle. nel during flexion a nd extension, this joint's only move ment. Posteriorly, on the distal end of the humerus, the • Traumatic insults, for example to radioulnar articulation, olecranon fossa receives the protrusive olecranon process of may alter these alignments. the ulna when the elbow is fully extended. THE LIGAM ENTS OF THE E LBOW HUMERORADIAL JOINT • The joint capsule i s thin and lax and i s continuous with the This joint is formed where the capitulum of the h umerus, a annular ligament, a strong band which encircles the head hemispherical surface, is met by the concave fovea of the of the radius. radial head. This ball and socket joint allows for flexion and ex tension as well as rotational movements. The radial head • The medial ligament (ulnar collateral ligament) is a thick trian is stabilized by the annular ligament. This ligament, which gular band, comprising an anterior and a posterior band encircles the radial head and a ttaches at both ends to the which unite a t a thin intermediate portion (Fig. 13.88). ulna, allows rotation and flexion /extension while forbid ding lateral and medial excursions of the head of the radius. • The anterior part attaches superiorly, via its apex, to the By stabilizing the ulna and radius together, the annular lig medial epicondyle of the humerus and inferiorly, via its ament ensures tha t these two j oints act as one during flexion base, to the medial margin of the coronoid process. and ex tension. • The posterior part is also triangular which attaches supe RADIOULNAR JOINT riorly to the posterior aspect of the medial epicondyle and inferiorly to the medial margin of the olecranon. This pivotal joint is formed where the rounded circumfer ence of the radial head fits against the radial notch of the • The intermediate fibers run from the medial epicondyle to ulna. While the proximal ulna remains stable during prona an oblique band which joins the olecranon and the coro tion and supination, the radius spins inside the annular lig noid processes. ament against the ulna and against the ball-shaped distal surface of the capitulum of the humerus. During this spin • The lateral ligament (radial collateral ligament) is attached ning action, the shaft of the radius rota tes around the ulna, superiorly to the distal aspect of the lateral epicondyle of which flips the forearm and hand over. Pronation and the humerus and inferiorly to the annular ligament. supination can occur at any point during flexion and exten sion if these radial joints are functional. Ruch et al (2006) implicate synovial plicae of the elbow as a possible cause of lateral elbow pain in pa tients with vague The interosseous membrane provides a continuing clinical symptoms. Although these pa tients failed to fibrous joint between the radius and ulna for the full length of the two bones. This membrane prevents upslip or dis placement of the two bones and also acts to transmit pres sure stresses from one bone to the other. It is an extremely strong fibrous network, which provides a place for muscu lar a ttachment as well as tremendous structura l support for the forearm. In fact, d uring structural distress, the radius and ulna are prone to fracture before the fibers of the mem brane are torn (Pia tzer 2004). ASSESSM ENT OF BONY ALIGN MENT OF TH E EPICO N DYLES (FIG. 1 3.87) • Patient's arm is hanging at the side. • Practitioner, standing behind, places thumb on medial epicondyle, index finger on olecranon, middle finger on lateral epicondyle.
1 3 Shoulder. arm and hand 487 Fat pads --1-.+'\" respond to conservative treatment, Ruch et al suggest that arthroscopic management may provide a successful treat Annular ligament ---,\\ Synovial ment option in such cases. membrane of radius --�-=:;f A S S E S S M E NT F O R L I GA M E N TO U S STA B I L I TY Sacciform recess • Patient is seated or supine. of synovial • Practi tioner holds patient's forearm proximal to the wrist membrane to avoid undue stress on the joints (this is the practi tioner 's 'motive hand') while the other hand (the 'stabi lizing hand') cups the distal humerus. • The patient is asked to slightly flex the elbow (i.e. the pro cedure is not performed in hyperextension), arm supinated, and the practitioner introduces a translation action at the elbow by means of a medial push with the motive hand and a simultaneous lateral push with the stabilizing hand, followed by a reversal of these two directions of push. • As these side-shift (translation) movements are gently and repetitively carried out, the stabilizing hand notes whether a normal degree of slight gapping is taking place as the valgus and varus stresses are applied . Figure 1 3.88 The head of the radius 'spins' inside t h e confi nes of EVALUAT I O N the a n n u l a r ligament (a nterior view). Reprodu ced w i th perm issio n CAUTION: Avoid testing (active or passive) for range of motion if there exists the possibility of dislocation, fracture, from Gray's Anatomy for Students (2005). advanced pathology or profound soft tissue damage (tear). There are three important reflex tests tha t help to evalua te the neural integrity of the upper extremity. They are placed here with the elbow since they are examined at the elbow, but they are commonly also used when evalua ting the shoulder and cervical region. Radial Ulnar BICEPS REFLEX collateral collateral ligament • This evaluates the integrity o f nerve supply from CS level. ligament ---\\,\\ • The seated pa tient's forearm is placed so that it rests on Annular ligament the practitioner 's forearm. • The practitioner cups the medial aspect of the patient's of radius ---t� elbow so that his thumb can be placed in the cubital fossa. Sacciform recess • The patient's arm must be relaxed. of synovial • The practi tioner taps his own thumbnail with a neuro membrane -_-../ logic hammer and the biceps should jerk slightly to the Figure 1 3.89 Joint capsule and ligaments of the elbow. Reproduced extent that it is both visible and palpable. with perm ission from Gray's Anatomy for Studen ts (2005). BRACHIORADIALIS REFLEX • This evalua tes the integrity o f nerve supply from C6 level. • The arm is supported in precisely the same manner as in the biceps reflex test above. • The brachioradialis tendon at the distal end of the radius is tapped (the tendon is tapped, not the prac titioner 's thumbnail) with the neurologic hammer and a palpable and visible jump should occur in brachioradiaIis.
488 CLI N I CA L A P P L I CATI O N OF N E U RO M U S C U LA R TECH N I Q U E S : T H E U P P E R BODY TRICEPS REFLEX • This evaluates the integrity o f nerve supply from C7 level. • The arm is supported in precisely the same manner as in the biceps reflex test above. • The triceps tendon where it crosses the olecranon fossa is tapped (the tendon is tapped, not the practitioner's thumbnail) with the neurologic hammer and a palpable and visible jump should occur in triceps. • Note: 1. An increase in normal reflex activity may indicate upper motor neuron disease. 2. A decrease in normal reflex activity may indicate a lower motor neuron lesion (e.g. a herniated disc). RANG E S O F M OTIO N OF THE ELBOW The neutral position o f reference for the elbow joint occurs F i g u re 1 3.90 From neutra l to fu l l ra nge of flexion of the elbow when the forearm and upper arm are in a straight line (Fig. joint. Relative extension returns the forearm back to neutra l w h i l e 13.90). Hence, the range of motion for true extension of the true extension of the elbow (beyond neutral) is termed elbow is actually 0°, since the forearm does not extend hyperextension . beyond neutral, except in a few subjects with hyperexten sion conditions due to ligamentous laxity. However, the term • As the patient attempts t o extend the elbow, the relative 'relative extension' is used when the forearm is returned strength of triceps and anconeus is being evaluated. toward a neutral position from any point of flexion. Neural supply to these muscles is from C7 and C8. The forearm is flexed when it is brought toward the ante • The patient begins with the forearm pronated and the rior aspect of the upper arm. Active flexion produces a practitioner restricts this position as the patient attempts range of 135-145° (Hoppenfeld 1976, Kapandji 1 982) with to supinate against resistance. This evaluates relative an additional 15° availab le wi th passive assistance. During strength of biceps, supinator and possibly brachioradi active flexion, various muscles will contract, depending alis. Neural supply is from C5 and C6. upon the rotational position of the forearm. • The patient begins with the forearm supinated and the Both active and passive range of motion tests may be practitioner restricts this position as the patient a ttempts used to assess limits of movement of the elbow joint. to pronate against resistance. This evalua tes the relative Bilateral comparison is possible by both sides performing strength of pronator teres, pronator quadratus and flexor action simultaneously. If active testing shows normal range carpi radialis. Neural supply is from C6-8 and TI. without pain or discomfort, passive tests are usually not necessary; however, with elbow flexion an additional 15° of ELBOW STRESS TESTS flexion may be achieved with assistance. • Patient is seated or supine. Restrictions tha t have a hard end-feel during passive • Practi tioner holds pa tien t's arm proximal to the wrist range of motion assessment are usually joint related. Restrictions that have a softer end-feel, with slight springi to avoid undue stress on the wrist joints (this is the ness still available at the end of range, a re usually due to extraarticular soft tissue dysfunction. RAN G E OF M OTIO N AN D STRE N GTH TESTS • Range of motion tests a re performed both actively and passively involving flexion (135-145°), extension (0°), forearm pronation and supination (90° each). • Strength i s tested with the practitioner (standing in front of the patient) cupping the flexed (to 90°) elbow with one hand ('stabilizing hand') while the other hand holds the patient proximal to the wrist.
1 3 Shoulder, arm and hand 489 J practitioner's 'motive hand') while the other hand (the I N D I CATI O N S FO R TREATM E NT 'stabilizing hand') cups the distal humerus. ( DYS FU N CT I O N S/SYN D R O M ES) • With the arm relaxed, normal range of motion is assessed involving flexion, extension, pronation and M E D IAN N E RVE ENTRAP M E NT supination. • Any pain or restriction of motion should be noted. This may be produced by the pronator teres, flexor digito • These symptoms could involve tendinitis, joint pa thol rum superficialis or the anomalous flexor digitorum super ogy or contractures. ficialis indicis. Impingement of the nerve within the carpal • If these tests are negative (i.e. if no pain or restriction is tunnel results in an all-too-common syndrome tha t affects noted), the same movements are then carried out against the hand and wrist. resistance. The practitioner notes which soft tissues are being lengthened (stretched) if pain or restriction CARPA L TU N N E L SYN D R O M E is noted. And these tissues are investigated further by means of active patient movements and/ or by pal The carpal tunnel is a narrow passageway a t the wrist that pation. allows passage of nine tendons, the median nerve and blood • The same movements are also observed with the patient vessels that serve the hand. The median nerve can become actively and slowly performing them (more than once to compressed within the carpal tunnel by a bone, enlarged ten gain insight into normal behavior). The practitioner don, scar tissue, excessive fluid or abnormal tissue, resulting notes which soft tissues are reported as being painful and in a number of symptoms that are associated with 'carpal these structures are subsequently palpated for dysfunc tunnel syndrome'. tion or assessed for shortness. Non-surgical treatment of carpal tunnel syndrome requires STRAINS O R SPRAINS assessment of biomechanics to determine if poor habits of use in work and recreation are factors as well as examination of • Bicipital attachment to the radius may be trauma tized on the shoulder, neck and forearm muscles for trigger points that hyperextension injuries. Palpation of the tendon will frequently refer into the wrist and hand. Additionally, tests to reveal extreme tenderness. Rest (in a sling) for a few days, rule out median nerve impingement by other muscles along plus appropriate sprain therapy (ice, etc.), is advised. its course may be required. • Hyperpronation or hypersupination inj uries may result If true impingement within the cana l is diagnosed, surgi in limitation to rotation and pain. The radial head may cal intervention may be suggested. This might include: actually dislocate. • Open release, which involves an incision (up to 2 inches) • If forced abduction or adduction occurs, rupture of the being made at the wrist and the carpal ligament cut to capsular apparatus, including ligamentous attachments enlarge the tunnel. to humerus, radius or ulna, is possible. • Endoscopic surgery, which involves two smaller inci • If a fall occurs in which the outstretched arm absorbs the sions (at the wrist and palm) through which a camera is compression injury, damage to the dorsiflexed wrist inserted to help guide a more precise cutting of the carpal (stretching the ventral soft tissues), the extended elbow ligament. This procedure minimizes scarring and scar or the shoulder is possible. The age of the individual - tenderness. and therefore tissue elasticity - will usually influence where damage occurs (e.g. wrist fracture in elderly, distal Although symptoms may be relieved immediately following humerus in younger individuals). surgery, it is not uncommon for it to take months for a full recovery to occur. Wrist joints may lose strength and pa tients • With hyperextension strain of the elbow, the following may need to undergo physical and occupa tional therapy as could all be swollen and tender on palpation: posterior well as make adjustments in the workplace and home. capsule, bicipital tendon, olecranon fossa, medial and lateral collateral ligaments, flexor a ttachments a t med Additional discussion of causes, symptoms and treat ial epicondyle. Pain will usually be eased by moving ment options is found on p. 507. the tissues in a direction which would reproduce the strain (see p. 225). U LNAR NERVE ENTRAPMENT • With hyperabduction strain, tenderness of the ulnar col The cubital tunnel, positioned on the posterior aspect of the lateral ligament, below the lateral epicondyle, is usual. medial epicondyle, is formed by the cubital groove (floor of Pain is usually eased by taking the joint in a direction that the tunnel) and an aponeurotic band (roof of the tunnel) reproduces the strain. which stabilizes the nerve during movement (Fig. 13.91). During flexion, the retinacular band becomes more tau t and • With hyperadduction strain, tenderness of the radial col closes in on the tunnel's space. This may irritate or com lateral ligament, below the medial epicondyle, is usual. press the ulnar nerve as it passes through the tunnel. Pain is usually eased by taking the joint in a direction that Addi tionally, if the wrist is extended and the shoulder is reproduces the strain.
490 C L I N I CA L A P P LI CAT I O N OF N E U RO M U S C U LA R T EC H N I Q U E S : T H E U PP E R B O DY Triangular Interval Profunda brachii artery \\+1�\\-+-C, Radial nerve (in radial groove) C:;::-<;L Inferior lateral cutaneous nerve of arm Branch 10 medial head of triceps brachii --I-ltWr '�\\ �l-- Posterior cutaneous nerve of forearm Medial epicondyle ---'\\\\ Ulnar nerve ---'t Figure 1 3.91 Nerve pathways of posterior aspect of u pper l i m b. Reprod uced with permission from Gray's Anatomy for Students (2005). held in a less than ideal pOSition, pressure may be further similar symptoms to cubital tunnel syndrome, such as a increased within the tunnel. Resting the elbow of the medial epicondylar ache with accompanying shooting pronated arm on the desk while working may also irritate points to the li ttle finger and ulnar portion of the hand this superficial portion of the ulnar nerve. (Cailliet 1996). The flexor carpi ulnaris may entrap the ulnar nerve, as it lies deep to this muscle and superficial to the A few inches more proximally, the nerv e .passes under flexor digitorum profundus. Additionally, an anomalous the 'arcade of Stru thers' as the nerve enters deep to the muscle, the anconeus epitrochlearis (Simons et al 1999), medial head of the triceps. This dense fascial arch is another may cause ulnar nerve compression when it is present. possible site of ulnar nerve entrapment and may produce
Lateral cord 1 3 Shoulder, arm and hand 49 1 .;.;-1 Medial cord Musculocutaneous nerve ---,YH= 1+.1--1 Median nerve --- Medial intermuscular septum Radial nerve --� Lateral cutaneous nerve of forearm --fA-+:l Figure 1 3.92 M uscu locutaneous, median and u l n a r nerves in the a r m . Reprod uced with perm issio n from Gray's Anatomy for Students (2005). Near the medial side of the wrist, the ulnar nerve can be primary cause. A tight grip on tools, such as screwdrivers or compressed within Guyton's canal (or tunnel), resulting in handles, can cause a compression ofthe nerve as thegripforces Guyton's canal syndrome (aka ulnar tunnel syndrome). the hard object into the palm. Ifthe symptoms arise as a result Symptoms include paresthesia and numbness in the distri ofan acute injury, likefalling on an outstretched hand, carpal bution of the ulnar nerve, and a trophy and weakness of fractures or dislocations may cause the nerve compression. muscles innervated by the ulnar nerve (hypothenar emi Longdistance cyclistsfrequently experience this condition. The nence), but not tenosynovitis since no tendons run through position of the hands on the handlebars places pressure directly the canal. Lowe (2006) notes: over the Guyton's canal; thus the condition's alternate name of handlebar palsy (Capitani & Beer 2002, Noth et al 1980) Because GCS [Guyton's canal syndrome] mainly develops People who use walking canes develop the condition as from external compression, occupational disorders are a well.
492 CLI N ICAL APPLICATI O N OF N EU R O M U SCULAR TECH N IQU E S : T H E UPPER BODY Enthesitis: 'Traumatic d isease occurring at the i nsertion of ASSESSMENTS FOR TENOSYNOVITIS AND muscles where recurring concentrations of muscle stress provoke EPICO N DYLITIS i nflammation with a strong tendency toward fibrosis and ca lcification'. (Simons et a l 1 999) 1. Cozen 's test (,tennis elbow'). The practitioner stabiljzes the patient's pronated forearm by cupping the elbow. If RADIAL N E RVE ENTRAPM ENT desired, additional stress can be applied to the suspect tissues by the practitioner's thumb pressing on the exten This may be produced b y the long head of the triceps, the sor tendons j ust distal to the lateral epicondyle. The supinator and extensor carpi radials brevis as well as an patient clenches and extends the fist and the practi anomalous flexor carpi radialis brevis muscle. Injury or tioner's other hand holds this and attempts to flex the overuse of any of these muscles can result in the develop wrist against the patient's resistance. This should only ment of ischemia and neural entrapment. test wrist extension and should not incorporate other muscles that move the elbow or finger joints. If tenosyn Radial tunnel syndrome (RTS, also sometimes called ovitis exists there will be pronounced sudden pain resistant tennis elbow) can occur at the elbow region as the reported at the lateral epicondyle as the contracting ten radial nerve passes through a number of fibro-osseous tun dons provoke irritation at a very likely site of enthesitis. nels, including the arcade of Frohse, where a portion of the nerve passes under the edge of the superficial head of 2. Mills test. The patient clenches the fist, flexes the elbow supinator. Lowe (2006) notes: 'The pain sensations of RTS and wrist, and pronates the arm. The practitioner offers develop mostly near the lateral epicondyle of the humerus, resistance as the patient then attempts to supinate and but periodically radiate into the anterior and lateral forearm extend the forearm and wrist. Pain noted at the lateral as well. RTS is frequently mistaken for lateral epicondylitis epicondyle confirms radiohumeral epicondylitis. because the pain sites are similar.' 3. Medial epicondyle test ('golfer's elbow') . Patient flexes elbow T E N O SY N OV ITI S ('T E N N I S E LB OW ' A N D/O R to 90° and supinates the hand while the practitioner 'GOLFER'S ELBOW') offers support by cupping the elbow. If desired, addi tional stress may be applied to the suspect tissues by the • This painful condition involves damage, inflammation practitioner 's thumb pressing on the flexor tendons just and dysfunction associated with the epicondyles of the distal to the medial epicondyle. The practitioner offers humerus. resistance as the patient then attempts to flex the wrist. This should only test wrist flexjon and should not incor • It may involve epicondylitis and/ or radiohumeral bursitis. porate o ther muscles that move the elbow or finger • The cause is thought to be repetitive trauma to the joint joints. If pain is noted, medial epicondylitis is suggested. involving supination or pronation of the wrist together E LBOW S U R G E RY A N D MANUAL TECH N I QU E S with elbow extension (for 'tennis elbow'). • The result of repetitive stress of this type is for contrac Davila & Johnston-Jones (2006) discuss evaluation guidelines tion to occur involving the extensor-supinator muscles of for assessing the 'stiff elbow', which usually involves intrinsic the forearm. and/ or extrinsic elements that limit movement. They note: • It is possible for the radial nerve to be entrapped as part 'Intrinsic contractures are by definition due to joint/intra of the etiology. articular incongruency, and therefore therapy and splinting • The medial epicondyle may also be involved in which cannot provide increase in joint motion.' The overall treat case the flexor-pronator muscles of the forearm are impli ment plan does incorporate non-operative therapy treatment cated (a condition known as 'golfer 's elbow' - see MET options, such as heat modalities, myofascial soft tissue mobi treatment recommendation for shortness of flexors of the lization, joint mobilization, muscle energy techillgues, passive wrist below). range of motion, active range of motion, extensive use of cor • It is possible for calcification at the margin of the joint to rective splinting, and strengthening exercise. occur or for lateral epicondyle erosion to take place. X-ray evidence would be needed to confirm these changes. They continue: • Symptoms of lateral epicondylitis would usually include severe, lancinating, often radiating pain on extension of All operative candidates must participate in a preoperative the elbow; residual dull aching pain at rest; squeezing therapy program of six to eight weeks to reduce extrinsic actions produce cramp-like pain; inflammation evidence contractures as feasible and to assess patient compliance heat and swelling - may be noted at the epicondyle; with an intensive postoperative therapy program. Corrective supination and pronation as well as grip strength will be splinting may be neededfor as long as six months to main diminished. tain gains made in surgery. The therapyfollowing manipu lation under anesthesia and open contracture release is similar. The therapist must know the details of the proce dure. Operative treatment for the stiff elbow progresses in a sequentialfashion to progressively release tissue structures
1 3 Shou lder, a rm a n d hand 493 limiting motion and reconstruct any structures as needed \\ to provide joint stability. Postoperative therapy consists of continuous passive motion, corrective splinting, modali � ties, and specific exercise techniques to maintain passive gains achieved in surgery. The therapy is extensive and requires full participation from the patient to maximize motion andfunction. T R EAT M E NT As previously discussed, biceps brachii and triceps brachii cross both the shoulder and elbow joints and should be assessed with dysfunctions of either of these joints. Since biceps brachii lies superficial to brachialis, it should be treated prior to the assessment of the deeper muscle. BRACHIALIS Fi g u re 1 3.93 With both t h u m bs deep to the b i ceps, b rachialis may be compressed as gliding strokes a re appl ied simultaneously with Attachments: Distal half o f the anterior su rface o f the both thumbs. humerus and intermuscular septa to the ulnar tuberosity, coronoid process and the joint capsule of the elbow positioned. The practitioner places one thumb on the medial side of the exposed portion of the brachialis and the Innervation: Musculocutaneous and radial nerve (C5-6) other thumb on the la teral side of the exposed portion of Muscle type: Postural (type I), shortens when stressed the brachialis. The thumbs will be deep to the belly of the Function: Flexion of the forearm at the elbow joint biceps and opposite each other on the sides of the anterior Synergists: Flexion: biceps brachii, brachioradialis, supinator upper arm (Fig. 13.93). Antagonists: Triceps brachii With lubrication, the practitioner glides the thumbs prox I nd ications for treatment imally, while simultaneously pressing them toward each other. This 'double-thumb' technique will entrap the • Soreness of the thumb (referred zone) brachia lis as pressure is applied . The gliding process is • Anterior shoulder pain repeated 7-8 times from the distal end until the deltoid is reached. Ca ution is exercised to avoid p ressing on the neu Special notes rovascu lar bundle on the medial upper arm by ending the stroke with both thumbs near the deltoid tuberosity as While most muscles perform more than one function, brachialis shifts laterally on the humerus. brachialis is one of the few muscles that provides only a sin gle motion, i.e. flexion of the forearm. It provides this func The b iceps brachii can usually be displaced slightly on t ion whether the arm is supinated, pronated or resisted . It is both the medial and lateral aspects to allow access to a small quiet (no activity) when the arm is loaded in a fully depend portion of brachialis fibers. The forearm should be passively ent position and works best when the elbow is flexed to 90°. flexed and supinated for best access. Short, gliding strokes or pressure release methods may then be applied directly Brachi alis has the ability to entrap the radial nerve (cuta onto the brachialis muscle. Pressure applied through the neous branch) and thereby causes symptoms of tingling, biceps bellies will address the central portion of brachialis numbness and dysesthesia of the thumb and the webbed and can be used if the biceps brachii is not too tender. space beside it. These symptoms may also be referred from trigger points in brachioradialis, supinator and other mus cles of the thumb, which should be treated as part of an overall examination. � N MT FOR B RACH I A LI S T R I C E PS A I\\I D A N C O N E U S With the patient resting supine, the arm being treated is A full discussion of triceps i s offered on p . 449. Triceps is slightly passively flexed and tucked under the practi also placed here to offer an additional supine position treat tioner 's arm. This position will allow room for the practi ment and to remind the reader that it should be assessed tioner's hands to glide proximally when they are correctly with all elbow dysfunctions as well as the previous shoul der conditions.
494 CLI N I CAL A P PL I CATI O N OF N E U R O M U S C U LA R TECH N I Q U E S : T H E U P P E R B O DY Tests for strength of triceps are given earlier in this chap between the two fingers, which are removed when treatment ter on p. 415. is applied. Short glides between the ulna and radius (in the space between what the fingers have outlined) will address '6 N MT F O R T R I C E P S ( A LT E R N ATIVE S U P I N E this small muscle which is often involved in elbow pain. \" POSITION) MET for triceps is described earlier in this section on The patient is supine and the practitioner stands cephalad p. 452. to the shoulder to be treated. The shoulder may be placed in flexion with or without flexion of the elbow. If both joints B RAC H I O RADIALIS are simultaneously moderately flexed, the triceps may be placed under excessive tension and may respond as Attachments: Proximal two-thirds o f the lateral supra extremely tender, especially at its a ttachment si tes. It is condylar ridge of the humerus and intermuscular sep therefore better to maintain one or both of these joints in tum to the (proximal) lateral surface of the styloid partial flexion rather than full flexion. process of the radius The practitioner applies lubricated gliding strokes in seg Innervation: Radial nerve (C5 and C6) ments to cover the entire surface of the posterior upper arm Muscle type: Postural (type I), shortens when stressed to assess the lateral and long heads of triceps brachii. The Function: Flexes the elbow and stabilizes it during exten- radial nerve lies deep to the lateral head and is vulnerable to entrapment by triceps (Simons et aI 1999). The practi tioner sion, brings it to neutral pOSition (semisupinated) should avoid compression of the nerve while treating it. Synergists: Biceps brachii, brachialis Antagonists: Triceps The proximal glides may be repeated with increased pressure, if appropriate, to address the medial head of the I n d ications for treatment triceps, which lies deep to the lateral and long heads. Additionally, the medial head lies superficial on both the • Limited forearm movement medial and lateral aspects of the posterior a rm just above • Weakness the elbow and can be a ddressed in a marmer similar to • Pain brachialis by using a 'double-thumb' technique. Special notes To isolate the a ttachment of the long head of triceps on the infraglenoid tuberosity of the scapula, the thumb is slid Brachiorad ialis is a forearm flexor in neutral position, acting proximally along the tendon, which courses between teres on only one joint, the elbow. Con troversy about i ts actions major and teres minor. When the scapular a ttachment is began when it was wrongly named supinator longus as its reached, static pressure or mild friction can be used to action was thought to supinate the forearm (Simons et al assess and treat the attachment. Elbow extension is resisted 1999). While its supposed function to return the arm to neu to assure direct tendon contact. It may also be necessary to tral from either a supinated or a pronated position has muscle test for the two teres muscles since triceps passes inspired deba te, it does help prevent distraction of the between them before attaching to the scapula. elbow joint d uring rapid elbow movements. The olecranon attachment of the triceps is examined with While functioning as a flexor of the elbow, brachioradi finger friction or the beveled pressure bar. Pressure is placed alis is sometimes grouped with the extensors of the wrist directly on the tendon while the areas medial and la teral to due to i ts proximity to them and i ts innervation by an exten the tendon are avoided d ue to v ulnerable nerve passage. sor nerve. Its trigger point activity, somewhat like the wrist ex tensors, is into the elbow, forearm and the hand (web of '\" N MT F O R A N C O N E U S (see a lso p. 449) the thumb) (see Fig. 13.94, p. 496). It often becomes tender in association with the supinator and their similar pa in pat The anconeus, a small, triangular muscle positioned just lat terns require examina tion of both when either is suspect. Its eral and distal to the olecranon process, is easily addressed superficial location makes this muscle easily palpable and when treating the olecranon attachment of triceps. It therefore successfully addressed with massage and stretch extends the elbow and may serve to stabilize the elbow joint ing techniques. during pronation of the forearm by securing the ulna. The articularis cubiti (subanconeus muscle) is a small slip of the ASSESSMENT FOR STRENGTH OF medial head of the triceps and, when present, may insert B RAC H I ORADIALIS into the capsule of the elbow joint. • The patient i s supine with the arm a t the side, elbow The anconeus is easily isolated by placing an index finger flexed to 75°, forearm semisupinated. on the olecranon process and the midd le finger on the lat eral epicondyle while the practitioner's hand lies flat • The practitioner cups the pa tient's elbow with one hand against the pa tient's ex tended forearm. The anconeus lies to support it and offers resistance on the anterolateral aspect of the distal forearm.
1 3 Shoulder, arm and hand 495 • The patient is asked to resist the practitioner's effort to S U P I N ATO R (see Fig. 1 3.94) push the forearm into extension. Attachments: Supinator crest of the ulna, lateral epicondyle • The rela tive strength of each brachioradialis is tested. of the humerus and the ligaments and joint capsule of the elbow to the lateral surface of the proximal third of the It N M T F O R BRAC H I O RA D I A L I S radius With the forearm in a relaxed, semisupinated position and Innervation: Radial nerve - deep (posterior interosseous) passively flexed at the elbow to near 90°, brachioradialis is branch (C5 and C6, sometimes C7) grasped with pincer compression near its humeral a ttach ment. Tau t bands within the muscle are compressed Muscle type: Postural (type I), shortens when stressed between the thumb and fingers for 8-12 (up to 20) seconds Function: Supinates the forearm by spinning the radius; and the compression techniques are applied at thumb width intervals as far dista lly as possible. If tension and forceful elbow flexion referred pain are discovered and compression is applied to Synergists: Supination : biceps brachii the associated tissues, the patient should feel the discomfort fade as the pressure is sustained. If the discomfort or Elbowflexion: biceps brachii, brachioradialis referred sensation does not begin to fade within 8-12 sec Antagonists: To supination: pronator quadratus, pronator onds, the techniques are applied again with slightly less pres sure. A deeper grasp may also address the extensor carpi teres radialis longus and brevis, which lie deep to brachioradialis To elbowflexion: triceps, anconeus and are discussed with the forearm and wrist on p. 498. I nd i cations for treatment The muscle fibers may also be rolled between the thumb and fingers to discover tau t bands and nodules characteris • Elbow pain, such as in tennis elbow and golfer 's elbow tic of trigger points. Trigger points are treated with pressure • Lateral epicondylitis release techniques followed by stretching of the involved • Pain when supinating, such as to twist a doorknob, open tissues. a jar or use a screwdriver The practitioner follows the manipulation of the fibers • Elbow pain when using the elbow in any movement with lubricated gliding strokes from the s tyloid process to • Pain in the web of the thumb (referral zone) the humeral a ttachment. Hydrotherapy applications may precede or follow these procedures. Inflammation of the Specia l notes supinator muscle and epicondyles of the humerus should be ruled out before applying hea t to the elbow region. Ice The supinator muscle comprises two flat layers of muscles therapy may be applied to any of the muscles following that spiral around the radius to attach to the ulna. therapy, unless contraindicated. Contraction of its fibers will spin the radius against both the humerus (proximally) and the ulna (located to its medial � M FR FOR BRACHIORADIALIS side) to turn the palm and forearm toward the ceiling. Cou rsing betvveen these two layers of muscle is the deep • The patient i s seated with the arm at the side, elbow branch of the radial nerve, which lies vulnerable to entrap flexed, fist closed, thumb uppermost. ment by the supinator's fibers (Simons et aI 1999). Weakness in the supinator itself is not likely to be caused by this partic • The practitioner identifies brachioradialis by having the ular entrapment syndrome since innervation to the supina tor patient flex the elbow against resistance. branches off the radial nerve before it enters the muscle. • The patient releases the fist, relaxes the muscle and pal Supinator trigger points and ischemic fibers are often cre pation is performed to identify areas of contraction, ated with overuse or strain of this muscle. Common supina fibrotic change or other evidence of altered tissue status. tor symptoms may be initiated by manual use of a screwdriver, either with a difficult-to-turn screw (strain) or • The practitioner applies a broad, flat, thumb compres with numerous screws (repetitive), sorting envelopes by flip sion, one thumb width distal to the dysfunctional tissues. ping them into stack trays or postal boxes or straining to With this thumb contact, slight soft tissue traction is open a stuck jar lid or turn a stiff doorknob. Supinator may introduced, from the attachments above the lateral epi very rapidly become overly tender following overuse or condyle, to lengthen the fibers slightly. strain, while tending to rather urgently exhibit inflamma tory symptoms and weakness (very likely from trigger points). • With the arm relaxed and semisupinated, the patient is asked to extend it fully (drawing the dysfunctional tis Weakness in the muscles innervated by the radial nerve, sues under the compression force of the thumb) and then when not accompanied by pain, suggests nerve entrapment to return to the neutral starting position, while the firm and may be caused by a tumor pressing on the nerve or compression contact is maintained. some other lesion along its path (Simons et aI 1999) . While pain in the supinator area (tennis elbow) suggests a myofas • This procedure is repeated 3-4 times. ciaI cause, including trigger points or enthesi tis, it may or may not be accompanied by weakness of muscles supplied
496 CLI N ICAL APPLICATI O N OF N E U ROM USCULA R TECH N I Q U E S : THE U PP E R BODY r\\ the overlying muscles. However, repeated gliding tech niques, assisted pronation stretches and posttreatment ice Figure 1 3.94 Supi nator can entrap the rad i a l nerve as well as refer applications usually achieve a degree of improvement. to the elbow and web of thu mb. � M ET F O R S U PI N ATO R S H O RTN ESS by the radial nerve. When both pain in the supina tor area and weakness of muscles supplied by the radial nerve are • The patient is seated with elbow flexed t o 90°, forearm present, the cause is most likely myofascial trigger points pronated fully. with nerve entrapment due to tau t bands within the muscle (Simons et al 1999). • The practitioner stabilizes the arm against the patient's trunk at the elbow and applies a resistance contact with A S SE SS M E N T F O R STR E N GTH O F S U P I N ATO R the other hand to the proximal forearm. • The patient is seated with elbow flexed to 90°, forearm • The patient is asked to supinate the forearm against pronated fully. resistance for 7-10 seconds using minimal force. • The practi tioner stabilizes the arm against the patient's • After the isometric contraction the patient relaxes the trunk at the elbow and applies a resistance contact arm completely and then a ttempts, with the practi with the other hand to the distal forearm (Daniels & tioner's assistance, to pronate the forearm further. Worthingham 1980). • The patient is asked to supinate the forearm as the prac • This stretch is held for a t least 20 seconds. titioner evaluates the relative strength and compares one • This treatment can be usefully self-applied, especially in side with the other. cases of ' tennis elbow'. It N MT F O R S U PI N ATOR f M F R F O R S U P I N ATOR The brachioradialis and extensor carpi muscles are displaced laterally and lubricated gliding strokes are applied directly • The practitioner palpates the supinator from the lateral on the supinator, which lies deep to it (Fig. 13.94). The super epicondyle to its radial attachments and locates areas of ficial muscles are displaced medially and the gliding strokes dysfunction, fibrotic change or contraction. repeated on the remainder of the supinator muscle. Only a small piece of the muscle may be reached from each side of • The patient's arm is flexed at the elbow and prona ted and a fla t thumb contact is made distal to the restricted soft tissue area. • A light traction is applied to the soft tissues via the thumb along the long axis of the muscle and, while this is sus tained, the patient is asked to slowly and deliberately move the forearm from pronation to supination while extending the elbow and then to return to the starting position (pronated forearm, flexed elbow). • This is repeated 3-4 times. P R O N AT O R T E R E S Attachments: Humeral head: medial epicondyle of humerus (common flexor tendon) and medial intermuscular septum Ulnar head: coronoid process of the ulna to a common ten don at the pronator tuberosity of the radius approxi mately mid-shaft on the lateral surface of radius Innervation: Median nerve (C6-7) Muscle type: Not established Function: Pronates the forearm by spinning the radius and contributes to flexion of the elbow against resistance Synergists: Pronator quadra tus, brachioradialis (aSSistance to a neutral position) Antagonists: Supina tor, biceps brachii Indications for treatment • Deep pain on radial side of the anterior surface of the wrist
1 3 Shoulder, arm a nd hand 497 • A diagnosis of carpal tunnel syndrome • Pain upon full supination, especially if accompanied by extension of the elbow and cupping of the hand Special notes Pronator teres assists pronator quadratus (below) during rapid or forceful pronation of the forearm. The median nerve usually passes between the two heads of pronator teres as it enters the forearm (Gray's Anatomy 2005) and in some cases pierces the humeral head (Simons et al 1999). Sometimes the ulnar head is absent (Platzer 2004). Median nerve entrapment by the pronator teres is clini cally Significant. Koo & Szabo (2004) d ifferentiate between pronator syndrome and carpal tunnel syndrome (CST). Clinical symptoms of pronator syndrome include forearm pain as well as paresthesias and hypoesthesia in the cuta neous distribution of the median nerve (ie, the thumb, index, middle, and radial half of the ring finger). These symptoms may be attributed to CTS. However, although the symptomsfrom CTS arefrequent at night, the symptoms of pronator syndrome occur primarily from use during the daytime. These sensory symptoms also may be present over the thenar eminence in the distribution of the palmar cuta neous branch of the median nerve, which, having branched from the median nerve proximal to the wrist, does not travel through the carpal tunnel. Patients also may complain of perceived weakness in the extremity secondary to pain. ASSESS M E N T F O R STR E N GTH O F PRO N ATO R B TERES Figure 1 3.95 A: Pronator teres is palpated with tra nsverse friction. • The patient i s supine with forearm i n pronation. B : Strain-cou n terstra in for wrist problems, which often accompany • The pa tient's elbow is close to the trunk and is flexed to 60°. pronator dysfunction (see p. 496). • So that no abduction occurs during the test, the practi muscle (Fig. 13.95) to the point at which its belly is no longer tioner stabilizes the elbow against the patient's trunk accessible. Static compression may also be applied to its with one hand, while the other hand holds the proximal fibers, if needed. lower forearm, close to the wrist. • The patient is asked to resist the practitioner's attempts The distal attachment is sometimes palpable on the to supinate the forearm. lateral shaft of the radius. Inflammation of the common • The relative strength of pronator teres is assessed and flexor tendon may warrant ice applications to the medial compared on each side. epicondyle. It N MT F O R P R O N ATOR TERES The arm i s placed i n passive supination with partial flexion of the elbow. The practitioner palpates below the crease of the elbow for pronator teres as it courses diagonally from the medial epicondyle to the mid-shaft of the radius. The muscle is wider near the epicondyle and narrows consider ably before coursing deep to the brachioradialis and the radial wrist flexors. Resisted pronation will assist the prac titioner in locating the fibers. The practitioner applies unilateral transverse friction at thumb-width intervals from the proximal end of the
498 C LI N I CA L A PPLICAT I O N OF N E U R O M USCU LAR TECH N I Q U E S : T H E U PPER B O DY \" M F R FO R PRO N ATO R T E R ES or when pronation is resisted. It occupies the deepest layer in the distal anterior forearm, occasionally has fibers reach • The practitioner palpates and identifies an area of fibrotic ing more proximal than noted or reaching distaJ iy to the or contracted tissues in pronator teres. carpal bones and is sometimes absent (Platzer 2004). Stuart (1996) suggests that the deeper of two heads 'is a dynamic • The practitioner places a broad, flat thumb contact distal stabilizer of the distal radioulnar joint' . to the dysfunction, applying traction to the tissues along their fiber direction. Hwang et al (2005) have documented two myofascial referral patterns for pronator quadratus (PQ). • To maintain firm and precise compression contact, the other thumb may be superimposed on the first. The most common pattern involved pain spreading both dis tally and proximally from the injection site, along the • The patient is asked to slowly and deliberately fully medial aspect of theforearm (57%). 111 halfofthese cases, the pronate and then supinate the forearm. pain area extended to the medial epicondyle proximally and the fifth digit distally. The second main pattern revealed • This is repeated 4-5 times for each area of dysfunction. pain spreading distally to the third and/or fourth finger (29%). The pain patterns originatingfrom the PQ resemble � P RT F O R P R O N ATO R T E R E S the C8-Tl dermatomes, and ulnar and median nerve sen sory distributions. • The patient is supine and the practitioner palpates for an area of tenderness anterior to the medial epicondyle of It the humerus. N MT FO R P R O N ATO R Q U A D RATUS • Pressure is applied to this tender point, sufficient for the Pronator quadratus is the deepest of the anterior forearm patient to register this as an intensity of '10'. muscles and lies directly against the interosseous mem brane. A small portion of the muscle may be reached on • While pressure is maintained on this point, the practi both the radius and ulna by sliding the fingers or thumb tioner holds the proximal forearm and flexes the elbow (one or both sides at a time) under the more superficial until the pain 'score' drops appreciably. muscles and applying friction to the distal 2-3 inches (5-7.5 cm) of the anterior shaft of the ulna and the radius. • Fine-tuning maneuvers to reduce the score further include Caution should always be exercised to avoid compression assessing the effect of various degrees of pronation and of the radial artery and median nerve at the anterior wrist. internal rotation of the humerus. FOREARM, WRIST AN D HAND • Addi tional ease and therefore reduction in the pain score may be achieved by means of application of a light While the shoulder and elbow place the hand in a variety of (12 Ib/ 0.25 kg) compressive force, from the contact hand positions and at various distances relative to the body, the on the forearm through the long axes of the radius and fingers of the hand are designed for precise functional use ulna, toward the elbow joint. in a seemingly endless number of ways. With his usual eye towards engineering design, Kapandji (1982) offers: 'The • Once the pain score has dropped to '3' or less, the position human hand, despite its complexity, turns out to be a per is held for at least 90 seconds before a slow return to a neu fectly logical structure, fully adapted to its multiple func tral position and reassessment of function and discomfort. tions. Its architecture reflects Occam's principle of universal economy. It is one of the most beautiful achievements of PRO N ATO R Q U A D RAT U S na ture.' Attachments: Distal quarter o f the anterior surface o f the ulna William of Occam (14th century) stated the principle of to the distal quarter of the anterior surface of the radius scientific parsimony thus: 'The assumptions introduced to explain a thing must not be multiplied beyond necessity' Innervation: Median nerve (C8-T1) (Stedman's Medical Dictionary 2004). We have attempted to Muscle type: Not established provide an understanding of the simplest use of the hand Function: Pronates the forearm by spinning the radius and fingers while remaining astounded by i ts complexity. Synergists: Pronator teres, brachioradialis (assistance to a Among the numerous texts available on hand structure and hmction, Cailliet (1994), Gray's A natomy (2005), Hoppenfeld neutral position) (1976), Kapandji (1982), Platzer (2004), Simons et al (1999) Antagonists: Supina tor, biceps brachii and Ward (1997) provided references to many of the com ponents of this section. I n d i cations for treatment • Pain upon full supination • Weakness or inability to fully supinate Special notes Pronator quadra tus is the primary pronator of the forearm and is assisted by pronator teres during rapid movements
e::�;-J Annular ligament 1 3 Shoulder, a r m a n d hand 499 f-t-t- Oblique cord FOREARM Ulna Pronation and supination of the forearm occurs in the Interosseous elbow region with the articulation of the radioulnar and membrane radiohumeral joints, while the radius and ulna articulate distally with each other as well as with the proximal end of Radius ---t -;Iri--i+ Aperture for anterior the hand, the carpal bones. The radius and ulna, along with interosseous artery their interosseous membrane, provide attachment sites for the extrinsic muscles of the hand and wrist and influence r--<t Distal radioulnar joint the ability to flex, extend and rotate at the elbow joint as well as allowing wrist flexion, extension and deviations. � �t-Wr'Ist - Articular disc The ulna and radius therefore play a major role in the func J' 0 'I n t --:-\\ :;�; � tional use of the hand . __ Most of the muscles tha t lie in the forearm are extrinsic muscles of the hand. While some of these muscles provide Fig u re 1 3.96 The i nte rosseous membrane prevents movements of the wrist joint (positioning the whole hand), upslip or displacement of the ulna and radius and also others provide mobility to the fingers or thumb which facil acts to transmit pressure stresses from one bone to the other. ita tes the power of the tennis grip, the accuracy and deli cacy of strokes on piano keys and the precision of the brain During struct u ra l distress, the bones a re prone to fract u re surgeon. before the fibers of the membrane a re torn. Rep rod uced with perm ission from Gray's Anatomy for Studen ts Postural distortion can create altered shoulder position ing, which may reflect in compensation patterns affecting (2005). the elbow, wrist and finger joints. Janda (1996) poin ts out that as the upper body slumps and the shoulders round, the angle at which the humerus meets the glenoid fossa changes. The resulting alteration in the direction of the axis of the glenoid fossa causes the humerus to require stabiliza tion by additional levator scapula and upper trapezius activity, with increased activity from supraspinatus as well. Additionally, there will be biomechanical adaptive changes involving the arm, elbow and wrist joints. Similarly, any inability to fully pronate the hand may demand consider able shoulder, torso and /or wrist repositioning. These examples give emphasis to the need to constantly keep in mind the larger picture, out of which the local dysfunction may have emerged. It also underlines the need for reeduca tion of pa tterns of posture and use, as a part of all rehabili ta tion, even if the problem is as localized as a wrist disorder. When addressing pain in the forea rm, wrist and hand, it is important to treat trigger points in the torso and all shoul der girdle muscles, not only due to their potential trigger point referred patterns, but also for their potential to nega tively influence shoulder function or create compensatory usage patterns. W R IIST A N D H A N D The carpus, the true wrist joint, i s a n ellipsoid synovial radiocarpal joint formed by the distal end of the radius and the articular disc of the radioulnar joint and their articula tion with three proximal carpal bones (Kappler & Ra mey 1997). This disc separa tes the true wrist joint from the distal radioulnar joint and prevents the carpal bones from touch ing the distal end of the ulna, while still moving in relation
500 CLI N I CAL A PPLI CATI O N OF N E U R O M U SCU LAR TECH N I QUES : T H E U P PER BO DY Phalanges ---\\ Metacarpats ---\\ Carpal bones Hook of Tubercle of trapezium Carpal bones hamate Trapezium Tubercle of scaphoid Hamate Scaphoid Pisiform Wrist joint Radius Lunate Ulna Pisiform Tubercle Triquetrum Trapezium Trapezoid Hamate Capitate Carpal arch Carpal arch Fig u re 1 3.97 Bones of the hand a n d wrist. Reprod uced with permission from Gray's Anatomy for Students (2005J. to it. To each side of the wrist extends the styloid processes The carpus contains two rows of small bones that are of the ulna and radius, with the latter being longer. Fracture arranged so that the proximal row forms a palmar arch of the styloid process of the radius (Colles' fracture) is a whose proximal end is convex and whose distal end is con common fracture of the wrist. cave. Though four bones lie in the proximal row, only three
1 3 Shoulder. arm and hand 501 Capsule of metacarpophalangeal joint Pisometacarpal ligament Radial collateral Radial collateral --- Transverse ligament ligament ---+\"A<�:.1r metacarpal Pisohamate ligament ligaments --- Palmar radiocarpal Ulnar collateral ligament '-- Pisometacarpal ligament --/- ligament \"'-- Ulnar collateral ligament Fig u re 1 3.98 Bony structures a n d l igaments of the wrist. articulate with the radius (scaphoid, lunate and triquetral the design of its articular su rfaces. In con trast, the bones) . The fourth, the pisiform, functions as a sesamoid metacarpal joints of the remaining digits are limited, as are bone in the tendon of flexor carpi ulnaris and articulates the intermetacarpal articulations, each permitting slight only with the palmar surface of the triquetrum. gliding to allow some flexion, extension and rotation. These minor movements are especially important when opposing In the second row of carpal bones lie the trapezium, trape the thumb and small finger, grasping an object or when zoid, capitate and hamate, which articulate proximally with reaching precisely with individual fingers, as when playing the first row and distally with the metacarpal bones. The car a violin. tilaginous surfaces of each of the eight bones articulate with other bones while the rougher volar and dorsal surfaces The terminology used in various texts in relation to wrist accept ligamentous attachments. The two rows slide upon movement is confusing. The terms 'flexion', 'extension' and each other to a small degree (mid-carpal joint) and collec 'ulnar and radial devia tion' of the wrist seem to offer the tively upon the radius and articular disc. The distal row of simplest and most accurate choices and have been used in carpal bones is bound tightly to metacarpal heads as well as this section regarding movement of the hand, though occa to each other, making them together a functional unit. sionally other terms are used as well. The metacarpus consists of five miniature long bones Within the carpus, flexion (palmar flexion) of the wrist (metacarpa ls), each of which has a base, shaft and distal provides 85° of movement while extension (dorsi or volar rounded head tha t articulates with the proximal phalanges flexion) of the wrist (from neutral) also allows 85°. The hand to form what is commonly called the knuckles. Their pal may also be placed in ulnar deviation (adduction) of approx mar surfaces are longitudinally concave which allows space imately 40--45° or radial deviation (abduction) of 15° (Gray's for the palmar muscles. Though they appear to be parallel, A natomy 2005, Kapandji 1982) (see Fig. 13.99). All of those they actually radiate from the carpal bones, with the first movements may be combined to produce circumduction. metacarpal ( thumb) placed more anteriorly, proximally and rotated medially approximately 90° so that its palmar sur CAPSU LE A N D LIGAM E NTS O F TH E W R I ST face faces medially ( toward the other metacarpals) (Gray's Anatomy 2005), a condition which allows the thumb to have (FIG. 1 3.98) opposition with the fingers and which makes the human hand the remarkable instrument it is. • The articular capsule of the radiocarpal (true wrist) joint has a synovial lining which is strengthened by the pal The metacarpal joint of the thumb (trapezium with first mar radiocarpal, ulnocarpal, dorsa l radiocarpal, radial metacarpal) is a saddle joint which is highly mobile due to and ulnar collateral ligaments.
502 CLI N I CAL APPLICATI O N OF N E U RO M USCU LA R TECH N I QUES: TH E UPPER BODY • The palmar radiocarpal ligament attaches to the anterior metacarpal bone and are continuations of the tendon of margin of the distal radius and its styloid process, passing flexor carpi ulnaris. medially to connect to the anterior surfaces of the • The radial and ulnar collateral ligaments of the mid-carpal scaphoid, lunate and triquetral bones. joint are short. The radial collateral connects the scaphoid and the trapezium, and the ulnar collateral connects the • The palmar ulnocarpal ligament runs from the base of the styloid process of the ulna and the anterior margin of the trapezium with the triquetrum and the hamat�. These articular disc of the distal radioulnar joint to a ttach to the l unate and triquetral bones. ligaments are continuous with the correspondlOg liga ments of the wrist joint. • The palmar ligaments have apertures which accommo date passage of blood vessels and have a functional rela The 'true' elbow and the ' true' wrist joints are connected tionship with the tendons of flexor pollicis longus and functionally to the radius by means of the synovial jOi.iltS flexor digitorum profundus. (distal and proximal) as well as by an interosseous structu�e • The dorsal radiocarpal liga ment a ttaches proximally to the posterior border of the distal radius, traveling obliquely tha t binds and supports the bones of the forearm. ThiS medially to a ttach to the dorsal surfaces of the scaphoid, interosseous membrane forms wha t is in effect the fibrous lunate and triquetraI bones, where it is continuous with middle radioulnar joint. This fibrous 'joint' provides stabil the dorsal intercarpal ligaments. There is a functional rela i tv for the forearm, reducing stress on ligaments as add uc tionship with the extensor tendons of the fingers and wrist. Anteriorly it blends with the inferior radioulnar �ti n or abduction of the ulna occurs. This interosseous artiCLtia tion. membrane helps to spread compressive forces on the fore • The ulnar collateral ligament a ttaches to the end of the sty arm structures, whether they are transmitted downwards loid process of the ulna, dividing into two fasciculi, one from the shoulder or upwards from the hand. of which attaches to the medial aspect of the triquetrum and the other to the pisiform bone. If examina tion of elbow, forearm or wrist dysfunction fails to investigate for, or to treat, patterns of dysfunction in • The radial collateral ligament extends from the tip of the the interosseous membrane, results may be disappointing. styloid process of the radius to the radial aspect of the Kappler & Ramey (1997) state: 'Interosseous membrane scaphoid bone, with some fibers continuing to the trape dysfunction can perpetuate elbow or wrist disability long zium. The radial artery separates the ligament from the after orthopedic care and apparently complete heallOg of tendons of abductor pollicis longus and extensor pollicis strains, sprains, or fractures of the elbow or wrist should brevis. have taken place: Kuchera & Kuchera (1994) describe the relationship between the radius, the ulna and the radiocarpal joints as that of a parallelogram. LIGAMENTS OF THE HAND • The ulna is part of the elbow joint, relatively fixed at the ulnohumeral joint. • Dorsal and palmar ligaments run transversely and connect the scaphoid, lunate and triquetraI bones in the proximal • The radius is part of the wrist joint, rela tively fixed at the row of carpal bones. The dorsal ligaments are stronger radiocarpal joint. than the palmar ones. In the distal row of carpal bones the dorsal and palmar ligaments ex tend transversely • The radius has a greater degree of movement than the between the trapezium and the trapezoid, the trapezoid ulna due to i ts rotational component. and the capita te, and the capitate and hamate bones. A t the mid-carpal joint, on the palmar surface, the fascicles • Adduction or abduction of the ulna leads to reciprocal radiating from the head of the capita te to the surround ing bones are known as the radiate carpal ligarr:ent. �repositioning of the hand; for example, when t e �lna • In the proximal row of the carpal bones, the mterosseous abducts, the radius glides distally, forcing the wnst lOto ligaments connect the lunate and scaphoid bones to each increased adduction. The reverse occurs during ulna o ther and the lunate to the triquetrum, forming part of the ad duction, which automatically creates an abducted wrist. convex articular surface of the radiocarpal joint. In the • When pronation of the hand occurs, the distal radius distal row the interosseous ligaments are thicker; one con crosses over the ulna as the distal end moves anteriorly nects the capitate and the hamate, a second unites the cap and medially; toward the end of pronation, the radial ita te and the trapezoid and a third the trapezium and the head glides posteriorly (dorsally) on the carpal bones. trapezoid. The second and third are frequently absent. • When supination occurs, the distal radius crosses back over the ulna as the distal end moves posteriorly (later • Additional interosseous ligaments are the plsohamate and ally); at the ex treme of supination, the radial head glides pisometacarpal ligaments, which, together with the anteriorly. fibrous capsule, connect the pisiform with the palmar surface of the triquetral bone. These ligaments also con Pa l pation exercise nect the pisiform with the hamate and the base of the 5th The practitioner supports the flexed elbow so that the thumb is resting on the radial head. At the same time, the other
1 3 Shoulder, arm and hand 503 hand grasps the forearm just proximal to the wrist and alter radioulnar joints (usually the proximal joint) may require nately prona tes and supinates it. The movements described attention. above are felt for near the end of full pronation (radial head • Posterior radial head dysfunction is common following a glides posteriorly) and supination (radial head glides anteri fall forward onto the palm of an outstretched hand, orly). This palpa tion should be performed on a 'normal' as whereas an anterior radial head dysfunction is common well as on a 'dysfunctional' symptomatic forearm so that the following a fall backward onto the palm of the out differences in the movements described above can be noted. stretched hand of the extended arm. K EY (OSTEOPATH I C) PRI N C I P L E S FOR CARE O F ACTIVE A N D PASSIVE TESTS FOR ELBOW, FOREARM A N D WRIST DYSFU N CTION WRIST MOTION (mod ified from Ka ppler Et Ramey 1 997) CAUTION: Avoid testing (active o r passive) for range of • Minor restriction - for example, in gliding potential - is motion if there exists the possibility of dislocation, frac commonly the only symptom of dysfunction in this area. ture, advanced pathology or profound soft tissue damage Passive bilateral comparison of minor gliding motions is (tear). an accurate means of identifying sites of dysfunction. Both active and passive range of mohon tests may be used to assess limits of movement of the wrist joint. Bilateral com • Dysfunction of the ulnohumeral joint is commonly the pa rison is possible, performing action on each side simulta primary feature, with radioulnar dysfunction being sec neollsly in most cases. If active testing shows normal range ondary, seldom primary, in elbow dysfunction. without pain or discomfort, passive tests are usually not necessary. Remember the evidence and advice offered in • Any dysfunctional state of any joint in the arm will cause Chapter 11, pp. 254-255, that whereas a single movement in adaptive demands on all other joints of the arm, leading a test situation may not produce symptoms or evidence of to compensatory problems. dysfunction, repetitive motions replicate 'real life' and are more likely to be informa tive. • If wrist symptoms are reported, the elbow should be examined. • If elbow flexion is restricted after all ulnohumeral fea tures have been treated and if inflamma tion is absent, the Box 1 3. 1 5 Focal hand dystonia (FHd) - 'repetitive stra i n i nj u ry' (Byl 2006) Dr Nancy Byl (2006) has made a study of the effects of repetitive the workplace seem to be a major risk factor for this disorder (Hochberg et al 1 990). and inappropriate movement on the function of the hand. The notes on this topic, as set out below, are largely based on her years of The evidence for m icrotrauma from repetitive overuse of the research and findi ngs. u pper l i m b is convincing. Rest, ant iinflammatory med ications, Focal dystonia is a movement disorder that affects more change in biomechanics and good ergonomics are usua l ly effective than 1 million individuals in the US alone (Marsden & Sheehy treatment modalities. Unfortunately, some i nd ividuals m ust continue 1 990). In contrast to genera lized dystonia, which may affect the to work despite their symptoms and rest is a limited option in such entire body, focal dystonias present in the context of performing a cases. Thus, the repetitive stra i n i nj u ry becomes chronic with specific motor task usually with only one part of the body. When degenerative cha nges found i n tendons and m uscles (Barbe et al patients attempt to perform that target task, they experience 2003). restricting soft tissues and joint mobil ity (Barr & Barbe 2002). involuntary co-contractions of flexor and extensor muscles together with com pression of peripheral nerves (Stock 1 99 1 ). (Altenmueller 1 988). When that happens the ability to perform finely graded and sequenced movements is disrupted and I n some cases of cumu lative trauma, chronic neuropathic pain replaced by crude, uncontrol led movements (Rosenbaum & develops (Vi ikari-Juntura & Silverstein 1 999). In other cases fatigue Jankovic 1988). and clumsiness of the hand is reported, often associated with a In some people, an enduring FHd is expressed only in the context tremor (Fernandez-Alvarez et al 2003). of one specific posture and task; in others, it can slowly generalize to While there may be preexisting musculoskeletal risk factors (e.g. other related hand postures and uses, a nd can u ltimately d isable the decreased range of motion in finger spread, pronation and supination. entire hand (Utti et a l 1 995). Although the disorder is typically or shoulder external rotation), psychologica l factors (perfectionism, painless, some patients may have painful spasms and others can perseverance, impatience, anxiety) or social factors (work or personal experience increased sensitivity or a sense of dullness or even stress) are also often associated with the origin of focal hand dystonia. numbness of the affected l i mb. There is i ncreasing evidence of degradation of the somatosensory FHd typically develops during adulthood and has been reported in representation of the hand in patients with dyston ic hand about 0.5% of office workers and between 7 and 25% of musicians movements. If the origin is aberrant learning with degradation of the (Hoch berg & Hochberg 2000, Lim & Alten mul ler 2001 , Tubiana cortical hand representation in the brain, treatment should include 2003). In the majority of cases, repetitive movements performed in learning-based training strategies to reorga nize the bra i n (Sanger & Merzenich 2000). box continuES
504 C L I N ICAL A P P L I CAT I O N O F N E U R O M U SCU LAR TECH N I Q U E S : T H E U P P E R B O DY Box 1 3. 1 5 (contin ued) selective movements must be practiced to engage specific and relevant sensory neurons and increase u ncorrelated movement Etiology of occu pational hand cramps: aberrant c o m po n e n ts. learning Individuals performing tasks requiring intensive repetitive Exa m i n at i o n movements (e.g. working at a computer, playing an i nstru ment, During the musculoskeletal exa m ination the patient may complai n pitching a ball, screwing nails, playing golf) a ppea r to be at highest o f weakness b u t the muscles are usually strong unless there are risk for focal hand dystonia. signs of clear peripheral nerve compression with secondary atrophy (e.g. thoracic outlet, cubital tunnel, carpal tunnel). However, there • Performing artists often report having achieved a new high level may be an imbalance in strength, with the extrinsic muscles of performance using new techniques or a new i nstru ment, u nusually strong compared to the i ntrinsic muscles (Byl et al 1 996). sudden ly followed by involuntary, abnormal end-range postures of the fingers, making normal m usical performance impossible Poor posture is common (forward head and protracted shoulders) (Altenmuller 2003). and there may also be end-range limitations in finger spread, forearm rotation or shoulder external rotation (Wilson et aI 1 993). • It is hypothesized that dystonia, particularly focal dystonia of the neck, is genetic (Ozelius et al 1 997). The neurological examination will usually be normal (e.g. normal tendon reflexes, good coordination, stable gait, normal light touch) • In both general and focal dystonia, there is also strong evidence with some complai nts of ulnar neuropathy, but with normal nerve of an imbalance of i n h ibitory and excitatory pathways in the cond uction (Charness 1 993). g lobus palliduslsubstantia nigra (Black et al 1 998). However, some individua ls do note a worsening of normal • Some researchers report hand dystonia could result from cortical physiolog ical tremors, uncontrollable excitabil ity and possibly some motor dysfu nction (Toro et al 2000), degradation in the sensory dullness in the pads of the fingers when placed on the target thalamus (Lenz Et Byl 1 999) or disruption in cortical sensory surface. These patients may also perform poorly on tasks demanding activation, somatosensory representation or spatial perception cortical sensory d iscrimination (e.g. stereognosis or graphesthesia) (Tinazzi et al 2003). (Byl et al 1 996). • Other researchers report abnormal gating of somatosensory inputs Treatment (M urase et al 2(00), abnormal presynaptic desynchronization of To date, there are no i n tervention strategies that are 1 00% effective movement, abnormal muscle spindle afferent firing (Toro et al 2000) for restori ng normal motor control in patients with FHd. Botu linum or disruption of inh ibition in the spinal cord (Chen et al 1 995). toxin i njections or baclofen can decrease the severity of dystonic cramping by interfering with neural signals to the muscle (van Hilten • Some researchers have documented evidence suggesting FHd et al 2000). develops as a consequence of peripheral trauma, peripheral nerve entrapment or a natomic restrictions i n soft tissue (Weiner 2001 ). Surgery such as nerve decompression at the el bow or wrist may be helpful (Charness et al 1 996). The most controversial hypothesis is that FHd results from a berrant learning (Byl et al 2000). Byl Et Melnick ( 1 997) proposed the Surgical release of tight retinaculum or fascia has been tried with sensorimotor learning hypothesis as one etiol ogy of work-related limited success. Surg ical implantation of deep brain sti mu lators is focal hand dystonia. This suggests that repetitive use, simulta neous sometimes used for patients with focal hand dystonia. None of these fi ring, cou pling of m u ltiple sensory signals and vol u ntary medication or surgical approaches actually targets the defined coactivation of muscles lead to a degradation of the sensory cortical somatosensory degradation. representation of the hand and disruption in sensorimotor feedback (Xerri et al 1 999). Conservative exercise strategies based on the principles of neuroplasticity have been tried as alternatives, or supplementary, to Sanger Et Merzenich (2000) elaborated on this hypothesis, medications and surgery. Some of these learning approaches include proposing an integrated m u ltisystem computational model to explain constrai nt-induced therapy (also cal led sensory motor retuning) the origin of FHd. If the sensorimotor and the neural circu itry (Candia et al 2003), sensitivity training (Tubiana 2003), conditioning connecting the deep cortical n uclei, basa l ganglia and thalamus are techniques (Liversedge 1 960), ki nematic tra i ning (Mai Et Marguardt u nstable, then a focal or a genera l dystonia cou ld develop, 1 994), immobilization (Priori et al 200 1 ) and learning-based depending on the extent of the i mbalance across mu ltiple sensory sensorimotor training (Byl et al 2000). and motor systems (Sanger Et Merzen ich 2000). While some limited research has been carried out on these The computational model could explain why symptoms: techniques, none has been confirmed by randomized clinical trials. The strongest validation for learning-based behavioral training for 1 . develop in otherwise healthy individuals who perform highly the treatment of FHd is based on basic science evidence that the attended repetitive movements central nervous system is adaptable and focal hand dystonia may result from aberrant learning. 2. evolve variably over time 3. a ppear only during the performance of a target-specific task of People who successfu lly rehabil itate are those who can stop the activities that lead to the abnormal movements, integrate healthy, dystonic movements, persisting even when the task is no longer stress-free, normal biomechan ics i nto fu nctional hand use, create a performed repetitively positive, su pportive environment, manage stress, use good 4. decrease, but a re not remediated, with dopamine-depleting drugs ergonom ics, engage in wellness and fitness activities, and can carry or botulinum toxin out a learning-based sensorimotor training program to reorganize 5. are associated with a bnormalities i n somatosensory, sensorimotor the somatosensory maps of the hand. and motor representations of the dystonic limb. Within this context the authors of this text strongly maintain Based on the sensorimotor learning hypothesis integrated into the that NMT approaches - such as those described in this chapter computational model, appropriate treatment must help to that evaluate and assist in normalization of structural soft tissue and redifferentiate cortical and subcortical representations. If the osseous patterns of dysfu nction can create a useful complementary dystonia is severe, it may be necessary to tempora rily break the cycle background to reeducation of appropriate use. (e.g. botu linum toxin i njections) before retra i ning can be effectively i m plemented. This retra i n ing needs to be based on the principles of neuroplasticity. Pathol ogical connections m ust be uncoupled and
1 3 Shoulder, arm and hand 505 A c B Figure 1 3.99 The range of movement of the wrist joi nt. A: U l n a r and rad i a l deviation. B: Flexion and extension. C: Para l lel og ra m mecha nics of wrist and ulnar movements. Active and passive range of motion testing for the wrist Assessment tips should show: • Restrictions that have a hard end-feel during passive • flexion (85°) range of motion assessment are usually j oint related. • extension (85°) • ulnar deviation (45°) • Restrictions that have a softer end-feel, with slight • radial deviation (15°). springiness still available at the end of range, are usually due to extraarticular soft tissue dysfunction.
506 CLIN ICAL APPLI CATION OF N EU RO M USCULAR TECH N IQUES: T H E UPPER BODY A B Figure 1 3. 1 00 Strength tests for (Al carpa l flexors a n d (8) extensors. • Kal tenborn (1989) sta tes tha t if a passive movement and the same movements are repeated with the patient offer an ac tive movement in the same direction produce painful ing resistance and if pain then results, a soft tissue dys symptoms, this suggests an osseous problem. function probably exists (strain, tendinitis, etc.) . The reader is reminded of the previous advice (pp. 254-255) • If, however, a passive movement in one d irection and an regarding repeating tests several times in order to repro active movement in the opposite direction produce symp duce 'real-life' situa tions. Such tactics are more informa toms (pain, for example), this suggests a soft tissue tive than performing tests once only. problem. • The practitioner supports the wrist in one hand and with the other takes the pa tient's hand into radial and ulnar Supina tion and pronation tests of the forearm are listed deviation (abd uction and adduction). If pain results a with the elbow on p. 488. wide range of possibilities exist including sprain, fracture, tendinitis, arthritic change or subluxa tion. If no pain is R EFLEX AN D STRE N GTH TESTS reported and the same movements are repeated with the patient offering resistance and pain then results, a soft tis Strength testing sue dysfunction probably exists (strain, tendinitis, etc.). • Kappler & Ramey ( 1997) suggest that translation (gliding) • The patient clenches the fist and takes it into a flexed restrictions are often the only evidence of dysfunction, position. Stabi lizing the proximal wrist with one hand either producing pain or when the joint in one and covering the clenched fist with the other, the practi hand /wrist demonstrates a limitation when compared tioner a ttempts to ex tend the wrist against resistance. with the same joint on the other hand/ wrist. The metacar This evaluates strength of flexor carpi radialis and flexor pophalangeal and interphalangeal joints can usefully be carpi ulnaris. Neural supply is from C7, C8 and T1 (Fig. passively tested for anteroposterior glide, mediola teral 13.100A). glide and internal and external rotation potentials, none of which can be initiated by direct muscular action. • The practitioner holds the patient's extended clenched • The most common dysfunction affecting carpometacarpal fist (Fig. 13.1008) and resists as the patient attempts to joints (apart from that of the thumb), according to ex tend this. This evaluates strength of ex tensor carpi Kappler & Ramey (1997), is evidenced by a restriction in rad ialis longus and brevis and extensor carpi ulnaris. the ability to glide ventrally, such as would occur if the Neural supply is from C6 and C7 (Fig. 13.1008). d igi t were moving into ex tension. Wrist stress tests G A N G LI O N • The practitioner supports the wrist in one hand and wi th The development of a cyst-like swelling in association the other, takes the patient's hand, fingers relaxed, into with a tendon sheath or joint is thought to result from a pro flexion and ex tension. If pain results a \\-\\Tide range of tective process related to repetitive stress or to trauma possible causes exist, including sprain, fracture, tendinitis, arthritic change or subluxation. If no pain is reported and
13 Shoulder, arm and h a n d 507 Ulnar nerve entrapment may be produced by the 'arcade of • Compute� use (or any work requiring repetitive finger Struthers', a dense fascial a rch near the elbow, which may dexterity) for more than 2-4 hours/ day. produce symptoms similar to cubital tunnel syndrome, such as a medial epicondylar ache with accompanying shooting poi nts to • Infrequent rest breaks (suggests 3-5 minutes every 30 min the little finger and u l nar portion of the hand (Cai l l iet 1 996). The utes to stretch the neck, shoulders and upper extremity). flexor carpi ulnaris may entra p the u l nar nerve, as it lies deep to this muscle and su perficial to the flexor dig itoru m profundus. • Hypermobile j oints, as their instability makes these joints Additional ly, an anomalous muscle, the anconeus epitrochlearis more susceptible to inj ury. (Simons et al 1 999), may cause ulnar nerve compression when it is present. • Poor posture, including rounded shoulders and forward head, which encourages nerve entrapment. Radial nerve entrapment may be produced by the long head of triceps, the supinator and extensor carpi radialis brevis, as well as • Poor technique with activity/work, such as holding the an a nomalous flexor carpi radialis brevis muscle. phone to the ear w i th the shoulder, poor sitting postures or a computer screen set at a less than ideal angle. Median nerve entrapment may be produced by pronator teres, flexor digitorum superficialis or the a nomalous flexor digitoru m • Sedentary lifestyle, leading to overall decreased fitness superficialis indicis. Impingement of the nerve within the carpal level. tunnel may be due to subl uxation of carpa l bones, scar tissue or enlarged flexor tendons. • Stressful work environment, leading the person to work harder, not smarter. (Schafer 1987). Cysts in the region of the hand or wrist (also, rarely, found on the ankle or foot) are commonly known as • Arthritis, diabetes, thyroid disease or other serious med ganglions and comprise a tough outer fibrous coat and an ical conditions can accentuate the individual's response inner synovial layer surrounding a thick fluid. Symptoms to repetitive strain. that will depend on location and whether the cyst is inter fering with normal function or circula tion include aching • Long fingernails, causing awkward use of fingertips. discomfort, weakness (perhaps of grip strength) and an • Excessive alcohol or tobacco consumption, decreasing unsightly swelling. Spontaneous dispersion sometimes occurs. Traditionally, a firm blow with the family Bible was the body's ability to repair tissue damage. recommended in old texts to break the cyst and disperse the • Overweight, as increased adipose tissue may decrease swelling. The authors do NOT recommend this approach but have no specific non-invasive recommendations. tunnel space and the overweight person is less likely to Aspiration of the ganglion is often temporary whereas exci properly fit the furniture associated with their job. sion is more permanent. Cyriax (1982) notes that those occurring between the 2nd and 3rd metacarpal bones are Ingram-Rice (1997) points out that prevention is the best often mistaken for rheumatoid arthritis and, regarding course of action and stresses the need to ergonomically those particular ganglions, sta tes: 'Acupuncture affords design the workspace, including the height of desk, rela permanent relief; I have yet to meet a recurrence.' tionship of the chair to the desk, placement of the computer and phone (use headset if possible) and use of footstool. She CARPA L T U N N E L SYN D RO M E also suggests: Carpal tunnel syndrome is defined as compression of the Another excellent tool for computer operators is a [com median nerve within the carpal tunnel (see also p. 489). puter] program called ExcerciseBreak. This program will Compression of the nerve may be caused by: stop the work at predetermined intervals and take the indi vidual through a predetermined set ofexercises. In this way • subluxation of carpal bones (lunate in particular) the individual does not forget to exercise.1 • scar tissue • excessive pressure within the tLUmel d ue to enlarged Ergonomic screensavers are available (often free) and an Internet search should offer the reader the chance to access flexor tendons and acquire such a program. • abnormal tissue, such as osteophytes or tumors within Unfortuna tely, in recent years, carpal tunnel syndrome the canal has become a collective diagnosis for many hand and wrist • excessive fluid retention. problems without precise testing of median nerve dysfunc tion to confirm this finding. Additionally, since many trig Occupational therapist Barbara Ingram-Rice (1997) lists the ger points in the shoulder, neck and forearm muscles are foHowing risk factors in the development of carpal tunnel capable of duplica ting the symptoms of carpal tunnel syn syndrome. drome, these areas deserve evaluation. While carpal tunnel syndrome remains the most common nerve entrapment syndrome of the upper extremity, cubi tal tunnel syndrome (see p. 489) runs a close second (Simons et al 1999) due to increased computer usage, with resultant poor hand and arm positioning. 1 Exercise Break, Hopkins Technology, 421 Hazil Lane, Hopkins, MN 55343, 1-800-397-9211 .
508 CLI N I CA L A PP L I CATI O N O F N E U R O M USCU LAR TECH N I QU E S : T H E U P P E R B O DY Causes of carpa l tunnel syndrome trimmed). If pain is noted in all fingers apart from little finger, carpal tunnel syndrome is strongly indicated (Fig. • The most widely accepted explanation is that this condi 13.1018). tion results from a neural compression condition involv 3 . Oriental prayer test. The patient fully extends abducted ing the median nerve. fingers and thumb of each hand and places palms together. If thumbs cannot touch, this indicates paralysis • In this model, causes are thought to vary from increased of abductor pollicis brevis due to median nerve palsy structural volume of the nerve to a narrowing of the tun resulting from carpal tunnel syndrome (Fig. 13.101C). nel size. There is commonly a history of trauma to the area. Associated wrist tests • Other etiological suggestions include: 1. cervical arthritis as a precursor to carpal tunnel syn 1. Oschner's test. Patient is asked to interlock fingers by plac drome (Hurst 1985), suggesting that cervical mechanics ing palms together and interlacing the fingers, so that their should always be evaluated, and treated, if appropriate palmar surfaces rest on the dorsum of the contralateral 2. venous and lymphatic congestion (Sunderland 1976), hand. If the index finger on the suspected side cannot flex suggesting tha t blood and lymph flow should be nor in this way, median nerve paralysis is indicated. The lesion malized by means of attention to soft tissues as well as is likely to be at or above where branching of the nerve to to excessive sympathetic tone, possibly by correction flexor digitorum superficialis occurs (Fig. 13.102). of upper thoracic and rib dysfunction 3. altered vasomotion as a result of upper thoracic dys 2. Froment's test. If the ulnar nerve is paralyzed the patient function (Larson 1972) will be unable to form an '0' with thumb and index finger. 4. interference with axoplasmic flow (see Box 3.1, p. 47) as a result of minor compression somewhere along the 3. 'Pinch ' test and u lnar nerve entrapment signs. If the ulnar course of the median nerve, leading to the evolution of nerve is entrapped there will be weakness of the ability to distant denervation changes and symptoms (Upton & 'pinch', weak thumb abduction ('hitcher's thumb' posi McComas 1973). tion) and an inability to actively flex the metacarpopha langeal joints. Interosseous a trophy may be apparent. Symptoms 4. Bracelet test. The practitioner encircles the patient's wrist • Symptoms include pain and numbness, worse at night, with thumb and index finger and applies firm compres weakness, swelling and muscular hypertrophy. The sion to the distal radius and ulna. If sharp pain is thenar eminence may display atrophy. reported arising in the wrist and/ or radiating to the hand or forearm, rheumatoid arthritis is suspected. • There may be difficulty in pronating and supinating the forearm. PHALA N G ES • Direct manual compression or percussion of the carpal Movements of the fingers are described in relation to the axis tunnel (Tinel's sign) commonly provokes symptoms but of the hand and not that of the whole body. In otherwords, the these can be confused with normal response to percus hand has its own mid-line, which lies longitudinally along the sion of a nerve and are now considered by some to be an 3rd metacarpal bone and the middle digit (ray). Adduction unreliable test (Cailliet 1994). and abduction of the fingers and thumb are in relation to the mid-line, so that separating the fingers from each other is • When holding the wrist at a full flexed position causes abduction and approximating them is adduction. tingling and numbness (paresthesia) of the median nerve distrib ution (fingers of the radial side of hand), this is The metacarpophalangeal joints are composed of an considered a more reliable sign (see also Phalen's test irregularly convex surface articulating with a 'socket' that is below) for carpal tunnel syndrome. shallow, which allows for considerable movement. The phalanges, however, are hinge joints and are limited to flex • The diagnosis is confirmed by nerve conduction and ion and extension. EMC tests. Like the metacarpals, the phalanges have a proximal base, • If such tests are negative and symptoms persist, one of shaft and (distal) head, which are conveniently designed to the other etiological patterns, as listed above, may be stack one upon the other. The fingers are composed of three operating. phalanges laid end to end while the thumb has two. Tests for carpal tu nnel syndrome • The proximal end of the proximal phalanx carries a con cave, oval facet which conforms to its convex associated 1 . Phalen 's test. Patient places the dorsum of both flexed metacarpal head. wrists against each other and applies pressure (light) for a full minute. Symptom increase (pain, numbness, etc.) is • The distal end (head) of the proximal phalanx is a positive sign (Fig. 13.101A). smoothly grooved (like a pulley) to receive the base of the middle phalanx. 2. Tine/'s test. Patient has elbow flexed and hand supinated. The practitioner taps the volar surface of the wrist with a broad reflex hammer or the tip of an index finger (nail
1 3 Shoulder, a rm and hand 509 A B Figure 1 3. 1 0 1 Tests for carpal tunnel syndrome. A: Phalen's test. B: Tinel's test. C: Oriental prayer position. • The base of the middle phalanx has two concave facets which have a smooth ridge between them to conform to the above groove. • The head of the middle phalanx is similar to the head of the proximal one, with a pulley-like groove to receive the distal phalanx. • The distal phalanx conforms to the above groove while presenting a non-articular head which carries a rough palmar tuberosity for the attachment of the pulps of the fingertips. Figure 1 3. 1 02 Oschner's test. Median neNe para lysis may be CAR P O M ETA C A R PA L L I G A M E N TS (2 N D , 3 R D , ind icated if the index finger can not flex. 4TH , 5TH) • Dorsal ligaments connect carpal bones with metacarpals on dorsal surface, passing transversely from one bone to another.
5 1 0 CLI N I CAL APPLI CATI O N O F N EU RO M U SC U LAR TECH N I QU E S : TH E U PPER BODY A • Palmar ligaments connect carpal bones with metacarpals on the palmar surface, passing transversely from one B bone to another. Figure 1 3. 1 03 ARB : Range of flexion and extension of • Interosseous ligaments connect contiguous distal mar metacarpophalangeal joints. Reproduced with perm ission from gins of capitate and hamate bones with adjacent surfaces Kapandji ( 1 998) . of 3rd and 4th metacarpals. • Synovial membrane is often a continuation of the inter carpal joints. M ETACARPO PHALA N G EAL LIGAM ENTS • The palmar ligaments are thick fibrous structures on the palmar surfaces of the joints between the collateral liga ments wi th which they are connected. They are also blended with the deep transverse ligaments of the palm. • The deep transverse metacarpal ligaments are made up of three short, wide bands which connect the palmar liga ments of the 3rd, 4th and 5th metacarpophalangeal joints. • The collateral ligaments are strong, rounded cords lying at the sides of the joints attached to the tubercle on the side of the head of the metacarpal bones, passing obliquely distally to attach to the ventral aspect of the base of the phalanx. RANGE OF MOTION Metacarpophalangeal ranges of motion (of fingers) should be: • flexion - approximately 90°, with the index finger falling just short of 90° and each finger increasing progressively • extension - from a few degrees to up to 40° of active movement and up to 90° passive movement in individu als with lax ligaments (Kapandji 1982) • adduction - relatively small, negligible in flexion CP Ac Figure 1 3. 1 04 A-C: Range of motio n of phalangeal joints. Reproduced with permission from Kapandji ( 1 998).
1 3 Shou lder. arm and hand 5 1 1 • abduction - relatively small, negligible in flexion • MetacarpQphalangeal flexion 50° • circumduction - represents a combina tion of the above • Metacarpophalangeal extension 0° • Interphalangeal flexion 90° four, which produces a cone of circumduction • Interphalangeal extension 20° • passive rotation - 60° • Palmar abduction 70° - takes place at the car • active rotation - limited during flexion--extension; great pometacarpal joint and is perpendicular to the plane of est in the smallest finger. the palm • Palmar adduction 0° Interphalangeal ranges of motion (of fingers) should be: • Radial abduction 90° - is parallel to the plane of the palm • Radial adduction 0° • flexion: • Opposition is a composite movement of circumduction 1. proximal interphalangeal joint - greater than 90° of the first metacarpal, internal rotation of the thumb (as (increases from 2nd to 5th fingers) a whole) and maximum extension of the interphalangeal 2. distal in terpha langeal j oint - slightly less than 90° joint and varying degrees of the metacarpophalangeal (increases from 2nd to 5th fingers) j oint. • extension: TESTING THUMB MOVEMENT 1. proximal interpha langeal joint - none 2. distal interphalangeal joint - none or very small • The patient i s asked to touch the tip o f the thumb to the base of the little finger and to each fingertip and to • slight passive side-to-side movement. abduct the thumb as far as possible. TH U M B • If any joint restriction is noted, the muscles controlling the thumb should be palpated. Five bony structures (scaphoid, trapezium, a metacarpal and two phalanges) make up the osteoarticular column of • In addition, both thumb joints should be assessed pas the thumb. The combined four joints in the column allow sively, in all directions of motion, includ ing gliding for flexion-extension, abduction-adduction, rotation and (translation). circumduction. Additionally, the thumb is a ttached far more proximally to the hand than the fingers, giving it a DYS F U N CT I O N A N D EVALUAT I O N tremendous architectural advantage. Thumb dysfunction includes (among others) sprains associ Kappler & Ramey (1997) summarize the extraordinary ated with falls, hitting with clenched fist, bowling (which potential of the thumb: can a lso produce neural damage to the digital nerve from the edge of the hole of the ball) and chronic strains, which The carpometacarpal joint of the thumb is . . . a saddle-type may be associated with excessive use involved in playing joint, having both a concave and a convex articular surface. video games. Schafer (1987) reports that the commonest This configuration permits angular movements in almost trigger point in the region is that of add uctor pollicis. any plane with the exception of limited axial rotation. Only a ball and socket joint has more motion than the With any such presenting problems, careful evaluation of carpometacarpal joint of the thumb. Because it has very joint restrictions is essential; evaluation of muscular good motion, it is more likely to have compression strain or changes (including fibrotic infiltration, weakness and short sprain of the ligaments than to have a somatic dysfunction. ness modifications of flexors and extensors, respectively) and the influence of related joints (elbow, shoulder, upper THUMB LIGAM ENTS thoracic and cervical regions) will assist in formulating a trea tment plan. • The metacarpal bone of the thumb cormects to the trape zium by the lateral, palmar and dorsal ligaments, as well as PREPA R I N G FO R TREATMENT by the capsular ligament. The carpal and digital flexors (along with the pronators pre • The thumb's most common dysfunctional pattern relates viously discussed in cormection with the elbow region, to compression strain or sprain of i ts ligaments. p. 488) all lie on the anterior (flexor) surface of the forearm in two layers. The superficial layer flexors have their origins RAN G E OF M OT I O N AT TH E J O I NTS O F primarily on the medial epicondyle of the humerus while THE THUMB the deeper layer flexors arise from the ulna and radius. The most superficial layer includes the flexor carpi ulnaris and • Metacarpal flexion 50° - movement is parallel to the radialis, pronator teres, palmaris longus and flexor digito plane of the palm so that the ulnar side of the thumb rum superficialis. (Note: The flexor digitorum superficia lis sweeps across the palm • Metacarpal extension 0° - 'relative extension' moves the thumb back to neutral from any point of flexion but the thumb should not be extended beyond neutral
5 1 2 CLI N I CAL APPLICATI O N O F N E U RO M USCU LA R TECH N I Q U E S : T H E U PP E R B O DY o A E B F G c Figu re 1 3. 1 05 A : T h u m b in neutra l position. B : I nterphalangeal joint flexion. C: I nterphalangeal a n d metaca rpophalangea l joint flexion. D : Radial adduction. E : Pa l m a r a bd uction. F and G: Radial a bd uction. is included in the superficial layer even though it is covered perform occur within that joint. Since they are encountered almost completely by the other superficial muscles.) The during forearm palpation, the pronators and supina tors are deeper layer is composed of the flexor d igitorum profun discussed in relation to the other muscles of that region. dus, flexor pollicis longus and pronator quadratus (dis They should be evaluated and, if necessary, treated in rela cussed with the elbow). tion to dysfunctions of the wrist or hand since normal elbow function is necessary for normal use of the hand. The extensors occur in two layers on the posterior sur Additionally, trigger points lying in the pronators or face, many of which arise from the lateral epicondyle of the supina tors (and those of brachialis, brachioradialis and humerus. The superficial posterior forearm includes bra many shoulder cuff muscles) have been shown to have tar chioradialis and anconeus (both discussed with the elbow), get zones in the wrist, thumb or hand (Simons et aI 1999). extensor carpi radialis longus and brevis, extensor carpi ulnaris, extensor digitorum and extensor digiti minimi. The TE R M I N O LOGY deeper layer contains supinator (discussed with the elbow), extensor poliicis longus and brevis, abductor pollicis longus The remaining forearm muscles are easily identified by and extensor indicis. function since their names denote the work they do. Unfortunately for the reader who is struggling to identify The forearm muscles should also be considered in terms the anatomy, it can at times seem as though the forearm of function. For instance, even though the pronators and muscles all have the same name. Understanding why they supinator of the forearm lie within the forearm they are con sidered primary to the elbow, since the movements they
1 3 Shou lder, arm and hand 5 1 3 are named as they are assists in demystifying the apparent seeking just one trigger point that may be producing the confusion as the names start to make sense. In fact, knowl entire pattern (or syndrome). The combined trigger point edge of the sometimes lengthy names should assist the target zones for the neck and upper extremity muscles leave practitioner in readily identifying and locating the muscles. virtually no part of the distal arm untouched, as many of them have wrist, thumb or hand target zones. Simons et al The following terminology is basic to the nomenclature (1999) offer (at the beginning of each section) regional chart of the forearm and while this listing might appear simplis ing of areas of pain together with a list of the muscles that tic, combinations of these terms will be found to result in a refer into those regions. These lists can be used as a shortcut to muscle's name which not only usually identifies its function consider which muscles are most likely to be referring pain but often also its location and whether it has an assistant (as to a particular area and are particularly helpful when time is with longus and brevis). limited. A more thorough, detailed examination and treat ment plan should also include assessment of the synergists • Carpi muscles move only the wrist (extensor carpi radi and antagonists of muscles housing trigger points, as well as alis longus may weakly flex the elbow) range of motion assessments and postural considerations. • Digitorum muscles move the fingers (and assist with the ANTE R I O R F O R E A R M T R E AT M E N T wrist since they cross that joint as well) The muscles o f the superficial layer of the anterior forearm • Pollicis pertains to the thumb are addressed together and, unless contraindicated, fol • Indicis refers to the index finger lowed by treatment of the deeper layer. Identification of • Digiti minimi is the smallest finger dysfunctional muscles may require tests for strength and • Radialis muscles lie on the radial (thumb) side of the weakness and in some cases for length. Joints associated with the muscles under review require evaluation for their forearm influence on patterns of use and presenting symptoms. • Uinaris muscles lie on the ulnar side of the forearm Manual palpation, including NMT assessment methods, • If there is a longus, there is surely a brevis (shorter version offers a direct means for the localization of altered tissue status, whether this be tense, flaccid, fibrotic, edematous or of muscle with similar function to 'longus') indurated, and for the presence (or lack) of active trigger • If there is aflexor, there is also an extensor (although if there points, so allowing treatment to target the most involved structures, as well as distant influences on them. are t\"vo flexors, there are not necessarily two extensors) PAL M A R I S L O N G U S (FIGS 1 3. 1 06, 1 3. 1 07) When the muscle names are considered, one can quickly decipher what each term means for that muscle. For instance: Attachments: From the common flexor tendon on the • flexor carpi ulnaris occurs on the ulnar side of the flexor medial epicondyle to the palmar fascia (aponeurosis or (anterior) surface of the arm and serves to flex the wrist pretendinous fibers) and the transverse carpal ligament (flexor retinaculum) • extensor carpi radialis longus lies on the radial side of the extensor (posterior) surface of the forearm to serve the Innervation: Median nerve (C7-8 or Tl) wrist and (somewhere) has a companion, the brevis. Muscle type: Postural (type I), shortens when stressed Function: Tenses the palmar fascia to cup the hand; flexes Since most of the flexors attach to the medial epicondyle and the extensors to the lateral epicondyle, one can quickly the wrist; may assist pronation against resistance and identify the anatomy by considering the terms used. This (weakly) assist elbow flexion (Simons et a1 1999) concept is more true for the forearm musculature than any other region of the body. Synergists: For cupping the hand: thenar and hypothenar N E U RAL ENTRAPMENT muscles For wrist flexion: flexor carpi ulnaris, flexor carpi radialis, The medial and ulnar nerves can each b e entrapped by flexor digitorum superficialis and profundus anterior forearm muscles, including (for ulnar nerve) flexor carpi ulnaris, flexor digitorum superficialis and profundus Antagonists: To wrist flexion: extensor carpi ulnaris, exten and (for median nerve) pronator teres and flexor digitorum superficialis. Entrapment of the radial nerve is (rarely) sor carpi radialis brevis and longus, extensor digitorum, caused by an anomalous flexor carpi radialis brevis muscle smaller finger and thumb muscles (Simons et aI 1999). I n d ications for treatment D I STANT I N FL U E N CES • Prickling t o palm and anterior forearm I t i s important when addressing hand and wrist pain and • Diagnosis of Dupuytren's contracture (see below) dysfunction to include examination of function and dys • Tenderness in the palm, especially when working with a function of (including the presence of trigger points) the cer vical, shoulder, upper arm and elbow regions and to consider hand tool combined patterns of several trigger points rather than
5 1 4 CLIN ICAL APPLICATION O F N EU RO M USCULAR TECHN IQUES : T H E U PPER BODY Biceps--,- Brachia I Is---'a= Brachial artery--- Median nenle--- Common fascia --- Radial ner'le -------__'\"' Bicipital a Ulnar arte'rv--- Posterior interosseous ner'le---j Radial artE�ry------__ItI _---.t- .·\"1 Flexor carpi radi,alis---,.j Palmaris IOncluS--- Flexor carpi ulnami ;--- Flexor digitorum s loerllclcIIiS---Erf+.F Pronator teres Flexor (radial head) carpi radialis Flexor digitorum Palmaris Flexor longus carpi ulnaris Abductor pollicis longus---� Fig u re 1 3. 1 07 Com mon trigger poi nts of a nterior forearm. D ra w n Radial �rlp'rv-----____, __ after Simons et al (1 999). Median ner'le---------: ... ... \". when absent on one arm, is twice as likely to be absent bilat Ulnar artE�ry--f+-l_.�, eraJJy than unilaterally. When the muscle is present, its ten Ulnar nen/e-----F--c- 4l-r-If-I--- .rf don may be more easily distinguished from flexor carpi radialis by having the patient place all five digit pads Flexor together, with the metacarpophalangealjoints flexed and the Abductor pollicis brevis-----::,- .:. phalanges extended (as if picking up a marble with all five digits). The wrist may be flexed simultaneously, which may Guyon's canal ----f-.:\"--- -+-../ make palmariS longus even more distinct and / or cause the Flexor pollicis brevis---;r flexor carpi radialis to stand out as well. If the metacar pophalangeal joints are then extended (fingers in neutral, Palmaris brevis---.:J�r wrist flexed), the palmaris tendon softens and the flexor carpi radialis becomes more obvious. Even when the muscle Palmar aponeurosis;---¥ is absent, its palmar fascia is still present (Platzer 2004). Fig u re 1 3 . 1 06 The su perficial layer of the a nterior forea rm. Trigger points in this muscle may simula te Dupuytren's Reprod uced with perm ission from Gray's Anatomy (2005). contracture, a condition in which the palmar fascia thickens and shortens with resultant flexion contracture of the fin Specia l notes gers. Taleisnik (1988) classifies the disease as follows. Palmaris longus courses from the media l epicondyle to the Dupuytren 's contractu re characteristics palm, directly superficial to the flexor digitorum superfi cialis, with its tendon remaining outside the flexor retjnacu Stage 1 : A nodule of the palmar fascia that does not include lum (the only tendon that does). To some degree, it the skin, with no change in the fascia. separa tes the anterior forearm into ulnar and radial aspects, as the carpi muscles are found one on each side of the pal Stage 2: A nodule in the fascia with involvement of the skin. maris longus. The muscle a ttaches broadly onto the palmar Stage 3: Same as stage 2 but with a flexion contracture of fascia which, in turn, directs fibers into five groups with longitudinal orientation, each of which projects toward a one or more fingers. digit (ray). Stage 4: Same as stage 3, plus tendon and joint contractures. The palmaris longus tendon courses directly through the Cailliet (1 994) notes that, while surgical excision of the mid-line of the wrist. It may be absent on either ann and, fascia and skin bands may be necessary, the hand may lose
1 3 Shoulder, arm and hand 5 1 5 up to 25% of its grip power as a result. He also notes a non For deviation: extensor carpi ulnaris surgical intervention of injection of trypsin, chymotrypsin A, Antagonists:· To flexion: extensor carpi radialis brevis and hyaluronidase and lidocaine, coupled with forceful finger extension. Since the progression is often very slow, observa longus, extensor carpi ulnaris tion and minimal or no treatment are often indicated. To deviation: flexor carpi radialis and extensor carpi radi alis brevis and longus Simons et al (1999) point out that heredity is a factor in Dupuytren's contracture and suggest ruling out trigger I n d ications fo r treatment of wrist fl exors points as part of the problem. A distinguishing feature is that while Dupuytren's may cause a painful palm, only trigger • Loss of range or pain upon extension points in palmaris longus produce the prickling sensation. • Medial epicondylitis Simons et al describe a spray and stretch technique that cov • Carpal tunnel syndrome (some symp toms may be from ers the anterior forearm and hand, which may be beneficial. wrist flexor trigger points) Despite the fact that palmaris longus does not pass through the carpal tunnel, Keese et al (2006) point to its abil Flexor carpi ulnaris and radialis work together to power ity to increase intracarpal canal pressure during loading in fully flex the wrist while they unilaterally work with their wrist ex tension and suggest that it may play a role in the extensor counterpart(s) to produce radial and ulnar devia development of carpal tunnel syndrome. tion of the hand at the wrist. Since these two muscles arise from the common tendon of the medial epicondyle, they Palmaris longus loading increases canal hydrostatic pres should be evaluated and, if necessary, treated when epi sure rHore than any tendon passing through the carpal tun condylar inflammation or tenderness is found. nel when loaded beyond 20° of wrist extension (Keir et al 1 997). In this study, palmaris longus loading beyond 45° of As with many forearm trigger points, those in the flexor wrist extension was associated with the greatest absolute carpi radialis and u lnaris tend to refer to the portion of the carpal tunnel hydrostatic pressure. Despite the results of joint which the muscle serves, in this case the radial and biomechanical studies, the palmaris longus is not yet a ulnar aspects of the flexor surface of the wrist, respectively. proven indl?pendent riskfactorfor carpal tunnel syndrome. These trigger points, especially when combined with oth ers, such as those in subscapularis, will present many of the FLEXOR CARPI RAD IALIS common complaints associa ted with carpal tunnel syn drome and should always be examined in association with Attachments: From the common flexor tendon o n the that diagnosis. Trigger points and intlamma tion found in medial epicondyle of the humerus and from the ante attachment sites (such as the medial epicondyle) will often brachial fascia and intermuscular septa to the base of the resolve unaided if central trigger points associated with 2nd and 3rd metacarpals them are deactivated (Simons et aI 1999). Innervation: Median nerve (C6-7) FLEXOR D I G ITOR U M SUPERFICIALIS Muscle type: Postural (type I), shortens when stressed Function: Flexes the wrist; deviates the hand toward the (FIG. 1 3. 1 0B) radius (thumb) Attachments: Humeroulnar head: from the common tendon Synergists: Forflexion : flexor carpi ulnaris, flexor digitorum of the medial epicondyle of the humerus, the coronoid process of the elbow and (radial head) from the oblique superficialis and profundus, palmaris longus line of the radius in a common tendon sheath through the For deviation : ex tensor carpi radialis brevis and longus carpal canal to end in four tendons attaching (after split Antagonists: To flexion: extensor carpi ulnaris, extensor ting for profundus) to the sides of each middle phalanx carpi radialis brevis and longus To deviatioll: flexor and ex tensor carpi ulnaris Innervation: Median nerve (C7-Tl) Muscle type: Postural (type I), shortens when stressed FLEXOR CARPI U LNARIS Function: Flexes the middle phalanx on the proximal one, Attachments: From the common flexor tendon on the flexes the proximal phalanx on the metacarpal and tlexes medial epicondyle of the humerus and from the medial the hand at the wrist border of the olecranon to the pisiform bone and by liga Synergists: For finger flexion: flexor digitorum profundus, mentous fibers to the hamate and 5th metacarpal. A few palmaris longus fibers blend with tlexor retinaculum Forflexion of MCP joint: flexor digitorum profundus, pal maris longus, lumbricales, palmar and dorsal in terossei Innervation: Ulnar nerve (C7-8) For wrist flexion: flexor carpi radialis and ulnaris, flexor Muscle type: Postural (type I), shortens when stressed digitorum profundus, palmaris longus Function: Flexes the wrist; devia tes the hand toward the Antagonists: Tofingerflexion: extensor digitorum Toflexion ofMCP joint: ex tensor digitorum, extensor indi ulna cis, extensor digiti minimi Synergists: For flexion: flexor carpi radialis, flexor digito rum superficialis and profundus, palmaris longus
51 6 CLI N I CAL APPLICATION OF N EUROM USCU LAR TECH N IQUES: T H E UPPER BODY • Difficulty using scissors or shears • Difficulty grasping with ends of fingers, such as when curling the hair • Trigger finger (locking finger) Flexor pollicis longus I t+-- Flexor digitorum superficialis Special notes Flexor digitorum superficialis (sublimis) lies in the superfi cial layer of the anterior forearm, although it is covered for the most part by the remaining muscles of the superficial layer, while the profundus (perforatus) lies deep to it in the second layer of the forearm. Near its distal attachment to the middle phalanx, each superficialis tendon splits and the profundus passes through it to terminate on the distal pha lanx (Fig. 13.110) . Profundus acts a lone to flex the distal interphalangeal joint but is assisted by superficialis for flex ion of other hand and finger joints. While together they pro vide powerful and speedy movements of the fingers, gentle digital flexion is provided by the profundus alone. Fig u re 1 3. 1 08 Trigger points of digital flexors seem to extend Trigger fi nger beyond the tips of the dig its. l i ke l ightning. Drawn after Simons et a l (1 999). Trigger finger (locking finger) is a condition in which the movement of the finger (or thumb) stops for a moment dur F L E X O R D I G ITO R U I\\t1 PR O F U N D U S (FI G. 1 3. 1 09) ing flexion or extension movements and then continues with a jerk. Simons et al (1999) suggest loading the locked Attachments: From the proximal three-quarters of the finger by having the person (slightly) flex it more and medial and anterior surfaces of the ulna (from brachialis applying active resistance while the person pulls it, against to pronator quadratus) and interosseous membrane and the resistance, to its resting position. They note: 'Sometimes from the coronoid process of the elbow and aponeurosis, firm pressure applied to the tender spot where locking shared with the flexor and extensor carpi ulnaris to occurs will restore normal function, as if the tendon or ten become four tendons, each attaching to the base of a dis don sheath had become edematous locally and needed help tal phalanx of a single finger a fter perforating the tendon to return to normal.' They also suggest injection ( 1 5 ml of of flexor digitorum superficialis 0.5% procaine solu tion) 'apparently deep in the restricting fibrous ring around the flexor tendon' and offer supporting Innerva tion: Median and ulnar nerves (C8-Tl) evidence of its effectiveness in relieving trigger finger, Muscle type: Postural (type I), shortens when stressed though the return to normal function may be delayed by a Function: Flexes all joints it crosses, including the wrist, few days. See also Mulligan's 'mobilization with move ment' method, described on p. 520. mid-carpal, metacarpophalangeal and phalangeal joints Synergists: For finger flexion: flexor digitorum superficialis, FLEXOR POLLICIS LONGUS palmaris longus (perhaps) Attachments: From the anterior surface of the radius (from Forflexion ofMCP joint: flexor digitorum superficialis, pal distal to the tuberosity to the pronator quadratus), maris longus, lumbricales, palmar and dorsal interossei interosseous membrane and sometimes from the coro For wrist flexion : flexor carpi radialis and ulnaris, flexor noid process or medial epicondyle of the humerus to the digitorum superficialis, palmaris longus base of the distal phalanx of the thumb on its palmar Antagonists: Tofingerflexion: extensor digitorum surface Toflexion ofMCP joint: extensor digi torum, extensor indi cis, extensor digiti minimi Innervation : Median nerve (C7-8 or Tl) Muscle type: Postural (type I), shortens when stressed Ind ications for treatment of fi nger flexors Function: Flexes the interphalangeal, metacarpophalangeal (both layers) and carpometacarpal joints of the thumb. May mildly • Loss of extension of the fingers (especially when the abduct the thumb (Platzer 2004) wrist is also extended) Synergists: Flexor poBicis brevis, adductor pollicis Antagonists: Extensor pollicis longus and brevis, abductor • 'Explosive pain that \"shoots right out the end of the fin pollicis longus ger like lightning'\" (Simons et a1 1 999)
1 3 Shou l der, arm and hand 5 1 7 Biceps --:�-Ar --- Brachia artery --- Median nerve Brachialis ,--\"7 Brachioradialis ...�------------------ Superficial branch of Superficial fiexor muscles (cut)---' radial nerve Variable slip of fiexor pollicis longus ..,. --- ---------------- Posterior interosseous nerve M!�-- Radial recurrent artery from medial epicondyle --��\"'r-\\�..� Supinator----,-\\ -.,l- .. ,-- Anterior interosseous nerve --- Radial artery (cut) Posterior recurrent ulnar artE!ry---'\\i r-- Common interosseous artery P-;-- Posterior interosseous artery Flexor digitorum profundus---1I Inlerosseous membrane .-- Extensor carpi radialis longus Oust visible) ---=-= --:w,.; �-- Anterior interosseous artery Flexor carpi UlnclflS·--r'.l :'--\" Ulnar artery k--: Ulnar nerve kl-'r-- Flexor pollicis longus ·.�'r-- Radial artery (cut) Dorsal branch of ulnar nerv'e------------..\\;.;. Dorsal branch of ulnar aflElry.-- -------------'9'... .�r-- Pronator quadratus ..-. ::--- -------- Median nerve (cut) Guyon's canal --------------___ �-=�..,I:E:--: ------ Flexor carpi radialis tendon (cut) Flexor retinaculum ---:;, �-=-- Abductor pollicis brevis a'--- --'---- Flexor pollicis brevis Abductor digiti TlIrJilrfHi-· ---------------+ :--:' Adductor pollicis Flexor digiti minimi brevis ---t (transverse part) '\"-\" Lumbricals ..'-. --'-�- �:_':_-: --- Deep transverse metacarpal ligament �-�:\"':\"'-T Flexor digitorum superficialis tendon (cut proximally) \\-'-';--�f' Flexor digitorum profundus tendon Fig u re 1 3. 1 09 The deepest a nterior forearm m u scles. Reproduced with permission from Gray's Anatomy (2005). Indications for treatment and may be partially or completely absent (Gray's Anatomy 2005). • Difficulty with fine work requiring control of the thumb, such as sewing, fine painting or writing Trigger thumb • Pain in the thumb and extending beyond the tip Trigger thumb (like trigger finger) presents with locking in • Trigger thumb flexion and the inability to straighten the thumb without assistance (Simons et al 1999). It is usually caused by Special notes enlargement of the tendon (nodule) where it passes through a fibrous sheath. Cailliet (1994) notes (regarding trigger fin Flexor pollicis longus courses through the carpal tunnel and gers) that steroid injection to expand the sheath may allow between the two heads of flexor pollicis brevis before termi passage of the nodule, surgical intervention to slit the nating at the distal phalanx of the thumb. It is sometimes sheath may be necessary and that 'Excision of the nodule connected to either flexor digitorum superficialis or profun invariably causes formation of a new and often bigger dus, or to pronator teres (Gray's Anatomy 2005) or may arise nodule'. from the medial epicondyle of the humerus (Platzer 2004)
5 1 8 CLI N I CAL A PPLICATI O N O F N E U R O M U S C U LAR TECH N I Q U E S : T H E U P P E R B O DY Transverse part of adductor pollicis ---, Oblique part of adductor nnllli·rii� ---� Flexor digitorum profundus Extensor pollicis brevis ---- --� Vincula Abductor pollicis brevis ---� longa Extensor pollicis longus L-- Digital fibrous sheath Radial artery ____--I-_�__l_. L-_- __ Dorsal digital expansion L-_- ___ First lumbrical \"--' First dorsal interosseus Fig u re 1 3. 1 1 0 The flexor dig itorum profundus tendon passes t h rough the split flexor d ig itoru m su perficia l is tendon to attach to the most dista l p h a l a nge. Reprod uced with perm ission from Gray's Anatomy (2005). � N MT FOR ANTERIOR FOREARM Figure 1 3. 1 1 1 Superficial g l iding strokes add ress the w rist and hand flexors while deeper p ressure (if a ppropriate) treats the digital flexors. The patient i s seated comfortably opposite the practitioner with a table placed between them on which to support the muscles, a portion of which is a lso v isible from the poste arm. The forea rm to be treated is supinated w ith the hand in rior aspect. neutral position and rests comfortably on the table with the • Near the an terior elbow region, the short pronator teres fingers di rected toward the practitioner. This treatment may may be easily palpated, as it lies diagonally across the also be performed with the person supine as long as the central aspect of the uppermost portion. table provides enough support for the a rm . The superficial layer o f muscles is addressed first with lubrica ted gliding strokes along the course of the muscle, from the wrist to the medial epicondyle. The gliding strokes a re repeated 6-8 times on each muscle until the entire sur face of the anterior forearm has been treated. The order of treatment is not important but when learning to identify these muscles, the following order may be helpfu l . • From the mid-line of the wrist to the medial epicondyle will address the palmaris longus. • On the ulnar side of this landmark 'mid-line', a portion of the flexor digitorum superficialis is available and next to it (medially) on the most lunar portion of the anterior forearm lies the flexor carpi ulnaris. • On the radial side of the 'mid-line' lies the flexor carpi radialis. • Directing inferolateraJly across the most proximal por tion of flexor carpi radialis is the pronator teres (see pp. 496-497), which can be p alpa ted transversely while pronating the forea rm. • The most lateral (radial) aspect of the anterior forearm will include brachioradialis, radial wrist extensors and the supinator, which are sometimes called the radial
1 3 Shoulder, arm and hand 5 1 9 • Gliding strokes may again be applied with increased pressure (if appropriate) to influence the flexor digito rum superficialis, flexor digitorum profundus and the flexor pollicis longus. As the practitioner applies the gliding strokes to the oppo - site arm to treat or to compare the tissues, a hot pack (if appropriate) may be applied to the arm that has been Figure 1 3. 1 1 2 M ET treatment for forearm flexors. treated. The glid ing strokes are then repea ted. If the muscles are moderately uncomfortable with appropriate gliding on the ulnar and radial arteries and the ulnar and median strokes, inflammation may be present, especially with nerves. The pressure bar is an inappropriate tool for this area repetitive use conditions. In this case, heat would be con due to the vulnerability of these structures (see Chapter 9). traindica ted and an ice pack used instead. ASSESS M E NT A N D M ET TREAT M E NT O F Once the lubricated gliding strokes have been suffi SHORTN ESS I N TH E FOREARM FLEXORS ciently applied to warm and elongate the myofascial tissue, individual palpation of the muscles may easily distinguish A painful medial humeral epicondyle ('golfer's elbow') the superficial muscles, though the deeper bellies a re usu usually accompanies tension in the flexors of the wrist and ally no t as distinct . Know ledge of the musculature will be hand (Fig. 13.112). the practitioner 's greatest asset when attempting to locate these muscles. While active muscle testing may also assist • The patient is seated facing the practitioner, with the in locating them, several muscles are likely to be activa ted flexed elbow supported by the practi tioner 's fingers. by the same movement, which could be confusing unless the ana tomy is familiar. • The pa tient's hand is extended at the wrist, so that the palm is upward and fingertips point toward the ipsilat Transverse snapping palpa tion may be applied with the eral shoulder. thumb or fingertips to identify taut bands within any of these muscles. Since trigger poin ts occur wi thin taut bands, • The extended wrist should easily be able to form a 90° examination of any taut fibers found should be included, angle with the forearm if the flexors of the wrist a re not especially at the center of the fiber where central triggers shortened. occur. The muscles in the superficial layer often have lengthy tendons, making their endplate zone (where central • The practi tioner guides the wrist into greater ex tension trigger points occur) lie in the middle of the upper half of to an easy barrier, with pronation exaggera ted by pres the forearm. sure on the ulnar side of the palm. Tender attachment sites are often associa ted with a cen • This is achieved by means of the practitioner's thumb tral trigger point and will usually resolve with li ttle treat being placed on the dorsum of the pa tient's hand while ment needed, if the central trigger point is released (Simons the fingers stabilize the palmar aspect, fingertip pressing et al 1999). Trigger points and tender a reas may be treated the hand toward the floor on the ulnar side of the with sustained pressure, spray and stretch techniques, patient's palm. injection, dry needling and possibly through movement techniques such as active myofascial release (as described • The patient attempts to gently supinate the hand against below). Clinical experience has shown that trigger points resistance for 7-1 0 seconds following which, after relax are more easily deactivated following l ymphatic drainage a tion and on an exhala tion, prona tion and extension are of the area. increased through the new barrier. The medial epicondyle is often a site of tenderness and irrita tion due to tension placed on the common tendon that attaches to it. It is deserving of special attention and careful palpation, as its degree of tenderness may be marked. Additionally, central trigger points should be a ddressed in the five muscles (pronator teres, palmariS longus, flexor carpi ulnaris and radialis, and flexor digitorum superfi cialis) which merge into the tendon. Habitual overuse of the muscles should be decreased, with more frequent breaks from activities that stress them. Ice applications are useful, in 10-15 minute applica tions several times daily, in cases of chronic and acute distress of these tissues. When examining tendons and bony surfaces of the ante lior wrist area, caution is needed to avoid pressure or friction
520 C L I N ICAL A P P L I CAT I O N OF N E U R O M U S C U LAR T ECH N I Q U E S : T H E U PP E R B O DY gaMll wiodbai niylgisz, aatttriaorinngshwl attiati ohnngmlpeorsvetesosmuterhene,tpa(lpMapnWlei eModf)bmiynovtvhoeelvmepesrnaact �Ipni taiwionnhle�Icsrs,h,arlemstonsct tl.On I. MWM for flexion or extension restriction of the wrist is noted. At the same time the patient actively (or sometimes the \" practitioner passively) moves the joint in the direction of restriction or pain. • The patient is seated with the elbow of the (in this example) right arm flexed, forearm pronated. • The practitioner holds the distal aspects of the radius and ulna w ith the left hand, so that the web between the finger and It thumb lies over the dista l aspect of the radius. MWM for flexion restriction of finger joint • The web between the finger and thumb of the right hand is placed on the other side of the hand, covering the proximal row • Th e patient is seated and the practitioner sta buipl iztehsetJ.hO�i ndti,sWtaitl henad of the carpal bones. of the proxi mal bone of the pair which make • These contacts allow the practitioner to effectively translate finger and thumb hold, one contact on the lateral and one on the (glide, shunt) the wrist joint so that as one of the practitioner's medial aspect of the bone. ha nds moves medial ly, the other moves lateral ly. • The practitioner's other finger and thumb hold the proximal end • Mul ligan states, 'I have found in every case the successfu l glide of the distal bone of the pair making up the joint, again with one has been a l ateral one [of the ca rpal bones]'. contact on the medial and the other on the lateral aspects of the • While the practitioner holds the least uncomfortable direction of bone. The patient could be asked to do this. translation - al most a l ways, according to Mu lligan, a lateral • With these contacts the practitioner is able to easily translate (or translation of the carpals - the patient is asked to actively glide or shunt) the bones on each other, by gently taking one lat move the wrist into the restricted direction, flexion or eral and the other medial, and vice versa. extension. • The practitioner tests to see which of these options is the least • 'If the mobilization with movement procedure is indicated painful, as the finger is flexed. the range of movement will improve instantly and • Mulligan (1 992) states that, 'In nearly every case you will find p a i n l essly: that one d i rection is painful, and the other is not. You choose • This is repeated several times. the direction which is pai nless and ask the patient to flex his • If any aspect of the procedure is painful it should be modifIed stiff finger while you sustain the mobi lization. This active until it is painless, possibly by a ltering the angle of translation movement should be pa in free and the ra nge should very sl ightly or marginally modifying the practitioner's hand i n crease'. positions. • The procedure is repeated several times and the ra nge of • Reversing the practitioner's hand positions as i l lustrated movement and pain previously experienced is reassessed. facilitates translation as described above. • Mul ligan bel ieves that this method normal izes tracking dysfunctions, such as are known to occur with the patel la, but which are not com monly considered to occur in other j o i n ts . Figure 1 3 . 1 1 3 Mobil ization with m ovement ( M u l l iga n's method) Figure 1 3. 1 1 4 Mobilization with movement (Mulligan's method) for i n terphalangeal dysfun ction, w i th patient holding distal bone for wrist dysfunction. of involved joint.
1 3 Shoulder. arm and hand 52 1 • Repeat 2-3 times. Brachioradialis Triceps • This method can easily be adapted for self-treatment by Extensor carpi radialis longus --1-4_ Extensor carpi radialis brevis Fascial origin of the patient applying the counterpressure. extensor carpi ulnaris Extensor digitorum --H-'-+-fi' with anconeus deep '� M ET F O R S H O RTN E S S I N EXT E N S O RS O F T H E to this , WRIST AND HAN D Abductor pollicis longus --+f-llail ir. Extensor digiti minimi • The pa tient is seated facing the practitioner, with the --f:-' --- Extensor carpi ulnaris flexed elbow supported by the practitioner 's fingers. Superficial branch of radial • The patient's wrist and hand are flexed, so tha t the palm is facing downward and fingertips point toward the ipsi Extensor carpi radialis brevis .�':ff- Extensor indicis lateral shoulder. Extensor carpi radialis longus 'Mr-- U l n a • The flexed wrist should easily be able to form a 90° angle 1st dorsal II/-- Dorsal branch of with the forearm if the extensors of the wrist are not interosseous -..i-':JIl<\", ulnar artery shortened. H--Dorsal branch of • With the palm of the practitioner's other hand on the ulnar nerve dorsum of the patient's hand, the practitioner's fingers cover the patient's flexed fingers so that slack is removed \"-- Extensor retinaculum and the tissue is taken to its barrier. 1.--- Extensor digiti minimi • The patient is asked to attempt to take the fingers into extension against the practitioner's resistance for 7-10 �-'JA.\\1;-:=Abductor digiti minimi seconds, using minimal but steady effort. -'.tI1h+-+ lntertendinous • When the patient releases the isometric effort, the practi connections tioner, with the patient's assistance, takes the wrist and fingers into greater flexion without force and holds the Figu re 1 3. 1 1 5 Su perficial posterior forea rm. Reproduced with new position for at least 20 seconds. perm ission from Gray's Anatomy (2005). • The procedure is repeated 2-3 times. • Once the reported pain score has reduced to '3' or less, • This method can easily be adapted for self-treatment, by the position is held for 90 seconds before a slow return to neutra l . means of the patient applying the counterpressure. • Tender point pain o n the palmar surface i s treated i n the ,� PRT FO R W R I ST DYS F U N CT I O N ( I N C LU D I N G same way but with flexion instead of dorsiflexion. , CARPAL TU N N E L SYN D RO M E) • Several tender points can usefully be treated at one session. Jones (1985) w rites: It is our clinical experience that functional improvement is often immediate (improved range, etc.) but that reduction Because there are eight bones in the wrist, I had visions of in existing pain may take several days to manifest follow venj complicated maneuvers being necessary. I was sur ing PRT trea tment (see notes on PRT, pp. 427 and 498) . prised how easy wrist treatment usually is. I treat it as if it were just onejoint . . . ifthe wrist is tender on the dorsal side, ,� M F R F O R A R EAS O F F I B R O S I S O R r extend [dorsiflex] and rotate. If it is on the palmar side, I , HYPE RTO N I CITY flex and rotate. Occasionally I fine tune with sidebending. There are many [patients] with tender spots on the flexor • The practitioner identifies a localized area of hypertonic tendons that have been diagnosed [as having] carpal tunnel i ty, fibrosis, 'adhesion'. syndrome, which responds to this type of treatment. I can only guess that they have been misdiagnosed. • The practitioner palpates and locates an area of extreme sensitivity to light pressure on the dorsum or palmar sur face of the hand or wrist (see p. 497, Fig. 13.95B). • Using sufficient digital pressure to create discomfort which the patient can grade as a '10', the practitioner positions the hand and wrist to remove, as far as possi ble, the perceived tenderness/pain. • Tender point pain on the dorsum of the hand is usually relieved by dorsiflexion and slight wrist rotation one way or the other and possibly by additional sideflexion or translation.
522 CLI N ICAL APPLICATION OF N E U RO M USCULAR TECH N I QUES: THE U PPER BODY Brachioradialis ----if..). .,-T.-, riceps POST E R I O R F O R E A R M T R EAT M E NT Extensor carpi The superficial layer of the posterior forearm contains two muscles of the elbow joint - brachioradialis, anconeus - and radialis longus --IJH�n-ft five extensor muscles - extensor carpi radialis longus and brevis, extensor digitorum, extensor d igiti minimi and Exlensor carpi Flexor carpi ulnaris extensor carpi ulnaris. The deep extensors include supina radialis brevis --f--i+' Anconeus tor (elbow region), extensor indicis a nd three thumb mus r'r--+ Posterior interosseous cles - abductor pollicis longus, extensor pollicis brevis and Supinator recurrent artery extensor pollicis longus. Poslerior S U P E R F I CI A L LAY E R interosseous nerve --.,. Extensor digitorum and On the most lateral aspect o f the forearm lies the radial extensor digiti minimi group - brachioradialis, extensor carpi radialis longus and brevis - and the supinator, as if stacked upon each other. Abductor poliicis The most superficial and the deepest of these are discussed longus ---'1 with the elbow, while the two wrist extensors are included here. These four muscles can be conveniently addressed Extensor pollicis (palpated and treated) together in the semisupina ted fore brevis arm with applications of gliding strokes, pincer compres sion and flat palpation. This 'lateral forearm' position may Abductor pollicis longus -+-- Extensor retinaculum be varied toward greater pronation or supination to best Extensor pollicis brevis Extensor carpi ulnaris access or evaluate the muscles. They are also accessible with Extensor pollicis longus the arm pronated and a portion can be palpated with the -i-\"-- Extensor digiti minimi arm in supination. Extensor carpi '-- Extensor digitorum radialis longus The lateral epicondyle of the humerus, where many of Extensor carpi these muscles share a common tendon attachment, can be radialis brevis readily examined at the same time. When any (or several) of the muscles attaching into the tendon develop contractures, Figure 1 3. 1 1 6 Deep posterior forearm. Reprod uced w i th permission tension will be placed on the common tendon, which is from Gray's Anatomy (2005). capable of provoking an inflammatory response. Commonly called 'tennis elbow', lateral epicondylitis may be initiated, • The muscles involved are placed in a shortened (i.e. not aggravated and perpetuated by hand, wrist and finger stretched) position; therefore, jj the treatment were being extension activi ties, especially if these are repetitive and / or applied to the flexors of the forearm, the wrist would be stressful (Cailliet 1994). in slight flexion. Cailliet (1994) suggests three theories of etiology for • Firm finger or thumb pressure is applied to the tissues, symptoms that include deep tenderness accompanied by an slightly distal to the restricted tissues. ache at the lateral epicondyle, the muscula ture of which is painful upon palpation: • The patient is asked to slowly and deliberately extend and then flex the wrist. • tendinitis at the lateral epicondyle • radial nerve entrapment • In this way the flexors are placed at stretch (during wrist • intraarticular or osseous disorders. extension) and the area of restriction passes under the fixa tion produced by the practitioner's finger or thumb He notes that pain is intensified with resisted wrist exten contact. sion or radia l devia tion and that tenderness in the posterior interosseous nerve is reported when supina tion of the • As the wrist is flexed again the muscular and fascial tis extended wrist is resisted. sues, under pressure, shorten and relax . Treatment for such symptoms may include the following • This process is repeated 6-10 times. (Cailliet 1994). • Alternatively, the practitioner can introduce the a lternat Acute ing flexion and extension if the patient is unable to do so. • Precisely the same method can be used on any tissues • Rest the wrist and elbow by avoiding the activities tha t provoke the pain, avoid pronation of the forearm or wrist that can be compressed manually. or finger extension. • Self-treatment can be taught to the patient, with cau tions as to overtrea tment.
1 3 Shoulder, arm and hand 523 • Possible wrist splinting to decrease extension. Extensor Extensor carpi • Changes in patterns of use, including sports. carpi ulnaris radialis brevis • Possible steroid injection (Cailliet points ou t that acupuncture has been claimed to be more effective (Brattberg 1983)). Postacute • Gentle active and passive range of motion of wrist and elbow. • Gentle wrist exercises, including extension, radial and u lnar devia tions (in pronation and supination), wrist flex ion and circumduction,followed by a period of relaxation. • When exercises can be painlessly performed, light weight may be added and gradually increased (in weight and repetitions). • Surgical intervention may be considered as a final resort. We would a dd to this list - especially in the acute phase - the use of alternating (short) hot and cold applica tions (see Chapter 10), positional release methods (see Chapter 10), gently applied spray and stretch techniques and anti inflamma tory nutritional stra tegies (see Chapter 7), includ ing increased EPA (fish oil) supplementation and enzymes, such as pineapple bromelaine. EXTE NSOR CARPI RAD IALIS LO N G U S Extensor carpi radialis longus Attachments: From the distal third of the latera l supra condylar crest of the humerus and lateral intermuscular Brachioradialis septum (including fibers from the common extensor ten don) to the base of the 2nd metacarpal on the radial side Figure 1 3. 1 1 7 Composite of w rist extensors and b rachiorad ialis of the posterior surface trigger point patterns. Drawn after Simons et a l ( 1 999). Innervation: Radial nerve (C6-7) Synergists: For wrist extension: extensor carpi radialis bre Muscle type: Phasic (type II), weakens when stressed vis, extensor carpi ulnaris, extensor digitorum, extensor Function: Extension and radial deviation of the wrist, digi ti min.imi For radial deviation: extensor carpi radialis longus and weakly flexes and influences pronation and supination of flexor carpi radialis elbow (Platzer 2004) Synergists: For wrist extension: extensor carpi radialis bre Antagonists: To wrist extension: flexor carpi radialis and vis, extensor carpi ulnaris, extensor digitorum, extensor ulnaris, flexor digitorum superficialis and profundus, digiti min.imi palmaris longus For radial deviation: extensor carpi radialis brevis and To radial deviation: flexor carpi ulnaris, extensorcarpi ulnaris flexor carpi radialis Antagonists: To wrist extension: flexor carpi radialis and ulnaris, flexor digitorum superficial is and profundus, palmaris longus To radial deviation: flexor carpi ulnaris, extensor carpi ulnaris EXTENSOR CARPI RADIALIS BREVIS Attachments: From the common extensor tendon o f the lat- eral epicondyle to the base of the 2nd and 3rd metacarpals Innervation: Deep radial nerve (C7-8) Muscle type: Phasic (type II), wea kens when stressed Function: Extension and radial deviation of the wrist
524 CLI N I CAL A PPLICATI O N OF N EU RO M USCULAR TECH N IQUES : T H E U PPER BODY EXT E N S O R CAR P I U LNARIS the fingers grasp and work and are essential in this role when a power grip is used (Simons et aI 1999). Attachments: From the common extensor tendon and the posterior border of the ulna to the base of the 5th Brachioradialis is sometimes grouped with the extensors metacarpal of the wrist due to its proximity to them and its innervation by an extensor nerve. Its trigger point activity, somewhat I nnervation: Deep radial (C7-8) like the wrist extensors, is into the elbow, forearm and hand Muscle type: Phasic (type II), weakens when stressed (web of the thumb) (see p. 496, Fig. 13.94). Since it is often Function: Extension and u lnar deviation of the wrist tender in association when the wrist extensors are tender, it Synergists: For wrist extension: extensor carpi radialis brevis is included together with their examination, which is easily accomplished due to their proximity. and longus, extensor digitorum, extensor digiti minimi For radial deviation: flexor carpi ulnaris Neural entrapment. Simons et al (1999) point out that Antagonists: To wrist extension: flexor carpi radialis and extensor carpi radialis brevis and supinator have both been ulnaris, flexor digitorum superficialis and profundus, noted to entrap the radial nerve. Such entrapment may pro palmaris longus duce motor weakness of the muscles it serves, as well as To radial deviation: flexor carpi radialis, extensor carpi sensory loss or numbness and paresthesias, depending radialis brevis and longus upon which portion of the nerve is impinged. The ulnar nerve may also be entrapped nearby, at the cubital tunnel, I nd i cations for treatment of w rist extenso rs by the flexor carpi ulnaris muscle. • Lateral epicondylar pain (tennis elbow) EXT E N S O R D I G ITOR U M • Painful supination • Weakness of the grip Attachments: From the common extensor tendon of the lat • Pain in elbow, wrist or web of thumb eral epicondyle, antebrachial fascia and intermuscular • Reduces range of motion in wrist flexion or wrist septa to end in four tendons (which split into three inter tendinous connections) which attach to the dorsal sur deviations face of the middle phalanx (1) and the base of the distal phalanx (2) of the 2nd-5th fingers (see below) Speci a l n otes Innervation: Deep radial (C6-8) While all three carpi extensors are active during forceful Muscle type: Phasic (type 11), weakens when stressed wrist extension, extensor carpi radialis brevis primarily Function: Extends the fingers at all phalangeal joints, assists extends the hand during less demanding use. The wrist extensors are also important during flexion activities where in wrist extension and finger abduction, counteracts fin they stabilize the wrist to prevent excessive wrist flexion as ger flexion in a power grip LL \\ Middle finger extensor Ring finger extensor Extensor indicis Figure 1 3. 1 1 8 Composite trigger point referral patterns of fi nger extensors. Drawn after Simons et a l ( 1 999).
1 3 Shoulder, arm and hand 525 Synergists: For finger extension: lumbricales, dorsal interos missing, the digitorum provides an additional tendon to sei, extensor indicis, extensor digiti minimi take over its function (Platzer 2004). For wrist extension: extensor carpi radialis longus, brevis and ulnaris f NMT FOR SU PERFICIAL POSTERIOR FOREARM Forfinger abduction: dorsal interossei With the forearm in a relaxed, semisupinated posi tion and Antagonists: To finger extension: flexor digitorum superfi flexed at the elbow to near 90°, the brachioradialis is easily cialis and profundus, lumbricales, palmar interossei located and treated with pincer compression, lubricated To wrist extension: flexor carpi radialis and ulnaris gliding strokes and flat palpation. This muscle should be Tofinger abduction: palmar interossei released before the radial wrist extensors are attended to, since it is superficial to them. EXTENSOR D I G ITI M I N I M I After the brachioradialis is treated, the extensor carpi Attachments: From the common extensor tendon to join radialis longus may be grasped with pincer compression, with the extensor digitorum at the proximal phalanx to near its humeral attachment, by placing the treating thumb attach to the dorsal expansion of the 5th digit on one side of the muscle and the treating fingers on the other side, while grasping around the brachioradialis. Taut Innervation: Deep radial (C6-8) bands within the muscles are examined for trigger pOints, Muscle type: Phasic (type II), weakens when stressed which may be compressed by flat palpa tion against the Function: Extends the smallest finger, extends the wrist and underlying tissue or grasped with pincer compression as previously described. A deeper placement of the fingers ulnarly deviates the hand may also address the extensor carpi radialis brevis, which Synergists: Forfinger extension: extensor digitorum lies deep to the longus. A small portion of the supinator Antagonists : To finger extension: flexor digitorum superfi may be reached by gliding the thumb on the radial a ttach ment (see p. 484). Only a small portion of supinator can be cialis and profundus, lumbricales, palmar interossei accessed directly but application of repeated gliding tech To wrist extension: flexor carpi radialis and ulnaris niques, assisted pronating stretches and posttreatment ice To hand deviation: flexor carpi radialis, extensor carpi radi applications usually achieve satisfactory res ults, especially alis brevis and longus if the source of the muscular irritation (such as overuse) is eliminated. Ind ications for treatment Hydrotherapy applications may precede or follow these • Pain in elbow or fingers procedures. Inflammation of the supinator muscle and epi • Weakness of the grip condyles of the humerus should be ruled out before apply • Pain at elbow when gripping (such as shaking hands) ing heat to the elbow region. Ice therapy may be applied to • Loss of full flexion of the fingers any of the muscles following therapy. • Pain in the elbow, posterior forearm, wrist and fingers The patient is sea ted comfortably opposite the practi due to trigger points tioner with a table placed between them on which to sup port the arm. The forearm and hand to be treated a re Special notes pronated and rest comfortably on the table with the fingers directed toward the practitioner, as the table provides sup The ex tensor digitorum muscle has an interesting and com port for the arm. plex tendon arrangement at its distal attachment, which attaches to the capsules of the metacarpophalangeal joints, The superficial layer of muscles is addressed first, with bases of the proximal phalanges and to the middle and dis lubricated gliding strokes along the course of each muscle, tal phalanges. The interossei and lumbricales participate in from the wrist to the lateral epicondyle. The gliding strokes the fibrous dorsal expansion of the extensor digitorum ten are repeated 6-8 times on each muscle until the entire sur don, which is described in detail in Gray's Anatomy (2005, face of the posterior forearm has been treated. The order of see Fig. 53.43, p. 917) . treatment is not important but when learning to identify these muscles, the following order may be helpful. Variations o f extensor digitorum include additional bel lies (2nd finger), missing bellies (5th finger) and a doubling • From the midline of the wrist to the lateral epicondyle of the tendons to the individual fingers (Platzer 2004). will address the extensor digitorum. Simons et al (1999) also note a rare extensor digitorum bre vis magnus, which may be misdiagnosed as a ganglion cyst • On the ulnar side of this landmark 'mid-line' lies the or tumor, and an anomalous ex tensor digitorum profundus. extensor digiti minimi and, next to it, the extensor carpi ulnaris. The extensor digiti minimi may easily be considered as part of the extensor digitorum since they arise together • On the radial side of the ' mid-line' lies the brachioradi from the common tendon, are joined at the distal attach alis, extensor carpi longus and brevis and supinator, one ment and often are fused at the bellies. When the minimi is stacked upon the other as previously described on p. 522.
526 C L I N ICAL A P PLICATI O N O F N E U R O M USCU LAR TECH N I Q U E S : THE U P PER B O DY Figure 1 3. 1 20 Carefu l pa l pation of the l ateral e picondylar region may reveal infla m mation associated with the common te ndon attachment shared by several muscles. Figure 1 3. 1 1 9 Gliding strokes to the posterior forearm help active movement of most of these muscles will assist in d isti n g u ish the su perfici a l layer from the diagonally oriented deeper readily identifying them. layer. Transverse snapping palpation may be applied with the • The small anconeus may be palpa ted just distal to the thumb or fingertip to identify taut bands within any of elbow between the ulna and radius (a line between the these muscles. Since trigger points occur within taut bands, olecranon and the lateral epicondyle represents the prox examination of any taut fibers found should be included as imal edge of this small, triangular muscle). part of the NMT treatment/ examination, especially at the center of the fiber where central triggers occur. Most of • On the radial side of the distal one-third of the forearm, these muscles have lengthy tendons, making their endplate the deeper layer of muscles lies diagonally oriented, with zone (where central trigger points occur) more proximal abductor pollicis longus (proximal) and extensor pollicis than one would expect. brevis being the most palpable. Gliding strokes may again be applied with increased pressure (if appropriate) Tender attachment sites are often associated with a cen to influence the bellies of these two muscles, as well as tral trigger point and will usually resolve with little treat extensor pollicis longus and extensor indicis, which are ment needed if the central trigger point is released (Simons almost completely covered by extensor digitorum. et al 1999). Lewit (1985) states: 'Frequently, like trigger points in muscles, pain points [on the periosteum] are As the practitioner applies the gliding strokes to the oppo highly characteristic of certain lesions, and therefore have site arm to treat or to compare the tissues, a hot pack (if high diagnostic value. Their disappearance (improvement) appropriate) may be applied to the arm that has been also serves as a va luable test for the efficacy of trea tmen t.' treated. The gli ding strokes are then repeated. If the muscles Since these muscles are readily palpable, trigger point pres are moderately uncomfortable with appropriate gliding sure release is easily applied to them. Spray and stretch strokes, inflammation may be present, especially with techniques, injection, dry needling, lymphatic drainage and repetitive use conditions. In this case, heat would be con active myofascial release may also be used to deactivate traindicated and an ice pack used instead. referral patterns. The tissue should be stretched following treatment using MET, PNF or other appropriate stretching Once the lubricated gliding strokes have been suffi methods. ciently applied to warm and elongate the myofascial tissue, individual palpation may easily distinguish most of these The lateral epicondyle is deserving of special attention as posterior forearm muscles. Knowledge of the musculature numerous muscles attach to it (extensor carpi radialis will assist the practitioner in being correctly positioned and longus and brevis, extensor digitorum, extensor carpi ulnaris, supinator and anconeus). Careful palpation is sug gested, as it is often very tender, especially associated with wrist and elbow pain. Additionally, central trigger points should be addressed in all the muscles that merge into the common extensor tendon, which attaches here. Habitual overuse of the muscles should be decreased and frequent stretching of the forearm muscles employed as 'homework'. Ice packs are useful in 10-15 minute applications several times daily.
Radial nerve ----___ 1 3 Shoulder. arm and hand 527 Branch to YI-I&+I- Posterior brachioradialis ---_. interosseous nerve (continuation of Branch to extensor deep branch of carpi radialis longus---�'\" radial nerve) Branch to extensor v..�. -tI---- Posterior carpi radialis brevis interosseous artery Deep branch --�- Common Superficial branch ---HI interosseous artery Posterior interosseous artery --I-f ,_-- Anterior interosseous artery �t-- Ulnar artery Interosseous membrane Anterior view Extensor indicis --/-tT-\\ -\\ilr-- Abductor pollicis longus Mr:t--Tt\\ Extensor poliicis longus Anterior interosseous artery --+->-M 'M\\+I+-I Extensor pollicis brevis Posterior view Figure 1 3. 1 2 1 Deep posterior forearm with cou rse of posterior interosseous nerve (deep branch of rad ial nerve). Reproduced w i th perm ission from Gray's Anatomy for Students (2005). D E E P LAY E R are usually palpable when proximal gliding strokes are used and with precisely applied muscle tests. The deep layer o f the posterior forea rm contains supinator (elbow region), extensor indicis and three thumb muscles - ABDUCTO R POLLICIS LONGUS abductor pollicis longus, extensor pollicis brevis and exten sor pollicis longus. While the supinator is discussed with Attachments: From the dorsal surface of the ulna distal to the elbow, the four remaining muscles are addressed in the the supinator crest, interosseous membrane and middle order in which they lie on the posterior forearm from lateral third of posterior radius to the base of the first (radial side) to medial (ulnar aspect). While they are not metacarpal and trapezium always distinct, their fiber direction lies diagonally and they
528 C L I N ICAL A P P L I CATI O N O F N E U RO M U SC U LA R TECH N I Q U E S : T H E U P P E R B O DY Innervation: Deep radial (C7-8) grasping a ball) take on mechanical complexities requiring Muscle type: Phasic (type II), weakens when stressed simultaneous coordinated contraction of multiple muscles. Function: Abducts the thumb, extends the thumb at the car- When painfully dysfunctional, the thumb deserves due attention as the actions it performs are indispensable. pometacarpal joint Synergists: For abduction: abductor pollicis brevis The bellies of these thumb muscles lie wholly within the forearm with the long tendons projecting distally to attach For extension: extensor pollicis longus and brevis to the thumb. When examining for central trigger points Antagonists: To abduction: adductor pollicis (trigger point referral patterns have yet to be established in these tissues), it is useful to remember that central trigger To extension: flexor pollicis longus and brevis points occur in the fibers only and the tendons are disre garded when considering their locations. The attachments EXTENSOR POLLICIS BREVIS on the forearm are often tender and are palpated through extensor digitorum. Attachments: From the dorsal surface o f the ulna distal to abductor pollicis longus, interosseous membrane and EXTENSOR I N DICIS middle third of posterior radius to the dorsolateral base of the proximal phalanx of the thumb and sometimes to A ttachments: From the posterior distal third of the ulna and the distal phalanx interosseous membrane to the extensor digitorum ten don for the index finger Innervation: Deep radial (C7-8 or Tl) Muscle type: Phasic ( type II), weakens when stressed Innervation: Deep radial (C7-8) Function: Extends and abducts the thumb Muscle type: Phasic ( type 11), weakens when stressed Synergists: For extension: extensor pollicis longus, abductor Function: Ex tends the index finger and wrist Synergists: For extension ofindexfinger: extensor digitorum pollicis longus For abduction: abductor pollicis longus For extension of wrist: extensor carpi radialis brevis and Antagonists: To extension: flexor pollicis longus and brevis longus, extensor digitorum, extensor d igiti minimi To abduction: adductor pollicis For radial deviation: flexor carpi ulnaris Antagonists: To finger extension: flexor digitorum superfi EXT E N S O R PO L L I C I S LO N G U S cialis and profundus To wrist extension: flexor carpi radialis and ulnaris, flexor Attachments: From the middle third of the dorsal surface of digitorum superficialis and profw1dus, palmaris longus the ulna and the interosseous membrane to the base of the distal phalanx of the thumb I n d i cations for treatment I nnervation: Deep radial nerve (C7-8) • Limitation of flexion of index finger Muscle type: Phasic (type II), weakens when stressed • Pain in radial side of dorsal wrist extending to but not Function: Extends the distal phalanx of the thumb, extends i nto finger the proximal phalanx and metacarpal and adducts the first metacarpal. Platzer (2004) notes it dorsiflexes and It N MT F O R D E E P POSTE R I O R F O R EA R M radially deviates the hand Synergists: For extension: extensor pollicis brevis, abductor The bellies o f abductor pollicis longus and extensor pollicis pollicis longus brevis are palpated with short, 3-4 inch (7.5-lO cm) gliding For abduction: abductor pollicis longus strokes on the radial side of the distal forearm as the tissues Antagonists: To extension: flexor pollicis longus and brevis are pressed against the underlying bone. The diagonally To abduction: adductor POllicis oriented fibers are more easily palpated where they overlie the bone and become less distinct after they pass deep to the I n d i cations for treatment extensor digitorum. Their attachments along the ulna may be tender and are often palpable when the muscles are • Pain at the base of the thumb tested against resistance. • Loss of range or pain during flexion of the thumb • Pain with thumb movement Abductor pollicis longus and extensor pollicis brevis, as • Tenderness to direct palpa tion well as extensor pollicis longus and extensor indicis, may also be influenced with gliding strokes tha t offer increased Speci a l notes pressure through the overlying extensor digitorum. These three thumb muscles, joined by the flexor pollicis Transverse snapping palpation may be used through the longus (deep layer of anterior forearm), work with five extensor digitorum, provided it is not too tender. Since most muscles of the forearm refer their trigger point pa tterns i n tr i n s i c thu mb m u scles to provide a n amazing mobi lity which greatly exceeds that of the fingers. When this highly mobile digit interacts with the fingers, simple acts (such as
1 3 Shoulder, arm and hand 529 Box 1 3.1 8 Arthritis (Rubin 1 997) • Some researchers have identified a connection between both seronegative spondyloarthropathies and seropositive rheumatic Arthritic conditions are broadly d ivided into i nflammatory and conditions and bowel overgrowth with specific bacteria - for non-inflam matory forms, although the latter (such as osteoarthritis) exa mple, ankylosi ng spondyl itis is commonly associated with often have periods of i nflam matory activity. Klebsiella overgrowth and rheumatoid a rth ritis with Proteus (which is also commonly associated with b ladder i nfections i n Some of the major cha racteristics of i nflam matory a rthritis women) (Ebringer 1988). include: • Infectious a rt h ritis may be caused by gonococcal (or non-gono • joints are stiff i n the morn ing, usually with a g radual reduction i n coccal) bacterial i nfection and, more rarely, by viral or fu ngal stiffness during the day agents. Usua l l y only one joint is i nvolved and this will be swollen and tender. Other symptoms may i nclude fever, chills and skin • the affected joints are swollen and painful lesions. The patient is usually young and sexually active. • rest eases the pain and activity exacerbates it I nfectious arthritis is regarded as a medical emergency although • with rheumatoid arthritis, the commonest form of inflammatory fatal outcomes have declined as physicians have become more aware of the n eed for ra pid flu id drainage from the joint together arth ritis, there is usually a symmetrical d istribution (i.e. both with appropriate antibiotic thera py. hands and/or elbows and/or knees, etc.). • Juvenile rheu matoid arthritis may affect only a few joi nts and is Examination commonly reveals warmth, redness, a degree of synovia l usually chara cterized by the a bsence of rheu matoid factor and thickening, deformity, swel ling, weakness o f associated m uscles and antinuclear antibodies. Older boys who are also HLA-B27 positive loss of range of motion. (see a n kylosi ng spondylitis a bove) may progress to develop AS. All diagnosis should be based on evidence which builds a clinical • Crysta l-induced a rthritis usually occurs in middle age or later. picture and which ultimately confirms the likelihood of a condition. Commonly o n ly a single joint is affected. The cond ition is either For exa mple, laboratory tests can confirm a n arthritic cond ition but true or pseudo-gout with the diagnosis being made by micro may sometimes be related to conditions other than rheumatic ones. scopic exa m i nation of the synovia l fl uid to identify the type of crystal. • Elevated sedi mentation rate (present in a l l types of i nfla mmation and infection including i nflam matory arthritis) Non-inflammatory a rthritis • Osteoa rthritis (OA) is usually caused by a combination of joint • Positive antinuclear antibodies (a lmost always present in rheuma toid arthritis) 'wear and tear' together with an i n herited tendency (transmitted by autosomal dominant genes in women) which produces defects • Abnormal creatine phosphokinase may (or may not) confirm i n col lagen synthesis (Knowlton 1 990). polymyositis • Primary genera lized osteoarth ritis affects any (and someti mes a l l) of the joints of the extremities. • Rheumatoid factor is com monly found in asymptomatic people • Sometimes obvious overuse relating to occupational stresses over the age of 60 clearly contributes to the sites affected by OA. Leg length dis crepancy seems to contribute to the evolution of OA on the long A combi nation of features, sym ptoms and tests is therefore req u i red leg side. before a suitably qual ified and licensed i ndividual can make a • Erosive OA involves self-limiting inflammation affecting the distal diagnosis. interphala ngeal joi nts, producing erosion at the marg i ns and pos sible fusion. Radiographic evidence • Inflammatory rheumatic conditions usu a l ly show x-ray evidence Treatment Treatment of arth ritic conditions should take account of the of erosion, osteopenia, loss of joint substance. In other words, presence or otherwise of active i nfla m mation. No manual measu res there is a 'subtractive' picture - tissue has 'd imin ished'. should be utilized duri n g periods of active i nflammation apart from • Non-i nflammatory rheumatic conditions, such as osteoarthritis, gentle lymphatic dra i nage, positional release and non-stretching use tend to display an 'additive' picture, where an increase in bone of isometric contractions (e.g. Ruddy's methods, see p. 466). has taken place (osteophytes, for example). Hydrotherapy to assist in easing swelling and inflammation, as well as n utritional antiinfla mmatory strategies (see Chapter 8, p. 1 69), Inflam matory arthritis variations may be usefully i ntroduced. • Rheu matoid arthritis affects the joints of the body sym metrica l ly and predomina ntly affects women of childbea ring age. Rheumatoid factor and antinuclear antibodies will usually be found in the blood. • Seronegative spondyloarthropathies such as ankylosing spondylitis, psoriatic arthritis and Reiter's syndrome have asymmetrica l distri bution. Rheumatoid factor is not found with these conditions. They are associated with people who carry the HLA-B27 gene. toward the joints that they serve, it would be reasonable to extrinsic muscles. The intrinsic muscles of the hand are con assume that these would as well, but clear patterns have yet sidered in three groups. to be established for these muscles. 1. Thumb muscles - include thenar muscles abductor pollicis I NTRINSIC HAND M U SCLE TREATME NT brevis, opponens pollicis and flexor pollicis brevis and non-thenar adductor pollicis Fine movements of the fingers are controlled by the intrin sic muscles of the hand while gross movements of grip and 2. Hypothenar eminence - includes minimi muscles (abduc those which require power are primarily controlled by tor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi) and palmaris b revis 3. Metacarpal muscles - lumbricales and interossei (palmar and dorsal)
530 C L I N ICAL A P PLICAT I O N OF N E U R O M U SC U LA R TECH N I Q U E S : T H E U P P E R B O DY All of these muscles are served by the ulnar nerve except for The dorsal ex tensor expansion, a fibrous branching of the abductor pollicis brevis, opponens pollicis, superficial head ex tensor digitorum tendon on the posterior aspect of the of flexor pollicis brevis, and the 1st and 2nd lumbricales, proximal phalanges, plays an important role in association which are all innerva ted by the median nerve. None is nor with the intrinsic muscles. It is into this ex tension that the mally served by the radial nerve. interossei, lumbricales and abductor digiti minimi fibers merge, to act upon the fingers. This expansion forms a 'ten A don hood' that moves proximally and distally respectively as the finger is extended and flexed to assist in movement of B the finger. Fi g u re 1 3 . 1 22 ARB: The dorsal extensor expa nsion forms a 'tendon T H E NA R M U S C L ES A N D A D D U CTO R PO LLI C I S hood'. Reprod uced with permission from Gray's Anatomy (2005). The abductor pollicis brevis arises from the scaphoid tuber cle, trapezium, flexor retinaculum and the tendon of abduc tor pollicis longus to attach to the radial sesamoid bone, base of the first proximal phalanx (thumb) and the dorsal digital expansion of the thumb. It provides palmar abduc tion, which abducts the thumb at right angles to the palm. Opponens pollicls, lying deep to abductor pollicis brevis, arises from the flexor retinaculum and tubercle of the trape zium and a ttaches to the entire length of the first A5 --------------���-� � C3 A4 ---7�_ C2 --�- -+-;.-r!O: Cleland's ligament A3 --�-r7J_ C1 ---� -=-\"--+--\"--- ---:-: --- ---: -----+------------------- Grayson's tigament A2 ---l+', Long ftexor tendons ---Il\" 1st dorsal r-- interosseous �-- Adductor pollicis �--,\":= Flexor pollicis brevis Communicating branch between median and --------..t.t-'.I .\".,!kP. �ei�����li Recurrent branch of ulnar palmar digital nerves (variable) \" =:\"-: \"--- ---------- median nerve Superficial branch of ulnar nerve --- Deep branch of ulnar nerve ---;':\\ i Guyon's canal ---=� ;-:-: Flexor retinaculum Palmar cutaneous branch of ulnar nerve --------.-: =--- --+-..... Palmar cutaneous branch of median nerve --,-�;'4r1hLf ., �-- Abductor pollicis brevis Ulnar nerve --,-. I-+-r:-7\"_'�,# Median nerve Ulnar artery ---L',6r.; #:�':i'-- Radial artery Figure 1 3 . 1 23 Pa l m a r aspect of hand, su perficia l layer with palmar fascia removed. A = fi brous arc h ; C = cruciate (cross-shaped) ligaments. Reproduced with perm ission from Gray's Anatomy (2005).
1 3 Shoulder. a rm and hand 53 1 metacarpal's radial margin and its palmar surface. It pro sesamoid bone) shared with the first palmar in terosseous vides adduction, opposition and flexion of the thumb. muscle, which attaches to the base of the proximal phalanx of the thumb. It adducts and assists in opposition and flex Flexor pollicis brevis, lying medial to abductor pollicis ion of the thumb. brevis, has a superficial head arising from the flexor retinac ulum and trapezium tubercle and a deep head arising from In summary, the following muscles contribute to the the trapezoid and capitate bones. These two heads merge listed movement: together into a tendon attaching to the radial sesamoid bone and base of the first phalanx. It flexes, abducts and adducts • adduction - adductor pollicis, flexor pollicis brevis, the thumb. opponens pollicis Adductor pollicis arises from an oblique head, which • abduction - abductor pollicis brevis, flexor pollicis brevis attaches to the capi tate, bases of 2nd and 3rd metacarpals, • opposition - opponens pollicis, flexor pollicis brevis, palmar carpal ligaments and the tendon sheath of flexor carpi radialis, and a transverse head, which attaches to the adductor pollicis distal two-thirds of the 3rd metacarpal. These two tendons • reposition (return to neutral) - extrinsic thumb muscles converge into a common tendon (which contains a (extensor pollicis brevis, extensor pollicis longus, abduc tor pollicis). Area of distribution of superficial branch of ulnar nerve in hand Palmar branch of ulnar nerve from forearm --___ Medial two Palmar view lumbrical muscles ---.:;F\\�lH1fi!> I\",\\\\ c-H<-N-hF';l Adductor pOllicis Opponens digiti minimi L-'-�- Flexor pollicis brevis Abductor Opponens pollicis digiti minimi Superficial branch Deep branch (of ulnar nerve) (of ulnar nerve) --w-\\ Ulnar nerve ---H \"-- Abductor pollicis brevis ++1-+-1-+\"1 Ulnar artery Dorsal branch of ulnar nerve from forearm Dorsal view Figure 1 3. 1 24 Pa l mar aspect of hand w i th superficial m uscle layer and pa l mar fascia removed. Reprod uced with perm ission from Gray's Anatomy for Students (2005).
532 CLIN ICAL APPLICATION OF N EU RO M USCULAR TEC H N IQUES : T H E U PPER BODY r-- First lumbrical Fibrous digital nexor sheath --'1-=\\ =y--- Flexor pollicis brevis Deep transverse metacarpal ligament --=-.-:\", Abductor pollicis brevis Dorsal interosseous --\"-'+�_:F., ,oi-IJi� Adductor pollicis Palmar interosseous ---..t-' .-. \"'� ..r+------ Opponens pollicis Branch to fourth lumbrical Branch to joint Flexor digiti minimi (cut) --- Abductor digiti minimi -- Deep branch of ulnar nerve --- Flexor retinaculum (cut) --- .i: --'7-/ Tubercle of trapezium r-+-- Superficial palmar branch Superficial branch of ulnar nerve --'-cIr� f-1-: --- ------- Radial artery Guyon's canal -f------- -., ,../-, Flexor carpi radialis Ulnar artery ------+-�..,. --'J- --- --------- Flexor pollicis longus Ulnar nerve ---/+f. -;.:..J ._. _�_ +----------- Median nerve Pronator quadratus -------f-_- _�- Flexor carpi ulnaris ---t F--.; Palmaris longus Flexor digitorum profundus ----\\'\" and superficialis Figure 1 3. 1 2 5 Deep structu res of the palm and wrist. Reproduced with perm ission from Gray's Anatomy (2005). HYPOTH E NAR E M I N EN C E M ETACA R PA L M U SC L E S Palmaris brevis attaches the skin of the ulnar border of the Dorsal interossei (4) arise from two adjacent metacarpal hand to the flexor retinaculum and palmar aponeurosis. It bones to insert into the base of the proximal phalanx of the deepens the hollow of the palm by making the hypothenar adjacent (medial) finger and its tendon expansion. They flex eminence more prominent. the metacarpophalangeal joints and extend the interpha langeal joints, abduct the fingers from the mid-line of the Abductor digiti minimi arises from the pisiform, tendon hand and can rotate the digit at the metacarpophalangeal of flexor carpi ulnaris and pisohamate ligament and divides joint. into two slips, one of which attaches to the ulnar margin of the base of the 5th proximal phalanx while the other merges Palmar interossei (4) arise from the medial aspects of the into the dorsal digital expansion of the extensor digiti min 1 st, 2nd, 4th and 5th metacarpal bones and attach to the imi. It serves to abduct the little finger. extensor expansion (and possibly the base of the proximal phalanx) of the same digit. They flex the metacarpopha Flexor digiti minimi brevis lies next to abductor digiti langeal joints and extend the interphalangeal joints, adduct m inimi and arises from the hook of the hamate and the the fingers toward the mid-line of the hand and can rotate flexor retinaculum to a ttach to the ulnar margin of the base the digit at the metacarpophalangeal joint. of the 5th proximal phalanx. It flexes the metacarpopha langeal joint of the 5th digit. Lumbricales (4) arise from each of the tendons of flexor digitorum profundus and course to the radial aspect of the Opponens digiti minimi arises from the . hook of the metacarpal bone of the same finger, where each attaches to hamate and the flexor retinaculum to attach to the entire the respective extensor expansion (tendon hood). The lum ulnar margin of the 5th metacarpal. It brings the 5th digi t bricales extend the interphalangeal joint and may weakly into opposition with the thumb.
1 3 Shoulder, arm and hand 533 Opponens First dorsal interosseous Figure 1 3 . 1 2 7 The m uscles of the thenar e m i nence m ay be g rasped and com p ressed as shown or pal pated flat aga i nst underlying structu res. Heberden's \" N MT F O R PA LMAR A N D D O R SAL H A N D nodes The treatment o f the hand may be performed with the Abductor digiti patient lying supine or seated across the table from the prac minimi titioner. The surface of the table may be needed to support the hand when pressure is applied. Figure 1 3. 1 26 Heberden's nodes at the dista l phalangeal joi nts may be associated with t rigger poi nts in interossei. Drawn after With the hand supine, the thenar eminence is grasped Simons et al (1 999). between the thumb and finger of the same hand (Fig. flex the metacarpophalangeal joint. In addition, they appear 13.127). This is most easily applied if the thumb is relaxed to have a significant role in proprioception based on their and mildly, passively flexed. Each of the thenar muscles numerous muscle spindles and long fiber length (Gray's may be compressed and examined for tenderness in their Anatomy 2005). bellies, at thumb-width intervals. Flat palpation against the underlying tissue and metacarpal is also useful as well as flat compression of the tendon a ttachments. The muscles lying in the web of the thumb are most eas ily compressed with one digit on the palmar surface and the other on the dorsal surface. The compression techniques should be applied alongside the thumb as well as the index finger. The hypothenar muscles are compressed in a similar manner, using pincer compression and fla t compression. Very mildly lubricated, short gliding strokes can be applied to the hypothenar muscles as well as the entire palmar sur face of the hand. The beveled pressure bar is used to examine the interos sei muscles by wedging it between the metacarpals and angling it toward the bones (a beveled typewriter eraser may be substituted). Gentle friction is applied at tip-width intervals to each palmar and dorsal interossei muscle. The small pressure bar may also be used to scrape the palmar fascia and to apply very short, 'scraping' type strokes to each joint of the fingers (unless contraindica ted by arthritis, inflammation, infection or pain) (Fig. 13.128).
534 CLI N ICAL APPLICATI O N OF N EU RO M USCU LAR TEC H N I Q U E S : T H E U PPER BODY Myofascial spreads may be applied to the palmar surface of the hand to treat the palmar fascia. Appropriate hydrotherapies may accompany the treatment or may be given as 'homework'. Unless contraindicated (such as with inflammatory arthritis), the hands especially benefit from contrast hydrotherapy, applied by plunging the hands in alternating hot and cold baths of approximately 1 / 2-1 minute each for 8-10 repetitions. We have seen in this chap ter the tremendous mobility and associated instability of the shoulder joint, the essential movements of the elbow, and the complex arrangement of the architecture of the hand. In the next chapter, we will complete the construction of the upper half of the body with the structural and functional features of the thorax - from spinal mechanics to respiration. Figure 1 3. 1 2 8 The beveled-tip pressure bar can be wedged between the metacarpa ls to treat the interossei with static pressure or m i ld friction. Refe rences Byl N, Melnick M 1997 The neural consequences of repetition: clini cal implica tions of a learning hypothesis. Journal of Hand Altenmuller E 1988 Causes and cures of focal limb dystonia in Therapy 10(2) : 1 60-174 musicians. British Association for Performing Arts Medicine, London Byl N, Wilson F, Merzenich M et al 1996 Sensory dysfunction asso ciated with repetitive strain injuries of tendinitis and focal hand Altenmuller E 2003 Focal dystonia: advances in brain imaging and dystonia: a comparative study. Journal of Orthopaedic and understanding of fine motor control in musicians. Hand Clinics Sports Physical Therapy 23(4):234-244 19(3):523-538, xi Byl N, Nagarajan S, Newton N et al 2000 Effect of sensory discrimi Barbe M, Barr A, Gorzelany 1 et al 2003 C hronic repetitive reaching nation training of structure and function in a m usician with focal and grasping results in decreased motor performance and wide hand dystonia. PhYSical Therapy Case Reports 3:94-113 spread tissue responses in a rat model of MSD. Journal of Orthopaedic Research 2 1 ( 1 ) : 1 67-176 Cailliet R 1991 Shoulder pain. F A Davis, Philadelphia Cailliet R 1994 Hand pain and impa irment, 4th edn. F A Davis, Barden J, Balyk R, Raso V et al 2005 Atypical shoulder muscle acti vation in multidirectional instabili ty. Clinical Neurophysiology Philadelphia 1 1 6 ( 8 ) : 1 84 6 - 1 8 5 7 Cailliet R 1996 Soft tissue pain and disability, 3rd edn. F A Davis, Barlow R 1934 The sternalis muscle in American whites and P h i l a d e l p hia Negroes. Anatomical Record 6 1 :413-426 Candia V, Wienbruch C, et al 2003 Effective behavioral treatment of Barnes J 1996 Myofascial release in treatment of thoracic outlet syn focal hand dystonia in musicians alters soma tosensory cortical drome. Journal of Bodywork and Movement Therapies 1 (1 ):53-57 organization. Proceedings of the N ational Academy of Sciences USA 100(13):7942-7946 Barnes M 1997 Basic science of myofascial release. Journal of Capitani 0, Beer S 2002 Handlebar palsy - compression syndrome Bodywork and Movement Therapies 1 (4) :231-238 of the deep terminal (motor) branch of the ulnar nerve in biking. Journal of Neurology 249(10): 1441-1445 Barr A, Barbe M 2002 Pathophysiological tissue changes associated Celli L, Rovesta C, Marongiu M C et al 1998 Transplantation of with repetitive movement: a review of the evidence. Physical teres major muscle for infraspinatus muscle in irreparable Therapy 82(2) : 1 73-187 rotator cuff tears. Journal of Shoulder and Elbow Surgery 7(5) :485-490 Black K, Ongur 0, Pelmutter J 1 998 Putamen volume i n idiopa thic Chaitow L 2002 Muscle energy techniques, 2nd edn. Churchill focal dystonia. Neurology 51 (3):819-824 Livingstone, Edinburgh Chaitow L 2003 Positional release techniques, 2nd edn. C hurchill Bodor M, Montalvo E 2007 Vaccination-related shoulder dysfunc Livingstone, Edinburgh tion. Va ccine 25(4):585-587 Charness M 1993 The relationship between peripheral nerve injury and focal dystonia in musicians. American Academy of Boyle J 1999 Is the pain and dysfunction of shoulder impingement Neurology 162:21-27 lesion rea lly second rib syndrome in disgu ise? Two case reports. Charness M E, Ross M H, Shefner J M 1996 Ulnar neuropathy and Manual Therapy 4(1):44-48 dystoniC flexion of the fourth and fifth digits: clinical correlation in m usicians. Muscle and Nerve 19(4):431-437 Brattberg G 1983 Acupuncture therapy for tennis elbow. Pain Chen R, Tsai C, Lu C 1995 Reciprocal inhibition in writer's cramp. 1 6 : 285-288 Movement Disorders 10(5):556-561 B utler 0 1991 Mobilisation of the nervous system. Churchill Livingstone, Edinb u rgh Butler 0, G i fford L 1989 Ad verse mechanical tensions in the nerv ous system. Physiotherapy 75:622-629 Byl N 2006 Aberrant learning in individuals who perform repetitive skilled hand movements: focal hand dystonia. Journal of Bodywork and Movement Therapies 10(3): 227-247
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