Cubital tunnel syndrome (CTS)
GREEN |
• Intro: |
- Entrapment neuropathy caused by compression the median nerve in the carpal tunnel |
• Aetiology (risk factors): |
- Typically in 40 - 60 yrs
- 1-5% in general population
- F>M (3:1)
- Risk factors: carpal tunnel modifications, fluid imbalance, neuropathic factors
- Examples: carpal dislocation/subluxation, radius #, arthritis, cysts/tumours, pregnancy/menopause, obesity/kidney failure/hypothyroidism, oral contraceptives/heart failure/diabetes/alcoholism, vitamin deficiency/toxicity |
• Pathophysiology: |
- Caused by various factors
- Involves compression & traction affecting the median n.
- Compression leads to increased pressure, obstruction of venous outflow, localised edema, & impaired microcirculation of the median n.
- Lesions on the myelin sheath & axon cause inflammation & loss of normal physiological functions of surrounding tissues
- Worsening structural integrity of the nerve exacerbates the dysfunctional environment
- Repeated traction & wrist movements further injure the nerve
- Inflammation of any of the 9 flexor tendons passing through the carpal tunnel can compress the median nerve
- Sensory fibres are often affected before motor fibres, & autonomic nerve fibres may also be affected |
• Clinical presentation: |
- Numbness, tingling, & px in the thumb, 2nd, & radial portions of the 4th digits
- Ssx worsen at night
- Variability in Ssx distribution from wrist to shoulder
- Initially intermittent, worsen w/ activities like driving, reading, painting
- Nighttime exacerbation, relieved by shacking hand/wrist
- Leads to permanent sensory loss, muscle weakness, & clumsiness
- Challenges in tasks like opening doorknobs & buttoning clothes
- Dominant hand usually affected first |
• Physical examination: |
- Sensory loss or weakness in median n. distribution
- Thenar eminence spared in sensory loss
- Diminished thumb ABD & opposition strength, thenar eminence atrophy
- Tinel's sign
- Carpal tunnel compression test
- Phalen's test
- Median n. tension test
- Motor & sensory testing |
• Management: |
- 70-90% of mild to moderate cases respond to conservative care
- Some degree of recurrence, even after surgery
- Pts w/ CTS 2° to diabetes or wrist # have less favourable prognosis
- SMT / STW
- Nerve release
- Support brace at night
- Taping |
• Ddx: |
- Brachial plexopathy
- Cx myofascial px
- Cx spondylosis
- Compartment syndrome
- Ischemic stroke
- Mononeuritis multiplex
- Multiple sclerosis
- Median neuropathy in the forearm
- Motor neuron disease
- Diabetic neuropathy
- Cx radiculopathy
- Overuse injury
- Traumatic brachial plexopathy
- Neuropathies
- Tendonitis
- Tenosynovitis
- TOS |
Extensor tendinopathy*
GREEN |
• Intro: |
- Also known as tennis elbow & lateral epicondylitis
- Overuse injury
- Occurs due to eccentric overload of the extensor carpi radialis brevis (ECRB) tendon
- Results from repetitive strain during activities involving gripping, wrist EXT, radial deviation, & forearm supination
- Common in tennis, squash, & badminton |
• Aetiology (risk factors): |
- Most common cause of elbow Ssx
- F=M
- More common in pts >40 yrs
- Risk factors: smoking, obesity, repetitive movement for at least 2 h daily, & vigorous activity (loads >20kg) |
• Pathophysiology: |
- Condition: degenerative overuse process
- involves: extensor carpi radialis brevis & common extensor tendon
- Findings: granulation tissue, micro-rupture, abundance of fibroblasts, vascular hyperplasia, instructed collagen, lack of inflammatory cells |
• Clinical presentation: |
- Px w/ an insidious onset
- Overuse Hx is common, often w/o a specific traumatic event
- Px occurs 1-3 days after unaccustomed activities involving repeated wrist EXT
- Triggers: new equipment use or atypical workout circumstances
- Acute injuries or strains (e.g. lifting heavy objects, hard backhand swing)
- Acute injuries may lead to chronic overuse injury
- Px is usually located over the lateral elbow
- Worsens w/ activity, improves w/ rest
- Px severity varies, from mild discomfort during activities to severe px triggered by simple tasks (e.g. picking up coffee) |
• Physical examination: |
- Point of max. tenderness usually over lateral epicondyle or slightly distal
- Discomfort may extend along the tendon, w/ tightness in connecting muscle
- Px exacerbated by resisted wrist EXT, especially w/ EXT elbow & pronated forearm
- Resisted middle finger EXT w/ EXT elbow particularly painful, indicating increased tendon stress
- Absence of radicular Ssx or numbness/tingling
- Suggests alternative process such as radial n. entrapment if present, though conditions can coexist |
• Management: |
- Spontaneous recovery within 1-2 yrs in 80-90%
- RICE
- NSAIDs
- Bracing
- Forearm stretching & strengthening
- Progression to eccentric muscle strengthening of the common extensor tendon
- Invasive techniques if conservative care fails
- Surgery (if no improvement after 6-12 months) |
• Ddx: |
- Elbow bursitis
- Cx radiculopathy
- Posterolateral elbow plica
- PLRI
- Radial n. entrapment
- Radial n. syndrome
- Occult fracture
- Capitellar osteochondritis dissecans
- Triceps tendinitis
- Radiocapitellar OA
- Shingles |
Flexor tendinopathy
GREEN |
• Intro: |
- Also known as medial epicondylitis, pronator tendinopathy, & golfer's elbow
- Overload or overuse of the medial common flexor tendon
- Medial epicondyle is a common origin: pronator teres, flexor carpi radialis, palmar is longus, flexor digitorum superficialis, & flexor carpi ulnaris
- Innervated by median n.
- Together, they form the conjoined FX tendon (3cm long)
- This tendon crosses the medial ulnohumeral joint & acts as a 2° stabiliser parallel to the ulnar collateral ligament |
• Aetiology (risk factors): |
- 90% of cases are not sports related
- F>M
- 45-64 yrs
- Athlete risk factors: training errors, improper technique, equipment, lack of strength, endurance, flexibility
- Occupation risk factors: heavy physical work, excessive repetition, high BMI, smoking, comorbidities, high psychosocial work demands
- General risk factors: smoking, overuse, dominant arm, DM 2 |
• Pathophysiology: |
- Caused by overuse tendinopathy from repetitive loading of wrist flexors & pronator teres
- Leads to angiofibroblastic changes in the affected tendons
- Repetitive activity causes microtears in the tendon, resulting in tendonosis
- All muscles may be affected equally, except for palmaris longus
- Bony inflammation is not involved in this condition
- Microtears lead to collagen fibre remodelling & increased mucoid ground substance
- Focal necrosis or calcification can develop in the tendon
- Collagen strength decreases over time, leading to increased fragility & scar tissue formation
- Acute trauma can also cause medial epicondylitis from sudden violent muscle contractions, though less common |
• Clinical presentation: |
- Hx of acute traumatic blow or repetitive elbow use, gripping, or valgus stress
- Aching px on the medial or ulnar side of the elbow, which radiates from the epicondyle into the forearm & wrist
- Exacerbated: forearm motion, gripping, or throwing activities (overhead throwing, tennis, golf)
- Relief: rest
- Elbow stiffness, weakness, numbness, or tingling, 1° in an ulnar n. distribution
- Chronic cases may exhibit weakness w/ grip strength
- Ulnar n. Ssx in up to 20% |
• Physical examination: |
- Acute cases: swelling, erythema, or warmth
- Chronic cases: less likely to show abnormalities
- Tenderness: 5-10mm distal & anterior to medial epicondyle
- Pronator teres & flexor carpi radialis involvement
- Px elicited by resisted pronation or FX of wrist
- Weakness in affected arm
- ROM typically normal
- Golfer's elbow test: px during manoeuvre
- Tinel's test: +ve for ulnar neuropathy
- Valgus stress test: stressing ulnar collateral ligament (especially throwing athletes) |
• Management: |
- Good prognosis
- RICE
- NSAIDs
- Conservative care: aims for full, painless motion at wrist & elbow
- Strength exercises w/ focus on eccentric activity
- Dry needling, shock wave therapy, etc.
- STW/SMT
- Night splinting
- Elbow taping
- Corticosteroid injections, US, platelet-rich plasma injections
- Surgery |
• Ddx: |
- Neuropathy: C6 or C7 radiculogpthy, CTS, ulnar/median neuropathy, ulnar neuritis, anterior interosseous n. entrapment, tardy ulnar n. palsy
- Ligamentous injury: ulnar / medial collateral ligament instability, sprain, tear
- Intra-articular issues: adhesive capsulitis, arthrofibrosis, loose bodies
- Osseous concerns: medial epicondyle avulsion fracture, osteophytes
- Myofascial difficulties: flexor / pronator strain
- Tendinopathy: lateral epicondylitis, triceps tendonitis
- Synovitis
- Valgus extension overload
- Herpes zoster (dermatological) |
Myositis ossificans (MO)
YELLOW |
• Intro: |
- Benign, self-limiting ossifying lesion that can affect any type of soft tissue
- Most common form of heterotrophic ossification (HO), usually within large muscles |
• Aetiology (risk factors): |
- M>F
- 1° in young adults as result of trauma |
• Pathophysiology: |
- Metaplasia of the intramuscular connective tissue resulting ion extra osseous bone formation (w/o inflammation)
- Histologically can appear similar to osteosarcoma, thus, can lead to inappropriate management |
• Staging: |
3 stages:
Stage 1 (0-4 weeks):
- Following injury
- Inflammatory cascade that preceded ossification
- Calcification not apparent radiographically
Stage 2 (4-8 weeks):
- Calcification becomes radiographically seen
Stage 3:
- Peripheral bone formation
- Lamellar cortical & trabecular bone |
• Clinical presentation: |
- Onset followed by trauma, repetitive trauma
- Px, joint stiffness, oedema
- Lesion causes mechanical irritation of bursa, tendon, joint |
• Physical examination: |
- Px durance longer than of a sprain/strain
- Decreased ROM |
• Management: |
- Up to 70% of cases are asymptomatic
- Prognosis good after surgery
- Very little than can be done to accelerate the resorptive process (i.e. process of removing bone from the bruised region)
- Rest from aggravating activities
- Implementation of gentle px-free ROM exercises
- Surgical resection of mature bone once it has fully matured
- Can take 12-18 months after initial presentation
- Surgery only if there will be improvement in function as demonstrated by mobility, transfers, hygiene, & ADLs |
• Ddx: |
- Osteosarcoma |
Olecranon bursitis / Miner's elbow
YELLOW |
• Intro: |
- Inflammation of the synovial bursa
- Susceptible to trauma & infection due to superficial location, limited vascularity |
• Aetiology (risk factors): |
- M>F
- 30-60 yrs
- Underlying inflammatory conditions: RA, psoriatic arthritis, gout, etc
- Chronic medical conditions: diabetes, alcoholism, HIV
- Infection usually occurs through a transcutaneous route due to poor vascularity, often from direct inoculation via mild trauma |
• Pathophysiology: |
- Inciting events (trauma or infectious), trigger reactive inflammation in the bursa
- Leads to the extravasation of protein & synovial type fluid into the affected bursa
- Consequence is the development of a pronounced round swelling characteristic of this condition
- Trauma causes bleeding within bursa & release of inflammatory mediators, increasing recurrence risk |
• Clinical presentation: |
- Swelling over the olecranon process
- Initially, doesn't restrict elbow movement, setting it apart from swelling within the joint
- Swelling can progress & eventually limit elbow movement
- Characteristic appearance is round or "golf ball" shaped due to fluid confinement within the bursa |
• Physical examination: |
- Caused by infection shows signs of erythema & tenderness
- Systemic Ssx like fever & malaise can accompany infectious bursitis
- Fever is present in around 70% of septic bursitis cases, but its absence doesn't rule out infection entirely |
• Management: |
- Low risk of progression to systemic infection from infectious bursitis in healthy pt
Non-infective:
- Self-limiting & managed conservatively
- RICE
- NSAIDs
- Elastic bandage application
- Corticosteroid injections (risk of iatrogenic infection)
- Bursectomy considered for related episodes, especially w/ underlying bone spur
- Recurrent non-infective bursitis w/o a spur may benefit from surgical bursa excision
Infective:
- Requires antibiotics
- Aspiration & drainage are recommended
- Oral antibiotics for 7 days (longer courses don't reduce recurrence)
- Bursectomy may be necessary
- Systemic infection warrants further evaluation & appropriate treatment for sepsis or septic shock |
• Ddx: |
- Cutaneous abscess
- Hematoma
- Olecranon fracture
- Cellulitis
- Tendon rupture
- Septic arthritis
- Gouty arthritis
- Neoplasm
- Ligament rupture |
Posterior interosseous nerve entrapment
GREEN |
• Intro: |
- Compression neuropathy of the posterior interosseous n. (branch of radial n.)
- Passes through radial tunnel (Arcade of Frohse)
- Results in paresis & paralysis of the finger & thumb EXT
- Preserves wrist EXT due to innervation patterns |
• Aetiology (risk factors): |
- M>F (2:1)
- Dominant arm
- Trauma or space-occupying lesions (RA, brachial neuritis, spontaneous compression)
- Most common site: Arcade of Frohse (proximal edge of supinator)
- Also repetitive pronation/supination |
• Pathophysiology: |
- Nerve injury severity varies based on compression severity
3 categories of nerve injury:
- Neuropraxia: mildest form, demyelination, from compression/traction, slows conduction, may cause muscle weakness, -ve Tinel sign, recovery prognosis: days to 12 weeks
- Axonotmesis: demyelination & axon damage, muscle weakness, may have +ve Tinel sign
- Neurotmesis: severe, nerve completely transected, no nerve conduction, surgical correction needed for recovery |
• Clinical presentation: |
- Hx of trauma or fracture of the extremity
- Can be present in Monteggia fractures or radial head fracture-dislocations |
• Physical examination: |
- Weakness w/ finger EXT
- When asked to make a fist, wrist may deviate radially due to extensor carpi ulna's weakness
- Depending on injury severity, may be +ve Tinel sign |
• Management: |
- Pretty good prognosis
- Pts continue to improve months after surgery
- Athletes may return to play once full ROM & strength
Conservative:
- Splinting
- NSAIDs
- Physical therapy
- Activity modification
Surgical:
- Unsuccessful conservative therapy for at least 3 months |
• Ddx: |
- Radial tunnel syndrome: same sites of compression, however presents w/ forearm px w/o motor weakness
- Wartenberg syndrome: compression of superficial sensory radial n., no motor weakness, may present w/ paresthesia / numbness / ill-defined px over the dorsal radial aspect of hand |
Pronator teres syndrome (PTS)
GREEN |
• Intro: |
- Compression of the median n. by the pronator teres muscle in the forearm
- Innervation: C6-7
- |
• Aetiology (risk factors): |
- Rare & often overlooked & mistaken for CTS
- M>F
- Especially common in pts w/ additional fibrous bands
- PTS can occur due to: local trauma, compression w/ Schwanoma (rare tumour), & pts undergoing anticoagulation therapy & renal dialysis |
• Pathophysiology: |
Quick & repetitive grasping or pronation movements can lead to PT muscle hypertrophy & entrapment of the median n. |
• Clinical presentation: |
- Px in volar forearm region
- Weakness may be significant
- Muscle wasting rare, but mild weakness in: flexor pollicis longus (FPL), abductor pollicis brevis (APB), some involvement of flexor digitorum profundus (FDP) in 2nd & 3rd digits
- PT commonly spared due to early innervation |
• Physical examination: |
- Reproduction: resisted pronation + FX of elbow
- +ve Tinel sign over proximal edge of PT
- +ve Phalen test over PT muscle in 50%
Variable sensory loss:
- Involving palm or mimicking CTS
- Including thenar eminence, thumb, index, middle, & ring fingers |
• Management: |
- Good prognosis
- Light duty in 3-6 weeks (conservative care speeds up)
- Surgical cases: light duty in 6-8 weeks, regular duty in 10-12 weeks
- Rest, activity modification, NSAIDs, physical therapy
- Pts may usually continue work unless prominent motor or sensory deficits are present
- Surgery considered after fail of >6 weeks of conservative care |
• Ddx: |
- CTS
- AIN s.
- Ligament entrapments
- MN entrapment of hypertrophied lacertus fibrosis (bicipital aponeurosis)
- Brachial plexus injury
- Cx radiculopathy |
Pulled elbow
RED |
• Intro: |
- Also Nursemaid elbow or radial head subluxation
- Common injury in young children
- Radial head subluxation caused by axial traction resulting in px & inability to supinate forearm |
• Aetiology (risk factors): |
- 1-4 yrs
- 20% of upper extremity injuries in children
- Less common in >5 yrs because annular ligament strengthens w/ age
- F>M
- Recurrence rate: 20% |
• Pathophysiology: |
- Trauma: axial traction on pronated forearm + elbow EXT
- Lifted/swung by arms or pulling child's arm to prevent fall
- Displacement of the annular ligament leads to discomfort & px during arm movement
- Longitudinal traction (e.g. baby rolling onto their arm) can also lead to radial head subluxation (<6 months old) |
• Clinical presentation: |
Child's behaviour:
- Often nervous & may support affected arm protectively w/ opposite hand
- Arm held in complete or almost complete EXT + pronation
- Refusal to move the arm & becoming upset during examination
- Generally no px unless the arm is manipulated
Caregivers may report:
- Arm pulled upwards by the wrist or swung around by the arms prior to Ssx onset
- No known trauma or awareness of the incident causing the injury
- Onset of Ssx after FOOSH (less common) |
• Physical examination: |
- Tenderness at radial head
- Resistance to forearm pronation, supination, FX, & EXT
- Absence of ecchymosis, erythema, edema, or signs of trauma
- Intact circulation, sensation, & motor ability distal to the elbow
- Possible lack of cooperation w/ the exam
- Spontaneous reduction: radial head may spontaneously reduce before exam, reassurance to parents after exam is usually sufficient |
• Management: |
Closed reduction (brief but potentially painful):
- Px resolves post-reduction (within minutes)
- Techniques for reduction: hyperpronation (preferred) & supination/FX
- Arm function should be regained post-reduction; imaging if not
- Referral to orthopaedic surgeon if arm not used post-reduction
- No splinting or sling required
Post-treatment instructions:
- Avoid activities causing axial traction to arm to prevent recurrence
- Excellent prognosis post-reduction |
• Ddx: |
- Elbow fracture
- Fractured wrist
- Green stick fracture
- Hand injury
- Monteggia fracture
- Sypracondylar fracture
- Soft tissue damage of hand |
Medial collateral ligament sprain*
• Intro: |
- Stretching or tearing of ligaments, due to abnormal or excessive forces applied to a joint
- Classified in 3 grades |
Grade 1: |
- Mild stretching of the ligament complex w/o joint instability |
Grade 2: |
- Partial rupture of the ligament complex w/o joint instability |
Grade 3: |
- Complete rupture of the ligament complex w/ instability of the joint |
Causes of MCL injury: |
- Overstretched in a single incident, e.g. unnatural bending or twisting of elbow
- Repetitive ligament stretching, e.g. overhead throwing activities |
Outcome of MCL injury: |
- Increased valgus stress |
Prognosis: |
- Grade 1-2: 2-6 weeks & high-end sports in 8 weeks
- Grade 3 ruptures: significantly longer rehabilitation depending on whether surgical intervention was required & how much damage is present |
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