TABLE 23.3 Grading for Manual Muscle Testing

Elbow and forearm disorders: Most common elbow disorders include medial epicondylitis, also known as golfer’s elbow, and lateral epicondylitis, also known as tennis elbow. Medial epicondylitis is often caused by a repetitive valgus stress to the elbow. The repetitive throwing and swinging motions often lead to inflammation of the common flexor tendon at the elbow. Recurrent microtrauma can affect all medial elbow structures, which include the medial epicondyle, the medial condylar epiphysis, and the medial collateral ligament (MCL) of the elbow, which cause hypertrophy of the medial epicondyle (4). Patients usually report pain and sometimes swelling in the area just distal to the epicondyle, which may radiate proximally or distally. The patient may also provide a history of having difficulties with some wrist/hand movements like gripping a doorknob or carrying a shopping bag. On physical examination, the patient will illustrate tenderness distal to the medial epicondyle, reproducible with resisted wrist flexion. Sensation and deep tendon reflexes are usually normal except that ulnar neuropathy symptoms may occur in up to 20% of patients found to have a medial epicondylitis.

Lateral epicondylitis (aka tennis elbow) can occur insidiously from many different physical maneuvers, but is often attributed to poor technique during backhand swings or inappropriate grip strength or string tension, while playing racquet sports. These motions will cause microtearing of the extensor carpi radialis brevis. Patients will present with pain and weakness in grip strength and tenderness distal to the lateral epicondyle at the extensor muscle origin. Two tests that can be used to assess for lateral epicondylitis are Cozen test and the middle finger test. Cozen test is positive when resisted wrist extension triggers pain to the lateral aspect of the elbow, owing to stress placed upon the tendon of the extensor carpi radialis brevis tendon, with the elbow in extension. The middle finger test is positive for lateral epicondylitis when the proximal interphalangeal joint of the long finger is resisted in extension and pain is felt over the lateral epicondyle. The differential diagnosis for a patient with a suspected epicondylitis should include osteoarthritis, osteochondral loose body, triceps tendonitis, elbow synovitis, posterior interosseous nerve syndrome, median or ulnar neuropathy about the elbow, acute calcification about the lateral epicondyle, anconeus compartment syndrome, degenerative arthrosis, lateral ligament instability, bursitis, bone infection or tumor, radial head fracture, or collateral ligament tears.

Wrist and hand disorders: De Quervain tenosynovitis, a common disorder of the wrist/hand, most commonly occurs due to overexertion related to either household chores, one’s occupation, or recreational activities causing a stenosing tenosynovitis of the synovial sheath of the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) in the first compartment of the wrist due to repetitive use. Patients will often report pain at the dorsolateral aspect of the wrist with referred pain toward the thumb and/or lateral forearm. Physical examination will reveal pain and tenderness on the radial side of the wrist associated with recurrent movements. Edema and crepitus may also be present. Physical examination should also include the Finkelstein test, which is positive when pain is elicited in the radial wrist while the wrist is forced into ulnar deviation with the thumb enclosed in a fist. Sensation and deep tendon reflexes will be normal. Symptoms of numbness should alert the clinician to consider an alternative diagnosis with a neurologic cause (i.e., carpal tunnel syndrome, cervical radiculopathy). In some cases, de Quervain disease is associated with rheumatoid arthritis, and thus a full examination of the hand should be performed bilaterally to evaluate for any swelling, malalignment, or deformities of any of the joints.

The differential diagnoses for de Quervain tenosynovitis are carpal joint arthritis, rheumatoid arthritis, radial nerve injury, cervical radiculopathy, carpal tunnel syndrome, Kienbock disease, triscaphoid arthritis, intersection syndrome, ganglion cyst, scaphoid fracture, and radioscaphoid arthritis.

The ailments discussed above are only a small list of the injuries that can occur to the upper extremity. Disorders of the shoulder, elbow, wrist, and hand can greatly impact a patient’s activities of daily living (ADLs) and therefore are extremely important to diagnose and treat correctly in a timely manner, allowing the patient to return to his or her previous functional status.

Treatment of the above mentioned injuries should be individualized and take into account factors such as acuity and severity of the injury, first time occurrence vs. reoccurrence, complications associated with the injury, comorbid conditions that can have adverse impact on treatment plan, and age of the patient. Sample rehabilitation programs often consist of interventions such as modalities, strengthening and flexibility exercises, education on body mechanics with activities, and a home exercise program. Factors such as precautions while exercising, types of exercise equipment to be used, and rate of progression should also be considered.

MEDICAL KNOWLEDGE

GOALS

Demonstrate knowledge of established evidence-based evolving biomedical, clinical epidemiological, and sociobehavioral sciences pertaining to UEMI, as well as the application of this knowledge to guide holistic patient care.

Knowledge of anatomy and pathophysiology is the first step in developing a treatment plan for a patient with an upper extremity musculoskeletal disorder. This section focuses on the anatomy and pathophysiology of each disorder, the diagnostic testing used, and the available treatment options.

Shoulder disorders: RTC tears can either be traumatic or degenerative. Traumatic RTC tears are a common injury seen in the upper extremity in the younger population of athletes and laborers, whereas degenerative tears occur in older individuals. In a recent study by Mall et al., nine studies of traumatic RTC tears were analyzed, showing that the most common mechanism of injury was falling onto an outstretched arm, causing the supraspinatus muscle to be involved in 84% of tears, the infraspinatus torn in 39% of cases, and the subscapularis in 78% of injuries. Tear size was less than 3 cm in 22%, 3 to 5 cm in 36%, and greater than 5 cm in 42% of cases (5).

RTC tears can also occur in association with other shoulder injuries, such as a broken clavicle or dislocated shoulder. Chronic tears are indicative of extended use in conjunction with other factors such as poor biomechanics or muscular imbalance. Ultimately, most are the result of wear and tear that occurs slowly over time as a natural part of the aging process. They are more common in the dominant arm; however, a tear in one shoulder should raise suspicion for an increased risk of a tear in the opposing shoulder. Several factors contribute to degenerative or chronic RTC tears, of which repetitive stress is the most significant factor.

There are three types of tears that can occur to the RTC. A full-thickness tear can be massive and cause immediate functional impairments. A partial-thickness tear can be broken down into a tear on the superior surface into the subacromial space or inferior surface on the articular side. All these tears can be traumatic or degenerative (6).

As previously mentioned, history and physical examination are the most important elements in making any diagnosis; this includes diagnosing a RTC tear. There is no indication for any laboratory studies. Imaging studies can be helpful in confirming the diagnosis and eliminating other possibilities. MRI of the shoulder is the gold standard. A CT scan is a good study to see osseous structures but is not as effective in revealing soft-tissue injuries like a RTC tear. The initial imaging test usually performed is an x-ray to rule out any bony abnormalities. One might see a suggestion of a tear if there is upward migration of the humeral head or sclerotic changes at the greater tuberosity seen on x-ray. Over the past few years ultrasound is being used more frequently, as it is more cost effective and less invasive and has been proven comparable to MRI in efficacy in the diagnosis of supraspinatus tendon tears. It should be noted that a normal MRI cannot fully rule out a small tear (a false negative) and partial-thickness tears are also not as reliably detected (7).

Treatment of RTC disorders varies, and is dependent on its acute vs. chronic nature, the age and activity level of the patient, and how debilitating the tear is to the patient. Physical therapy is the mainstay of treatment and is successful in most patients. The basic phases of rehabilitation include (a) pain control and reduction of inflammation, (b) restoration of normal shoulder motion, (c) improved strength, (d) improved proprioception, and (e) return to task or sport-specific activities. Pain control and reduction of inflammation may be obtained by a combination of relative rest, icing, electrical stimulation, and acetaminophen or a nonsteroidal antiinflammatory medication. Subacromial injections of corticosteroid can also be therapeutic. If a patient’s condition has not improved in 3 months then a surgical consultation should be considered. There is no evidence of better results from early rather than delayed surgery, and many with partial tears and some with complete tears will respond to nonoperative management. For this reason, many first recommend nonsurgical management of RTC tears. Early surgical treatment may be considered in acute tears that are significant (greater than 1 cm–1.5 cm) or in young patients with full-thickness tears who have a significant risk for the development of irreparable RTC changes (8).

Elbow and forearm disorders: Medial and lateral epicondylitis are the most common disorders of the elbow, with lateral epicondylitis accounting for the majority of cases. Medial epicondylitis, which accounts for 10% to 20% of epicondylitis in the elbow, is usually found in the dominant elbow of a golfer or pitcher due to the valgus stresses that are placed on the elbow by activities such as swinging the golf club or throwing a ball. The phase of throwing in which most stress is often placed on the medial elbow is during the late cocking and acceleration phases of a pitch. Medial epicondylitis in many cases is due to training errors (i.e., not warming up adequately), improper technique, or poor equipment. The muscles affected are of the flexor muscle group.

Lateral epicondylitis, on the other hand, also known as tennis elbow, is a term that can be misleading as most people who have it didn’t get it from playing tennis. The mechanism of action for this type of injury is mostly due to overuse and poor mechanics that lead to an overload of the extensor and supinator tendons. Poor technique with racquet sports including improper backhand, inappropriate string tension, and inappropriate grip size are just some examples of how an athlete, especially an amateur athlete, can sustain this injury. The muscles mainly affected in a case of lateral epicondylitis are the extensor carpi radialis brevis, extensor carpi radialis longus, and the extensor digitorum communis.

The workup for diagnosing epicondylitis is often based on history and physical examination where laboratory studies are often of no value and imaging is rarely used. Plain radiographs of the elbow may show calcifications adjacent to the medial epicondyle in 20% to 30% of patients with medial epicondylitis but it has been shown that imaging is unnecessary in the workup of this condition (9). MRI is rarely used and only useful to rule out other causes of elbow pain like partial tendon tears, ligament injury, or in cases of recalcitrant epicondylitis.

Wrist and hand disorders: De Quervain tenosynovitis is defined as a stenosing tenosynovitis of the synovial sheath of tendons of the EPB and APL in the first dorsal compartment of the wrist due to repetitive use. Inflammation at this site is commonly seen in patients from cumulative microtrauma. Inflammation can also occur after a single episode of acute trauma to the site. Although this condition is seen in both males and females, it commonly has a predilection for females, especially during pregnancy and the postpartum period. No testing is available for de Quervain disease, other than serology testing for rheumatoid arthritis if clinical suspicion prevails. No imaging studies are needed and physical examination is often sufficient to make the diagnosis. However, in a setting of acute trauma, a radiograph can be performed, which may show a suggestion of fracture or osteonecrosis.

Initial treatment can start with rest, ice, splinting, and nonsteroidal anti-inflammatory medication, although there are some studies that show these treatments are ineffective (11). A rehabilitation therapy program can be implemented to reduce pain and improve function. In the acute phase, the therapist can use cryotherapy at the radial styloid to reduce inflammation and edema, followed by topical steroids that can be delivered into the subcutaneous tissue by phonophoresis and iontophoresis (12). The goals of therapy are to strengthen and regain ROM at the thumb, hand, and wrist. A thumb spica splint can be utilized to manage symptoms as it inhibits gliding of the tendon through the abnormal canal. Injection of anesthetic in combination with corticosteroid is currently the most frequently used treatment modality with an 83% cure rate (13). Surgery is considered a last resort reserved for those who fail injection therapy. Surgery involves incision of the skin, slitting or removal of a strip of the tendon sheath, closure of the skin, and application of a compression bandage that is removed in a week. The patient returns to normal activities after 2 to 3 weeks. On average, surgical success rates range from 83% to 92% (14).

In summary, for most upper extremity injuries a thorough history and physical examination are usually sufficient in obtaining the correct diagnosis. Laboratory studies and imaging should only be performed to accurately document the diagnosis and rule out other more serious conditions like tumors or rheumatologic disease. Radiologic examinations should start with an x-ray, and will range from CT, MRI, or ultrasound varying on the location and severity of the injury. Furthermore, blood work may be appropriate, such as uric acid levels, ESR, CRP, and rheumatoid factors, but only in cases where there is a high suspicion of underlying disease.