OMT for the Upper Extremity: Elbow, Forearm and Wrist

Carlton A Richie III, D.O.

Midwestern University

Clinical Associate Professor of OMM

Nathan Nakken, D.O.

Midwestern University

Clinical Assistant Professor of OMM

1

Learning Objectives• Review the anatomy and motions of the upper extremity with emphasis on the elbow, forearm & wrist

• Understand the common somatic dysfunctions of the elbow, forearm and wrist including radial head and carrying angle

• Describe common orthopedic problems of the elbow, forearm, and wrist as well as their mechanism of dysfunction, and treatment options including OMT

• Have an enhanced palpatory sense of the structures

• Diagnose and treat dysfunction in pronation & supination of the elbow joint with muscle energy and counterstrain

• Know provocative test for lateral epicondylitis

• Know how to treat forearm dysfunction with muscle energy

• Know how to diagnose and treat carpal tunnel syndrome using OMT

2

Speaker Disclosures

• We have no disclosures

3

Special Thanks!

4

Shannon Scott, DO FACOFP

Sean Reeder, DO, Associate

Dean

Rich Dobrusin, DO

Lab Outline:

Lab Outline

• Motion Testing

• Sensory Testing

• Provocative Tests

• Muscle Energy of the forearm

• HVLA of the radial head• Counterstrain of the medial/lateral epicondyle

• Flexor Retinaculum Stretch

• Opponens Roll

• Self Stretches

5

Upper Extremity Lecture Outline

Elbow6

Ulnohumeral joint | Elbow1

• This is “the elbow”

• Hinge joint

• Capsule Strong Medially-Laterally Weak A/P

Strengthened by muscle tendons that cross over the elbow

• Ulnar collateral ligament “Primary elbow stabilizer” Injured in repetitive overhead

throwing (i.e. pitching)

7

Radial

collateral lig.

Ulnar

collateral

lig

Joint capsule

Radioulnar joint | Elbow, forearm, wrist1

• Proximal joint

Allows pivoting action

Pronation/supination

A/P glide of the radial head

Flexion – radial head glides Anteriorly

SD

8

Functional Anatomy |Annular Ligament

• Encircles the radial head

• Strong fibers

Continuous with:

Radial collateral ligament

Joint capsule

9

Annular ligament

Olecranon bursa

Olecranon bursitis21

• Basics Inflammation of a bursa

• Tx OMT (structural findings, SCS,

lymphatic tx)

Modify activity (stop leaning on elbow)

Rest

Ice

NSAIDs

Corticosteroid injections (if failed conservative tx)

Bursal excision (last resort) 10

Nursemaid’s ElbowRadial head subluxation

• Basics:

Subluxation of the radial head

Caused by traction

Annular lig. Slides over the radial head

• S/S:

Usu. hold arm against body, pronated, elbow slightly flexed

11Uptodate, Nursemaid Elbow

Treatment for Nurse Maid’s Elbow

• OMT to reduce: Moderate pressure over the radial head

Hyperpronate the wrist

“May repeat up to 2 times (ensure no signs of fx)

This method is more successful than supination method

Alternate: Place thumb over radial head

Supinate

Then flex the affected elbow (quickly)

Lab today Will learn SCS for radial head – good to reduced pain

and swelling after your reduce the subluxed radial head

Tx early to avoid possible fibrosis 12

Anatomy | Muscles13

Elbow Flexors1

• Primary flexor

Brachialis

• Secondary flexor

Biceps

• Innervation

Musculocutaneous n.

14

Brachialis

Biceps

Elbow Extensors1

• Primary Triceps

• Secondary Anconeus

• Innervation Radial n.

15

Triceps

Anconeus

Wrist Extensors1

• Primary

Extensor carpi radialis longus/brevis

Extensor carpi ulnaris

• Innervation

Radial n.

16By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See

"Book" section below)Bartleby.com: Gray's Anatomy, Plate 418, Public Domain,

https://commons.wikimedia.org/w/index.php?curid=527307

Lateral Epicondylitis

• Pain in the upper forearm and elbow

• Ages 30-60s, peak in 40s

• Overuse injury of the forearm muscles in: extension of wrist

supination

• Risk factors: Screwdriver (carpenters, supinator attaches to lateral

epicondyle)

Painting (painters) Plumbers

Racquet sports (poor technique) Direct blow to the lateral elbow

• Symptoms Lifting palm down hurts (forearm extensors)

Patients complain they can’t open doors or start their car without pain.

17

Lateral Epicondylitis• Diagnosis

Have pt grab the back of a chair and try to lift it→ pain at the elbow.

Applying pressure one finger breath below the lateral epicondyle in the Losee position (pt’s elbow flexed to 90 deg then placed across abdomen with palm facing up) will reproduce pain.

18

Elbow

Lateral Epicondylitis Physical Exam

Physical Exam:

• Lifting, especially with the palm

facing down increases the pain;

• Holding lightweight object such as

a cup may be difficult

• Swelling may be present but

minimal (Remember your

palpation of the joint capsule-it is

only palpable if abnormal!)

• Then perform a provocative

test…see figures

Elbow

Lateral Epicondylitis Provocative Test:

• Indication: suspected lateral

epicondylitis (tennis elbow)

• Contraindication: can’t follow

command/ fracture

• Description: with affected elbow

at 180 degrees and shoulder forward

elevated to 90 degrees and wrist at 0

degrees extend the 3rd finger

against operators index finger that

is applying a downward force. A

positive (+) test is one that

reproduces pain in the affected

lateral epicondyle

Elbow

Lateral Epicondylitis Differential Diagnoses (Ddx)

1. Fracture of the radial head

2. Osteoarthritis

3. Osteochondral loose body,

4. Radial nerve irritation in the

upper forearm (fascia, fascia,

fascia!)

5. Elbow synovitis

6. Calcification of the extensor

muscle at the attachment to

the lateral epicondyle

7. Triceps tendonitis.

Treatment of Lateral Epicondylitis

• OMT

• Activity modification Rest

More flexible racquet

Lower string tension

Larger grip

Home exercise—stretch!

• Ice, NSAIDs, PT

• Tennis elbow brace w/activities until pain free

• Steroid oral/injections22

https://www.braceability.com/pro

duCarpal Tunnel

Syndrome/counterforce-tennis-

elbow-brace

Elbow

Lateral Epicondylitis: Treatments

• Relative rest • Eliminate aggravating movements (stop

using your forearm?!)• General stretching & forearm

strengthening exercises • Use of tennis elbow forearm strap during

activities • Osteopathic manipulation • Heat or ice • NSAIDs or oral steroids• Injectable steroid into the “maximum

area of tenderness” • In refractory cases a surgical fasciotomy

and tendon transfer may be required

OMT for Lateral Epicondylitis

• Direct: Myofascial Release

• Indirect: SCS lateral epicondyle/forearm extensors, Myofascial Release

• Lymphatic:

Proximal to distal: thoracic inlet, abdominal diaphragm, eeffleurage of the upper extremity

Arm Shake

• 90-95% respond to conservative treatment (asymptomatic in 3 wks)

24

Golfer’s Elbow- Medial Epicondylitis (less common)

25

Except in Arizona!

Medial Epicondylitis

• Basics

Pain in the forearm flexors and medial epicondyle

Repetitive use injury with flexion of wrist

26

Wrist Flexors1

• Primary

Flexor carpi radialis (median n.)

Flexor carpi ulnaris (ulnar n.)

27

Flexor Carpi

Radialis

Flexor Carpi

Ulnaris

• Primary

Pronator terres

Pronator quadratus

• Secondary

Flexor carpi radialis

• Innervation

Median n.

28

Pronator

terres

Flexor Carpi

Radialis

Pronator

quadratus

Wrist pronators1

Elbow

Counterstrain of Medial and Lateral Elbow:

• Indications: tennis elbow (lateral) golfer’s elbow (medial)

• Contraindications: Fracture in the area used to treat the somatic dysfunction. A torn

ligament if positioning would risk further damage

Technique: indirect

• Medial = at or near the medial epicondyle of the humerus associated with common

flexor tendon and the attachment of the pronator teres muscle.

• Lateral = On the anterolateral aspect of the radial head at the attachment of the

supinator

Lateral Medial

Elbow

Counterstrain of Medial and Lateral Elbow:

1. Radial head/Lateral

Epicondyle-hold in full extension

then fully supinate& abduct

(fig 1)

2. Pronator /Med Epicondyle-

The patient's elbow is flexed, the

wrist is markedly pronated, and

the forearm is slightly adducted

(fig 2)

Fig 1

Fig 2

Forearm31

FOOSH InjuriesPronation- Posterior Radial Head

(dorsal glide)

Supination-Anterior Radial Head

(volar glide)

• Anterior radial head

Decreased posterior glide

32

• Posterior radial head

Decreased anterior glide

Anterior

Posterior

Forearm

Physiology

• The radius and ulna can be thought of conceptually as two cones lying next to each

other but pointing in opposite directions.

This permits supination and pronation as the

radius ROLLS around the ulna.

Anatomy Terms:o Volar refers to the palm

o Dorsal is posterior

o Ventral is anterior

Forearm

Physiology

Date of download: 5/15/2019 Copyright © Wolters Kluwer

From: Upper Extremities

Forearm supination

A.During supination, as the distal radius

moves posteriorly, the radial head

(proximal) glides anteriorly.

B.Reciprocal motion occurs at the proximal

and distal radioulnar joints during

pronation and supination.

Foundations of Osteopathic Medicine: Philosophy,

Science, Clinical Applications, and Research, 4e, 2018

(Illustration by W.A. Kuchera, DO, FAAO, with permission.)

Forearm

Physiology

Date of download: 5/15/2019 Copyright © Wolters Kluwer

Forearm pronation

A.Reciprocal motion occurs at the proximal

and distal radioulnar joints during pronation

and supination.

B.B. During pronation, as the distal radius

moves anteriorly, the radial head (proximal)

glides posteriorly.

(Illustration by W.A. Kuchera, DO, FAAO, with permission.)

Foundations of Osteopathic Medicine: Philosophy,

Science, Clinical Applications, and Research, 4e, 2018

From: Upper Extremities

Forearm

Physiology

• The radius and ulna can be thought of conceptually as two cones lying next to each

other but pointing in opposite directions. This

permits supination and pronation as the

radius ROLLS around the ulna.

Think of the elbow position as a teeter totter

Forearm

Physiology

• Remember WE MUST think in the Anatomic Position for the radial head

Forearm

Motion Testing

• Patient attempts to extend/supinate elbows while maintaining forearms together…this

allows the physician to compare normal from

the dysfunctional side

• See figure (18.65)

Forearm

Muscle Energy of Forearm: Treatment of FOOSH injuries

RESTRICTED SUPINATION (likes to

pronate):

1. Lateral hand stabilizes the flexed elbow (at

90degrees) and monitors the radial head

2. The medial hand supinates the forearm to the

barrier

3. The patient performs 3-5 muscle contractions in the pronation direction for 3-5 seconds each

against resistance offered by the physician’s

medial hand

4. The physician engages a new SUPINATION

barrier after each patient effort

Of note: we all live in a pronation world (e.g. typing)

so the supination restriction is the most common

restriction

Forearm

Muscle Energy of Forearm:Treatment of FOOSH injuries

RESTRICTED PRONATION (likes to

supinate):

1. The lateral hand stabilizes the flexed elbow

(at 90 degrees) and monitors the radial head.

2. The medial hand pronates the forearm to the

barrier.

3. The patient performs 3-5 muscle contractions in the supination direction for 3-5 seconds

each against resistance offered by the

physician’s medial hand.

4. The physician engages a new PRONATION

barrier after each patient effort.

Forearm

Muscle Energy of Forearm:Treatment of FOOSH injuries

RESTRICTEDEXTENSION (likes

to flex):

1. Patient sitting on table facing the

physician

2. Doctor’s medial hand grasps the distal

supinated forearm with the lateral

hand stabilizing the elbow.

3. The patient’s elbow extension barrier is

engaged.

4. The patient then performs a series of 3-

5 muscle contractions in the flexion

direction 3-5 seconds each against the

doctor’s resistance

5. The goal is to get to 180 degrees or

equal to the unaffected side when

complete

Forearm

HVLA of Radial Head:

• Remember HVLA is a direct “into the barrier

technique”

→If the radial head is anterior we must drive it

posterior

→If the radial head is posterior we must drive it

anterior

• Indication: supinated or pronated forearm

• Contraindication: radial head fracture Joint

hypermobility Local metastasis Ligament

disruption

• Category = direct

• →Motion test both before and after each

technique

Forearm

HVLA of Posterior Radial Head

Treatment of FOOSH injuries

HVLA for Restricted Supination

(Posterior or Dorsal Radial Head)-elbow likes to pronate

= most common!!!

Technique:

1. Operator stands in front of patient grasping proximal forearm with index

finger of lateral hand overlying posterior (dorsal) aspect of radial head

(fig 18.67)

2. The operator then engages the barrier of extension, supination, and slight

adduction.

3. The operator then thrusts in an anterior(ventral) direction (fig 18.68).

Forearm

HVLA of Anterior Radial Head

Treatment of FOOSH injuries

HLVA for Restricted Pronation = likes to supinate

(Anterior or Volar Radial Head)

Technique:1. The operator pronates and flexes the patient’s forearm while the

thumb holds the radial head posteriorly (in a dorsal position)

(fig 18.69 then fig 18.70)

2. When barrier is engaged, an increasing elbow flexion thrust is

performed.

What is it?

45

Case:• A 35-year-old competitive weightlifter presents with exercise

induced pain, and tightness in the right forearm that begins 20-30 minutes after heavy lifting. The pain usually resolves within 15-30 minutes of leaving the gym. Physical exam reveals tenderness to palpation over all the musculature of the anterior forearm. What is the best diagnosis?

a. Carpal tunnel syndromeb. Exertional compartment syndrome

c. FOOSH injury

d. Medial epicondylitise. TFCC injury

f. Ulnar nerve entrapment

46

Case:• A 35-year-old competitive weightlifter presents with exercise induced pain, and

tightness in the right forearm that begins 20-30 minutes after heavy lifting. The pain usually resolves within 15-30 minutes of leaving the gym. Physical exam reveals tenderness to palpation overall the musculature of the anterior forearm. What is the best diagnosis?

a. Carpal tunnel syndrome (pain/paresthesias of the first 3.5 digits of the hand)b. Exertional compartment syndrome (pain out of proportion, pain with passive

movement, paralysis, paresthesia or numbness, pulselessness or pallor)c. FOOSH injury (no h/o fall on an outstretched hand)

d. Medial epicondylitis (good thought, forearm flexors attach here, and pain can radiate down the forearm, additionally workouts can cause repetitive use injuries, but no mention of any pain over the epicondyle)

e. TFCC injury (pain on the medial aspect ulnar side of the wrist)f. Ulnar nerve entrapment (pain/numbness on the 1.5 digits (ulnar side), claw hand,

weakness in grip strength, inability to make a fist)

47

Compartment Syndrome21

• Symptoms (6 P’s): Pain out of proportion Pressure (muscle tightness)

Paresthesia or numbness Pulselessness

Pallor Paralysis

• Diagnosis Compartment pressure >30-40

mmHg

• Tx Urgent fasciotomy to prevent muscle

ischemia and rhabdomyolysis

48

https://www.youtube.com/watch?v=Q5Rrch-0TBA

Volkmann's Contracture

• Basics Permanent flexion contracture

Caused by ischemia often secondary to increased compartment pressure

Any of the elbow or upper arm fx can cause this

• Tx Emergency

Restore blood flow

Reduce compartment pressure

49

Carrying Angle

• F > M Men 5°, females 10-12°

• Increased carrying angle seen in: Females

Obesity

Trauma

Chronic Somatic Dysfunction

• Symptoms1: Medial/Lateral epicondyle pain (confused with

med/lateral epicondylitis)

Wrist pain

Forearm tightness

• Increased carrying angle = increased risk of ulnar nerve neuropathy.14

50

Functional Anatomy | Carrying Angle

Increased Decreased

51

Olecranon moves

medially- adduction

Distal Ulnar & Wrist -

abduction

Olecranon moves

laterally - abduction

Distal Ulnar & Wrist -

adduction

Wrist52

Radiocarpal joint | wrist1

• True wrist joint:

Carpal bones

Radius

Articular disc

• Motions

Abduction/adduction

Flexion/extension

Combined = circumduction

53

Smith’s/Colles’ fracture21,12

• Basics Fx distal radius

Most common fx in adults (1.5% of all ED visit) Common fx with osteoporosis

Typically caused by FOOSH

Colles’ fx = dorsal displacement

Smith’s fx = palmar displacement

• Diagnosis “Dinner fork" deformity

Wrist x-ray A/P, lateral and oblique views

• Tx Nondisplaced - immobilization in a splint or cast

Displaced - closed reduction and possible surgical fixation

OMT distal to the site of fx to: Reduce swelling (lymphatic tx)

Balance innervation to the arm (T1-4) 54

Intercarpal joints1

• Synovial joints

• Mnemonic: Sally Left The Party To Take Cathy Home Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate

55

Nerves and Entrapments56

Brachial Plexus

• C5-C8 and T1

• Osteopathic

considerations:

Scalenes

Clavicle

1st rib

Pec Minor

• By Gray - Gray's

Anatomy, Public

Domain,

https://commons.wikime

dia.org/w/index.php?cur

id=4245589

57

By Gray - Gray's Anatomy, Public Domain, https://commons.wikimedia.org/w/index.php?curid=4245589

DTRs

Biceps (C5)

Brachioradialis (C6)

Triceps (C7)

58

Sensation | Dermatomes of the UE

• Lateral arm (C5)

• Lateral forearm (C6)

• Index and middle finger (C7)

• Medial forearm (C8)

• Medial arm (T1)

• Axilla (T2)

59

Nerve Entrapments1

• Ulnar = Cubital

tunnel/Guyon's canal

• Radial = Radial tunnel syndrome/Posterior

interosseous syndrome

• Median = carpal tunnel syndrome/pronator

syndrome

60

Case:

• 21 y.o. male complains of medial L elbow pain. He sustained an injury to the L elbow 6 weeks ago after falling off of his motorcycle. X-rays in the ER were negative for fracture. Wrist flexion draws the hand laterally. There is difficulty making a fist due to paralysis of most intrinsic hand muscles. Flexing the 4th and 5th digit is difficult causing a claw hand appearance. There is loss of sensation to those digits on the palmar aspect. What is the best diagnosis?

A. FOOSH Injury B. carpal Tunnel syndrome

C. Ulnar nerve entrapment D. TFCC injury

E. Increased carrying angle61

Case:• 21 y.o. male complains of medial L elbow pain. He

sustained an injury to the L elbow 6 weeks ago after falling off of his motorcycle. X-rays in the ER were negative for fracture. Wrist flexion draws the hand laterally. There is difficulty making a fist due to paralysis of most intrinsic hand muscles. Flexing the 4th and 5th digit is difficult causing a claw hand appearance. There is loss of sensation to those digits on the palmar aspect. What is the best diagnosis?

A. FOOSH Injury (probably did have a FOOSH, but what is causing all the ulnar nerve dysfunction – medial elbow not near radial head)

B. Carpal tunnel syndrome (Numbness of 3.5 digits, median not ulnar nerve)

C. Ulnar nerve entrapment (lateral deviation- ulnar nerve runs flexor carpi radialis, paralysis of intrinsic muscles –ulnar n. innervates the lumbricals, claw hand – flexor digitorum profundus gets innervation from median as well as ulnar nerve)

D. TFCC injury (pain on the medial aspect of the wrist, fall on an extended pronated wrist)

E. Increased carrying angle (medial glide of the olecranon, adduction of the elbow with abduction of the wrist and ulna)

62

Ulnar Nerve | Cubital tunnel syndrome1

• Basics Compression at the elbow =

cubital tunnel

• Symptoms Ache medial elbow

May radiate to forearm and ulnar 1.5 digits

• Diagnosis Pain with tapping the medial

elbow

Pain with prolonged flexion

Hypothenar atrophy (ulnar) Grip weakness (interossei)

Claw hand 63

Ulnar Nerve Entrapment | Guyon’s canal

64

Ulnar nerve palsy—

(clawhand)

The shaded areas represent

the usual distribution of

anesthesia.

Handlebar neuropathy

Treatment• OMT

• Activity modification: Stop resting your medial

elbow on the desk

• NSAIDs

• Brace

• Elbow pad

• Surgery: Ulnar nerve transposition

65

Radial Nerve | Radial Tunnel Syndrome1,12,

• Basics Compression of deep branch of

radial nerve as it enters the supinator

• Symptoms Pain like lateral epicondylitis

Often misdiagnosed Epicondylitis that doesn’t get

better

• Diagnosis Forced flexion of 3rd digit

against resistance = Radial tunnel syndrome12

66

Median Nerve | Pronator Syndrome1

• Basics Proximal compression

As passes through the pronator terres m.

• Symptoms Pain in the prox. forearm

• Diagnosis Sensory changes in first 3.5 digits

Pain worse with pronation against resistance

67https://scarysymptoms.com/2015/07/what-is-pronator-syndrome-causes/

Case: • A 39 y/o female card dealer comes to your office with complaints of

nocturnal bilateral hand paranesthesia and several month history of slow onset fatigue. Eating and sleeping habits have been consistent with hrs of sleep per night. On physical exam you note mild thenar wasting. Tapping over the transverse carpal ligament reproduces her symptoms. Blood work comes back 2 days later with the following results: WBC 3.9, Hg 12.2, urine hCG neg, TSH 24 mU/L. What would be the best referral for this patient?

a. Endocrinology

b. Hematology

c. OB/Gynd. Orthopedics

e. Sleep medicine

68

Case:• A 39 y/o female card dealer comes to your office with complaints of

nocturnal bilateral hand paranesthesia and several month history of slow onset fatigue. Eating and sleeping habits have been consistent with hrs of sleep per night. On physical exam you note mild thenar wasting. Tapping over the transverse carpal ligament reproduces her symptoms. Blood work comes back 2 days later with the following results: WBC 3.9, Hg 12.2, urine hCG neg, TSH 24 mU/L. What would be the best referral for this patient?

a. Endocrinology

b. Hematology

c. OB/Gynd. Orthopedics

e. Sleep medicine

69

So what was going on with this patient?

• Neuropathy secondary to Hypothyroidism

• Did she have Carpal Tunnel Syndrome?

Probably on the R, but note it did not stay better with surgery.

• MORAL of the story:

Treat the PATIENT, not symptoms!

70

Median Nerve | carpal Tunnel Syndrome1

• More on this later

71

Ap

plied

An

atom

y of th

e wrist, T

hum

b, and

Han

d, 108

Carpal Glide1

• When the wrist extends →

Carpal bones glide anteriorly (ventrally displaced)

Can narrow carpal tunnel

Just the opposite with Flexion SD

• FOOSH injuries (are wrist

extension injuries)

Expect to find ventrally displaced carpal bones

Triquetral

72

Carpal Tunnel Syndrome1

• Basics 25.6 cases/200,000 work hours

Carpal Tunnel Syndrome affects 10% of all workers

• Symptoms Pain refers to forearm, neck

Worse at night

Flick sign

• Diagnosis Weakness/atrophy of thenar?

(late sign)

EMG (gold standard)

Osteopathic considerations Pt may have extended wrist

somatic dysfunction

Resulting in anterior glide of the carpal bones (carpal bones prefer ventral glide)

Commonly will have Flexion somatic dysfunction of the wrist

Tight forearm flexors

73

Wrist

Anatomy

carpal Tunnel Syndrome

• Symptoms15: Late signs:

weakness, atrophy of the thenar eminence Weakness with

thumb abduction (opposable thumb)

Recurrent branch of the median nerve

75

Causes of Carpal Tunnel SyndromeCommon15:

1. Pregnancy2. With repetitive wrist

motions3. Diabetes4. Rheumatoid Arthritis5. There is also familial carpal

tunnel syndrome6. Thickened flexor

retinaculum7. Ganglion cyst or mass

compressing the nerve

Less common15:

1. Acromegaly 2. localized amyloidosis3. Chronic renal failure4. Leukemia5. Hypothyroidism6. Hyperparathyroidism

76

Functional Anatomy | Median Nerve

77

Median Nerve16:-C6-T1

-Innervates the flexors and pronators

-Note the palmaris Longus tendon over the top

Flexor Retinaculum (FR)↑ Fluid→ swelling→

FR may eventually

scar and thicken

Carpal Tunnel

Provocative Tests for Carpal Tunnel:

3 Provocative Tests:

1. Tinel’s

2. Phalen’s & reverse Phalen’s

3. Carpal tunnel Compression Test

Indication: suspected carpal tunnel

syndrome

Contraindication: absence of tissue

integrity (open wound/fracture/recent

surgery/crush injury)

Technique: provocative

Carpal Tunnel

Provocative Tests

Tinel Sign: With your index finger, strike the median nerve where it passes through

the carpal tunnel, under the flexor retinaculum and volar carpal ligaments. A tingling

sensation radiating from the wrist to the hand along the median nerve distribution is a

positive Tinel’s sign, indicative of carpal tunnel syndrome.

median nerve distribution is a positive Tinel’s sign, indicative of carpal tunnel syndrome.

Carpal Tunnel

Provocative Tests

• Phalen’s: The symptoms of carpal tunnel

syndrome(Carpal Tunnel Syndrome) are

reproduced by having the patient hold his

wrists in maximum flexion against each other

for upwards of one minute

• Reverse Phalen’s: The symptoms of Carpal

Tunnel Syndrome are reproduced by having

the patient hold their wrists in maximum

extension (praying hands) for up to one

minute. This test could be helpful in

determining the degree of Carpal TunnelSyndrome.

Carpal Tunnel

Provocative Tests:

Median Nerve Compression

(Durkan's) Test

In this test the examiner presses firmly with the

thumb over the space between the flexor carpi

radialis and palmaris longus tendons at the distal

flexion crease. This is the point where the median

nerve enters the carpal tunnel.

-compression is held upwards of 1 minute

-a positive test is one where neurologic

symptoms occur in the median n. distribution

-this is the most sensitive of all tests for Carpal

Tunnel Syndrome

Treatment of carpal Tunnel Syndrome

• Ergonomics Modify activities

Wrist splint 2-6 wks15

• +/- NSAIDs

• OMT Treat cervical

Thoracic

Scalenes

1st rib

Clavicle

Pec minor

Transverse carpal ligament

Carpal bones

• Home stretches

• If not improving: Corticosteroid injection

Surgical consultation If weakness, or thenar muscle atrophy

82

Osteopathic Considerations in Carpal Tunnel Syndrome

• Carpal Tunnel Syndrome is related to forearm flexor hypertonicity17

• SCM spasm causes forearm flexor hypertonicity17

• Scalene Reflex Pressure on the transverse carpal

ligaments in goats showed firing of the scalenes on EMG20

40 mmHg fired ipsilateral scalene 100 mmHg fired the contralateral

scalene too

83

Scalene pain patterns, Myers, 4618

Osteopathic considerations in treatment1

• Carpal bones Ventrally displaced carpal

bones

• Transverse carpal ligament Still’s technique of the wrist

and direct carpal ligament release (lab today)

• Double crush Experiment on dog sciatic n.

did not show decrease in nerve conduction. Needed two points of nerve impingement23-24

Scalenes

Clavicle

1st rib

Pec minor

• Fascia of the forearm Remove restrictions on the

median n.

84

OMT for Carpal Tunnel Syndrome | Balance sympathetics1

• Sympathetics, fascia and blood flow Abramson et.al. showed ↓

blood supply to a nerve will ↓ conduction velocity25

• Internal rotation of the temporal bones ↑ sympathetic tone

If found treat the temporal bones

• Upper thoracics Larson added that upper

thoracic lesions alter the vasomotor tone to the UE26

Also ribs

This will balance sympathetic tone: Improve blood flow

Increase nerve function

↓ lymph/venous congestion

85

OMT for Carpal Tunnel Syndrome | Decrease congestion1

• Venous/Lymph drainage

Check fascial restrictions to lymph/venous drainage. Sunderland showed lymph and venous congestion contribute to Carpal Tunnel Syndrome28

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OMT for Carpal Tunnel Syndrome | Tx the C-spine1

• C-spine

Hurst et. Al showed a relationship between cervical spine arthritis and b/l Carpal Tunnel Syndrome27

Brachial plexus

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Wrist

Flexor Retinaculum Stretch :

“A.T. Still’s Wrist Technique”

Indication: carpal tunnel syndrome

Contraindication: fracture can’t follow commands,

pain in firing muscles

Technique: direct

Wrist

Flexor Retinaculum Stretch:

• This technique is intended to stretch the flexor tendons of the wrist, to stretch the Flexor Retinaculum, causing a decreased

pressure on the contents of the carpal tunnel. The Flexor

Retinaculum Stretch is highly useful for treating both carpal

tunnel and general wrist motion restrictions.

Technique

• Patient position: seated on the table

• Physician position: standing facing the patient

A. The physician interlaces his or her fingers of both hands and encircles

the patient’s wrist. The physician’s thenar eminence should contact the

patient’s wrist over the Flexor Retinaculum (picture A ).

B. As firm compression is provided by the physician, the patient actively

opens and closes hand 5-10 times (picture B). This results in

distraction. Release and retest

A

B

Wrist

Opponen’s Roll: aka “Sucher Technique”

• Indication: carpal tunnel syndrome

and desire to stretch the transverse

carpal ligament

• Contraindication: severe pain with

trying to perform procedure

• Technique: direct

Wrist

Opponen’s Roll:

• This maneuver stretches the muscles and the ligamentous attachments of the wrist, which releases pressure on the

Median nerve.

Technique:

• Patient Position: Seated on the table.

• Physician Position: Standing facing the patient

1. The patient’s hand is held palmar side up.

2. Grasp the patient’s hand by placing your thumbs over the hypothenar and thenar eminencies.

3. Simultaneously, abduct, extend and laterally rotate

(supinate) the thumb, while adducting, extending and

internally rotating (pronate) the fifth digit along the axis of

the first metacarpal bone. Begin gently and increase pressure to patient’s tolerance.

4. An alternative hold for better leverage involves the physician

lacing his or her fifth digits in the patient’s first and fourth

web spaces with thumbs over the hypothenar and thenar

eminences.

Wrist

Self Stretches for Carpal Tunnel Syndrome:

Extension-Dorsiflexion stretch

Technique:

• Patient position: standing, with side to be treated

next to wall but far enough away to allow full elbow

extension.

1. Place your hand flat against a wall with fingers

pointing up and elbow fully extended….forearm is

PRONATED

2. Lean into the wall, causing extension across theflexor retinaculum.

3. Hold for 5 seconds, relax, then repeat.

Technique:

• Patient position: Same as above for last stretch

1. Same stretch as above except this time fingers point

down…forearm is SUPINATED

Wrist

Self Stretches for Carpal Tunnel Syndrome:

Flexion-Palmar Flexion stretch

Technique:

• Patient position: Same as for

above stretch

1. Place the back of your hand, fingers

pointing up, flat on the wall. Make

sure elbow is fully

extended…SUPINATED forearm

2. Lean into the wall, causing a

flexion stretch across the flexor

retinaculum.

3. Hold for 5 seconds, relax and

repeat.

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Is there evidence OMT helps with carpal tunnel syndrome?

• Ramey, KA “MRI assessment of changes in swelling of wrist structures following OMT in patients with carpal tunnel syndrome” AAO Journal 1999, 2 (Vol 9) 25-31

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2. Moore, KE and Dalley AF, Clinically Oriented Anatomy, 1999 4th ed. Lippincott Williams & Wilkins, pg722-759

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6. Hoppenfeld, S, Physical Examination of the Spine and Extremities, Appleton-Century-Crofts, Norwalk, Connecticut, 1976,35-104.

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8. Jones, LH, et al, Jones Strain-CounterStrain, 1995, 132-134.

9. Gilroy, Anne, et all, Atlas of Anatomy, 2008, 266-299.

10. http://medicinembbs.blogspot.com/2013/03/ulnar-tunnel-syndrome.html

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19. Dickson, David Robin, Claire CL Dickson, and Robert Farnell. "Pain at the base of the thumb." BMJ: British Medical Journal (Online) 350 (2015).

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nerve pressure and scalène muscle activity." Journal of reconstructive microsurgery 11.04 (1995): 271-275.

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29. Ramey, KA “MRI assessment of changes in swelling of wrist structures following OMT in patients with carpal tunnel syndrome” AAO Journal 1999, 2 (Vol 9) 25-31

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30. DiGiovanna, 2nd ed. pp 305-30631. Emergency Orthopedics, 3rd edition 11632. Foundations for Osteopathic Medicine, 2nd ed pp 964 –

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pronation/supination of elbow

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57. Hand Surgery Resource 2018 photo of the Durkin’s test