This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
– Shape of distal portion of bone allows Shape of distal portion of bone allows for rotation with pronation/supinationfor rotation with pronation/supination
Splits at level of PIP joint to allow Splits at level of PIP joint to allow Flexor digitorum profundus to pass to Flexor digitorum profundus to pass to distal phalanxdistal phalanx
Attaches on middle phalanxAttaches on middle phalanx
Muscles of the (Volar) ForearmMuscles of the (Volar) Forearm
for the index finger (EI, for the index finger (EI, indicis = index finger) and indicis = index finger) and little finger (digiti minimi = little finger (digiti minimi = little digit/finger)little digit/finger)
Muscles of the (Dorsal) ForearmMuscles of the (Dorsal) Forearm
Extensor Pollicis Longus (EPL)Extensor Pollicis Longus (EPL)– Extends distal phalanx of thumb Extends distal phalanx of thumb
at IP jointat IP joint
Extensor Pollicis Brevis (EPB)Extensor Pollicis Brevis (EPB)– Extends proximal phalanx of Extends proximal phalanx of
thumb at MCP jointthumb at MCP joint
Abductor Pollicis Longus (APL)Abductor Pollicis Longus (APL)– Extends, abducts & rotates the Extends, abducts & rotates the
thumb at the CMC jointthumb at the CMC joint
(pollicis = relating to thumb)(pollicis = relating to thumb)
Muscles that Rotate the ForearmMuscles that Rotate the Forearm
Bringing the forearm to neutral:Bringing the forearm to neutral:– BrachioradialisBrachioradialis– Also assists with elbow flexionAlso assists with elbow flexion– ““beer drinking muscle”beer drinking muscle”
Muscles of the (Volar/Palmar) HandMuscles of the (Volar/Palmar) Hand
Muscles of the (Volar/Palmar) HandMuscles of the (Volar/Palmar) Hand
Hypothenar muscles = Hypothenar muscles = muscles moving the little muscles moving the little fingerfinger– Flexor Digiti Minimi Flexor Digiti Minimi – Abductor Digiti Minimi Abductor Digiti Minimi – Opponens Digiti MinimiOpponens Digiti Minimi
Intrinsic Muscles of the HandIntrinsic Muscles of the Hand LumbricalsLumbricals
– Origin on FDP tendon, inserts on Origin on FDP tendon, inserts on proximal phalanx of digits 2-5proximal phalanx of digits 2-5
– Flexes MCP joints and extends IP jointsFlexes MCP joints and extends IP joints Dorsal InterosseiDorsal Interossei
– Abducts digits 1, 2 & 4 Abducts digits 1, 2 & 4 – Flexes MCP joints and extends IP jointsFlexes MCP joints and extends IP joints
Palmar InterosseiPalmar Interossei– Abducts the fingers towards 3Abducts the fingers towards 3rdrd digit digit– Flexes MCP joints and extends IP jointsFlexes MCP joints and extends IP joints
Brachial PlexusBrachial Plexus Network of nerve fibers that goes through the neck, Network of nerve fibers that goes through the neck,
the axilla (armpit) and into the arm and handthe axilla (armpit) and into the arm and hand Responsible for all the cutaneous (skin) and muscular Responsible for all the cutaneous (skin) and muscular
innervation of the upper limb (except the trapezius innervation of the upper limb (except the trapezius
muscle)muscle)
Radial NerveRadial Nerve The radial nerve innervates the following muscles, in this The radial nerve innervates the following muscles, in this
Anterior Interosseous Nerve (branch of Anterior Interosseous Nerve (branch of median nerve)median nerve)– Flexor Digitorum Profundus (index and middle)Flexor Digitorum Profundus (index and middle)– Flexor Pollicis LongusFlexor Pollicis Longus– Pronator QuadratusPronator Quadratus
Palmar Recurrent Motor Branch (branch of Palmar Recurrent Motor Branch (branch of median nerve)median nerve)– Abductor Pollicis BrevisAbductor Pollicis Brevis– Opponens PollicisOpponens Pollicis– Flexor Pollicis BrevisFlexor Pollicis Brevis
Common Palmar Digital Nerve (branch of Common Palmar Digital Nerve (branch of median nerve)median nerve)– Lumbricals 1 & 2Lumbricals 1 & 2
Ulnar NerveUlnar Nerve
The Ulnar nerve innervates the following muscles, The Ulnar nerve innervates the following muscles, in this order:in this order:– Flexor Carpi Ulnaris (FCU)Flexor Carpi Ulnaris (FCU)– Flexor Digitorum Profundus (ring and small Flexor Digitorum Profundus (ring and small
fingers)fingers)
Deep Branch of Ulnar Nerve:Deep Branch of Ulnar Nerve:– Abductor Digiti MinimiAbductor Digiti Minimi– Opponens Digiti MinimiOpponens Digiti Minimi– Flexor Digiti MinimiFlexor Digiti Minimi– 3rd and 4thLumbricals3rd and 4thLumbricals– Dorsal InterosseiDorsal Interossei– Palmar InterosseiPalmar Interossei– Flexor Pollicis BrevisFlexor Pollicis Brevis– Adductor PollicisAdductor Pollicis
Inspection/ObservationInspection/Observation PalpationPalpation ROMROM Muscle StrenghtMuscle Strenght NeurovascularNeurovascular Special TestsSpecial Tests
ObservationObservation Posture and alignmentPosture and alignment Swelling/edema, ecchymosisSwelling/edema, ecchymosis Changes in skin, nails or hair (or Changes in skin, nails or hair (or
arm/hand)arm/hand) Contractures and other deformitiesContractures and other deformities Functional range of motion (& right vs. Functional range of motion (& right vs.
left UE)left UE) Observe the contours and take note of Observe the contours and take note of
Neuromuscular Neuromuscular Peripheral nerves = all of the nerves Peripheral nerves = all of the nerves
that lie outside of the brain and that lie outside of the brain and spinal cord spinal cord – Motor nervesMotor nerves– Sensory nervesSensory nerves
Injury causes loss of sensation, Injury causes loss of sensation, movement or bothmovement or both
Look for specific dermatome or Look for specific dermatome or myotome patterns if you think the myotome patterns if you think the injury is at the nerve rootinjury is at the nerve root
NB: Some cervical problems present NB: Some cervical problems present as UE problems, so do not forget to as UE problems, so do not forget to assess the C-Spineassess the C-Spine
StrengthStrength To test muscle strength, use the manual muscle To test muscle strength, use the manual muscle
testing grading system:testing grading system:– Grade 0 = no muscle contraction visible or palpableGrade 0 = no muscle contraction visible or palpable– Grade 1 = no movement but there is a flicker (or palpable) Grade 1 = no movement but there is a flicker (or palpable)
of muscle contractionof muscle contraction– Grade 2 = full range of motion with no gravity Grade 2 = full range of motion with no gravity – Grade 3 = full range of motion against gravity (no extra Grade 3 = full range of motion against gravity (no extra
resistance)resistance)– Grade 4 = full range of motion against gravity, with Grade 4 = full range of motion against gravity, with
moderate resistancemoderate resistance– Grade 5 = full range of motion against gravity, with Grade 5 = full range of motion against gravity, with
maximum resistancemaximum resistance
Remember that disuse, immobilization, and other Remember that disuse, immobilization, and other medical conditions can cause muscle weakness, medical conditions can cause muscle weakness, even when the nerve is intact. even when the nerve is intact.
Sensory TestingSensory Testing
Monofilaments (small fibres of different Monofilaments (small fibres of different sizes) or other fine pointed tools (pin, paper sizes) or other fine pointed tools (pin, paper clip etc.) clip etc.)
Cotton ball (moving light touch)Cotton ball (moving light touch)– The patient should not look at the injured area The patient should not look at the injured area
and then tell the therapist when they think the and then tell the therapist when they think the therapist is touching their skin with the pointed therapist is touching their skin with the pointed tool (E.g. “tell me when you feel me touch your tool (E.g. “tell me when you feel me touch your hand”). hand”).
Sensory testing should be done before use of Sensory testing should be done before use of heat, ice or splinting (potential for tissue heat, ice or splinting (potential for tissue damage)damage)
Apprehension TestApprehension Test Crank TestCrank Test Speed TestSpeed Test Hawkins and Kennedy TestHawkins and Kennedy Test Neer TestNeer Test Full can and Empty can TestsFull can and Empty can Tests Finkelstein TestFinkelstein Test Tinel and Phalen Sign, Duran's TestTinel and Phalen Sign, Duran's Test
Specific ConditionsSpecific ConditionsMorag CrockerMorag Crocker
TendonitisTendonitis
Tendonitis Tendonitis = = Inflammation, swelling and Inflammation, swelling and irritation of a tendon (attaches muscle to irritation of a tendon (attaches muscle to bone); usually used to describe more acute bone); usually used to describe more acute tendon inflammation. tendon inflammation.
TenosynovitisTenosynovitis = = inflammation of the inflammation of the sheath (called synovium) sheath (called synovium) that surrounds a tendon.that surrounds a tendon.
Tendinopathy = term to Tendinopathy = term to describe problems with describe problems with either the tendon or the either the tendon or the tendon sheathtendon sheath
TendonitisTendonitis Cause:Cause:
– OveruseOveruse– Direct injury to tendonDirect injury to tendon– Rheumatic diseaseRheumatic disease– Infection (very rare)Infection (very rare)
Presentation:Presentation:– Tenderness with pressure on the tendonTenderness with pressure on the tendon– Pain with movementPain with movement– Stiffness after restStiffness after rest– Visible swelling and local warmth (may or Visible swelling and local warmth (may or
may not be present) may not be present)
TendonitisTendonitis Common areas are elbow (lateral Common areas are elbow (lateral
epicondylitis), biceps, wrist & thumb epicondylitis), biceps, wrist & thumb Treatment:Treatment:
Radial side of wrist, over MCP & CMC jointsRadial side of wrist, over MCP & CMC joints move the thumb away from the plane of the handmove the thumb away from the plane of the hand
Cause:Cause:– repetitive movements requiring pinching or repetitive movements requiring pinching or
grasping, particularly in combination with wrist grasping, particularly in combination with wrist movementmovement
Special tests:Special tests:– Finkelstein’s test = examining therapistFinkelstein’s test = examining therapist
grasps the thumb, applies traction, grasps the thumb, applies traction, and ulnarly deviates the hand sharply. and ulnarly deviates the hand sharply. A resulting sharp pain along the distal A resulting sharp pain along the distal radius, close to the wrist, is considered radius, close to the wrist, is considered a positive test. a positive test.
the hand, where FDP & the hand, where FDP & FDS tendons enter the FDS tendons enter the flexor tendon sheath flexor tendon sheath
– Most commonly affects Most commonly affects the ring finger, just the ring finger, just proximal to MCP joint proximal to MCP joint
Trigger FingerTrigger Finger
Symptoms:Symptoms:– Causes clicking, catching (“triggering”) of Causes clicking, catching (“triggering”) of
fingers with joint flexionfingers with joint flexion– May also cause stiffness, pain, tenderness and May also cause stiffness, pain, tenderness and
swelling in the palm of the handswelling in the palm of the hand Causes:Causes:
– Repetitive or forceful grasping (finger flexion) Repetitive or forceful grasping (finger flexion) causes thickening of the flexor tendons (and/or causes thickening of the flexor tendons (and/or narrowing of the flexor tendon sheath)narrowing of the flexor tendon sheath)
– Tendon gets stuck when gliding through the Tendon gets stuck when gliding through the tendon sheath tendon sheath
Several types but splint must prevent some degree Several types but splint must prevent some degree of finger flexion, so that the thickened part of the of finger flexion, so that the thickened part of the tendon does not go through the sheath and catch tendon does not go through the sheath and catch
Safety PositionSafety Position
Safe position when hand must be Safe position when hand must be immobilizedimmobilized– Maintains length of soft tissues to prevent Maintains length of soft tissues to prevent
contracturecontracture– Prevents intrinsic muscles from being Prevents intrinsic muscles from being
overpowered by stronger flexor & extensor overpowered by stronger flexor & extensor musclesmuscles
Safety PositionSafety Position
Used for:Used for:– Traumatic injury/acute conditionTraumatic injury/acute condition– BurnsBurns– Crush injuryCrush injury– Inflammatory joint diseaseInflammatory joint disease– Prevent contracturePrevent contracture– Reduce pain & inflammationReduce pain & inflammation– Or any condition causing significant swelling, Or any condition causing significant swelling,
as this can cause “clawing” (MCP extension & as this can cause “clawing” (MCP extension & IP flexion)IP flexion)
Safety PositionSafety Position Position of joints:Position of joints:
– Wrist position = 30° extension Wrist position = 30° extension – MCP position = 70° flexionMCP position = 70° flexion– IP position = full extension (if possible)IP position = full extension (if possible)– Thumb position = full abductionThumb position = full abduction
Why?Why?– Intrinsic muscles flex MCP joints and extend IP jointsIntrinsic muscles flex MCP joints and extend IP joints– If intrinsic muscles weakened, If intrinsic muscles weakened,
they are overpowered by EDC and FDP/FDS, leading to MCP they are overpowered by EDC and FDP/FDS, leading to MCP joint hyperextension & IP joint flexionjoint hyperextension & IP joint flexion
– Will eventually cause contractureWill eventually cause contracture– With crush or burn, scar tissue will With crush or burn, scar tissue will
also contract as the hand healsalso contract as the hand heals
Nerve InjuriesNerve Injuries
Complete nerve laceration requires Complete nerve laceration requires surgical repair to restore innervation surgical repair to restore innervation – The body does try to repair itself by The body does try to repair itself by
sprouting new axons (part of the nerve) sprouting new axons (part of the nerve) from the injured nerve, which can from the injured nerve, which can eventually bridge the gap between the eventually bridge the gap between the cut ends of the nervecut ends of the nerve
Nerve damage (not completely cut or Nerve damage (not completely cut or crushed) can be repaired/regrowcrushed) can be repaired/regrow– Typically at a rate on 1-2 mm per day Typically at a rate on 1-2 mm per day
Nerve InjuriesNerve Injuries Goal of physiotherapy treatment is to Goal of physiotherapy treatment is to
prevent problems from developing during prevent problems from developing during the time that the patient does not have the time that the patient does not have sensation or full motor control:sensation or full motor control:– For lack of sensation, they must learn to use For lack of sensation, they must learn to use
visual observationvisual observation– Splints and passive movement exercises are Splints and passive movement exercises are
used to maintain tissue length (in the hope that used to maintain tissue length (in the hope that the patient eventually regains muscle the patient eventually regains muscle innervation) innervation)
– Splints also used to maintain function while the Splints also used to maintain function while the patient does not have proper muscle controlpatient does not have proper muscle control
As a nerve re-grows, altered sensation can As a nerve re-grows, altered sensation can be uncomfortable:be uncomfortable:– Graded desensitization exercises Graded desensitization exercises
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Form of median nerve injuryForm of median nerve injury– Compression of median nerve as it Compression of median nerve as it
passes through the carpal tunnel passes through the carpal tunnel (created by curve of carpal bones (created by curve of carpal bones and carpal ligament)and carpal ligament)
Signs & symptoms:Signs & symptoms:– Numbness and tingling of the radial Numbness and tingling of the radial
3 ½ fingers3 ½ fingers– clumsiness, due to weakened musclesclumsiness, due to weakened muscles– Pain (or altered sensation) especially at Pain (or altered sensation) especially at
night night – Atrophy of thenar musclesAtrophy of thenar muscles
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Causes:Causes:– Repetitive movements (ex. Typing, weeding/farming)Repetitive movements (ex. Typing, weeding/farming)– Vibrations (ex. tool use)Vibrations (ex. tool use)– Inflammation of the flexor tendon sheaths (ex. rheumatoid Inflammation of the flexor tendon sheaths (ex. rheumatoid
arthritis)arthritis)
Special tests:Special tests:– Durkan’s test: press with both thumbs over the Durkan’s test: press with both thumbs over the
carpal tunnel for 30 seconds.carpal tunnel for 30 seconds.– Phalen’s test: patient flexes own wrists for Phalen’s test: patient flexes own wrists for
about 60 seconds. about 60 seconds. – Tinel’s test: tap the median nerve over the volar carpal Tinel’s test: tap the median nerve over the volar carpal
tunnel tunnel
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Treatment:Treatment:– Rest (from aggravating activities)Rest (from aggravating activities)– NSAID’sNSAID’s– Splinting in neutral wrist position Splinting in neutral wrist position
Nighttime and for aggravating activitiesNighttime and for aggravating activities
Median Nerve InjuryMedian Nerve Injury Injury at distal forearm, wrist or hand:Injury at distal forearm, wrist or hand:
– Affects: thenar musclesAffects: thenar muscles– Lose: thumb abduction & oppositionLose: thumb abduction & opposition– Potential for adduction contracturePotential for adduction contracture
Splinting goals:Splinting goals:– Maintain thumb abduction & oppositionMaintain thumb abduction & opposition
Ulnar NerveUlnar Nerve The Ulnar nerve innervates the The Ulnar nerve innervates the
following muscles, in this order:following muscles, in this order:– Flexor Carpi Ulnaris (FCU)Flexor Carpi Ulnaris (FCU)– Flexor Digitorum Profundus (ring and small Flexor Digitorum Profundus (ring and small
fingers)fingers)
Deep Branch of Ulnar Nerve:Deep Branch of Ulnar Nerve:– Abductor Digiti MinimiAbductor Digiti Minimi– Opponens Digiti MinimiOpponens Digiti Minimi– Flexor Digiti MinimiFlexor Digiti Minimi– 3rd and 4thLumbricals3rd and 4thLumbricals– Dorsal InterosseiDorsal Interossei– Palmar InterosseiPalmar Interossei– Flexor Pollicis BrevisFlexor Pollicis Brevis– Adductor PollicisAdductor Pollicis
Ulnar Nerve PalsyUlnar Nerve Palsy Injury at level of distal forearm, wrist or hand:Injury at level of distal forearm, wrist or hand:
– Weak intrinsic muscles are overpowered by flexors (FDS, Weak intrinsic muscles are overpowered by flexors (FDS, FDP) & extensors (EDC), FDP) & extensors (EDC), causing clawing of little and ring causing clawing of little and ring fingersfingers
An injury higher up (level of humerus to proximal An injury higher up (level of humerus to proximal forearm) results in same clawing as above but to forearm) results in same clawing as above but to lesser degreelesser degree
Splints for Ulnar Nerve PalsySplints for Ulnar Nerve Palsy
Splinting goals:Splinting goals:– Resting hand/safety positionResting hand/safety position– As wrist movement not affected, no need to As wrist movement not affected, no need to
support wristsupport wrist
Radial NerveRadial Nerve The radial nerve innervates the following The radial nerve innervates the following
muscles, in this order:muscles, in this order:– TricepsTriceps– AnconeusAnconeus– BrachioradialisBrachioradialis– Extensor Carpi Radialis LongusExtensor Carpi Radialis Longus– Extensor Carpi Radias BrevisExtensor Carpi Radias Brevis– SupinatorSupinator
Radial Nerve PalsyRadial Nerve Palsy Most commonly injured below level of Most commonly injured below level of
triceps muscle innervationtriceps muscle innervation Injury at level of middle humerus to middle Injury at level of middle humerus to middle
(to distal) forearm:(to distal) forearm:– Lose: wrist, finger & thumb extensionLose: wrist, finger & thumb extension– Loss of wrist extension results in hand weakness Loss of wrist extension results in hand weakness
Splinting goals:Splinting goals:– Dynamic splint to use tenodesis effect ORDynamic splint to use tenodesis effect OR– Splint to maintain wrist and finger extensionSplint to maintain wrist and finger extension
Splints for Radial Nerve PalsySplints for Radial Nerve Palsy
Causes:Causes:–Loss of sensation (and/or)Loss of sensation (and/or)–Loss of motor control (and/or)Loss of motor control (and/or)–NeglectNeglect–Pain Pain
40% of stroke patients experience pain in the 40% of stroke patients experience pain in the affected side, within 6 months of stroke.affected side, within 6 months of stroke.
StrokeStroke Causes of pain:Causes of pain:
1.1. Complex Regional Pain Syndrome (CRPS)Complex Regional Pain Syndrome (CRPS)– Severe shoulder and hand pain plus a swollen hand Severe shoulder and hand pain plus a swollen hand – Usually develops approximately 1 month or more after Usually develops approximately 1 month or more after
strokestroke– Extremely sensitive handExtremely sensitive hand– Changes in nails and skin. Changes in nails and skin. – Causes unknown: Causes unknown:
Malfunctioning pain pathwaysMalfunctioning pain pathways Autonomic nervous system Autonomic nervous system Limited limb movementLimited limb movement
– Treatment is difficult: neuropathic pain meds & mobilize Treatment is difficult: neuropathic pain meds & mobilize limb earlylimb early
2.2. SpasticitySpasticity
3.3. Shoulder subluxationShoulder subluxation
SpasticitySpasticity
ArthritisArthritis
Glenohumeral jointGlenohumeral joint AC jointAC joint Thumb CMC jointThumb CMC joint OA of the IP jointsOA of the IP joints RA of the MP jointsRA of the MP joints GA of elbow and wristGA of elbow and wrist