CERVICAL RADICULOPATHY

Cervical radiculopathy is a condition that results from tension and compression of the nerve roots in
the cervical vertebrae. This condition is usually caused by poor posture over a long period of time. A
forward head posture leads to decreased facet joint alignment, which can cause decreased bone
integrity, formation of bone spurs, as well as spinal stenosis, which leads to an encroachment on the
nerve root. General symptoms of radiculopathy include pain, numbness, cervicogenic headaches, and
weakness that radiates to other parts of the body. People will usually present with unilateral pain, and
issues can present in the neck, as well as shoulder and scapular regions. The patient is usually unable to
achieve positions due to discomfort or poor brachial plexus mobility. It is very treatable.

EVALUATIONS
It is important to obtain an occupational profile, assessment of posture, ROM, MMT, and functional
observations. The best way to test for this is using the cervical cluster tests:
1. Spurling's A and Spurling's B- laterally flex neck to same side and extend neck, then push down
toward the spinal cord to compress the nerve space. Test both sides. If there is pain, that is a (+)
result.
2. Cervical Rotation- (+) test if ROM test for cervical rotation/turning neck is <60.
3. Upper Limb Neurodynamic Test- Purpose is to develop tension on the brachial plexus nerve
bundle. Place the pt in supine, then use the following sequence: Shoulder in IR, elbow at 90;
move the shoulder into neutral; move the shoulder joint into 100 abduction; turn shoulder in
ER, forearm in supination, elbow still at 90; place elbow into full extension; place wrist/fingers
in full extension. (+) if pt experience pain/tension in some step in the sequence. These tests are
available for testing the median n., radial n., and ulnar n.
4. Cervical Distraction- Pt is placed in supine, and their head is slightly tugged away from the
spinal cord. (+) test if the pt's symptoms are alleviated.
The dx is more likely the more (+) test results a pt has from this cluster. 4/4 indicates a 90% likelihood.

TREATMENTS
It is important to address muscular involvement by easing tension and pain in scalenes, levator
scapulae, trapezius, and pectoralis mm.. Using a scalene stretch, SCM stretch, trapezius mm stretches,
doorway stretch or corner stretch is an example to stretch these. Include joint mobilizations, ROM and
muscle strengthening exercises, postural retraining and education, improving sleep position, postural
exercises and changing the work-place setup. An example of exercise is educating a patient on the
proper posture of sitting while typing on a computer at a desk at work.

PRECAUTIONS
It is important to test between intrinsic and extrinsic muscle involvement to discriminate between
scalenes or the levator scapulae/trapezius. This can be completed by testing ROM of shoulder and neck
with arms at rest, and then in a cross-arm position. In a cross-arm position, the scapular elavators
relax, and an improvement in ROM after indicate the extrinsic cervical structures are contributing to
motion loss; no change is a problem with the intrinsics. Make sure you connect any
treatment/intervention back to occupation.
LOWER BACK PAIN
Lower back pain is a musculoskeletal condition that affects up to 75-80% of the population sometime
during their lifetime. The number one cause of the condition chronic bad posture when
sitting/standing/sleeping prolonged postures, and improper lifting techniques. These can also be
caused by a muscle "sprain or strain," a degenerating disc, or a herniated disc. Other causes include
trauma, biologic factors such as osteoporosis, tumors, pregnancy, sedentary lifestyles, genetics, mental
health conditions, weight gain, or occupational demands. This condition can also lead to radiculopathy,
nerve root compressions, and other health conditions. Lower back pain is very common and is very
treatable.

EVALUATIONS
There is no "go-to" assessment for thoracic-related
conditions. It would be important to focus on different
assessments and evaluations, such as developing an
Occupational Profile, a work-place assessment, postural
assessment of the vertebra and shoulder alignment, as
well as hip alignment. You could also conduct a
thorough review of the patient's medical history, go
through pain scales, and a self-report of symptoms
during occupation-based tasks. Posture analyzing apps can help to detect deformities.

INTERVENTIONS
The main goals during therapy is a complete
reeducation on body mechanics and safe
postural techniques. Pts can strengthen back
muscles and core muscles in order to
increase proper posture, as well as ROM
exercises to increase motion and joint
stability. Physical modalities can be used for
pain management and loosening some
muscles. The McKenzie Method (right
picture) is an example of a stretch that can
treat lower back pain and radiculopathy. The goal of this method is to "centralize" pain from the leg to
the lower back. Most therapy activities can be focused on performing daily tasks, but allowing a
reeducation of proper posture and body mechanic techniques. The use of foam noodles and towel rolls
can be helpful in improving posture. Other interventions include doorway stretches, scapular
strengthening, chin tucks to improve forward head posture. Collaborating with PTs is important.

PRECAUTIONS
Progress strengthening exercises with caution and although ROM is important, avoid any motions that
inflict pain to pt.
THORACIC OUTLET SYNDROME
Thoracic Outlet Syndrome is a term that encompasses many different clinical issues in the shoulder
region --- a "catch-all" term. The thoracic outlet provides the pathway for the neural and vascular
structures to and from the upper limb, and an issue to this has profound and disabling results. TOS is
usually rare, and it is more common to see brachial plexopathy in women. Some causes are unknown,
but can range from genetics, sports-related injuries, trauma (car accidents), posture-related, or
repetitive stress. Symptoms can include headaches, pain, weakness and tingling in the arm/hand,
dropping objects, weak hand grasp, hand cramps, waking up with a "dead arm," intolerance for
overhead activities, and discomfort with straps laying over the shoulder. A full recovery of all
symptoms is rare, but they can be managed or reduced to allow for a return to restricted activity. This
is a lifelong injury. The condition is characterized by periods of high and low neural irritability based on
your client's activity level and degree of pathology.

EVALUATIONS
General assessments include an occupational profile, PMH, postural assessment, DASH/QuickDASH,
ROM/MMT, functional limitations, but assessments should also include:
1. Brachial Plexus Mobility Test
2. Elevated Arm Stress Test
3. Tinel's Sign- lightly tapping over different nerves to elicit a tingling sensation in the
nerve distribution.
4. Myotome and Dermatome screening
TOS can also be diagnosed with a vascular component with the absence of a radial pulse, or a neural
component involving unilateral headaches in the occipital region with facial pain from the angle of the
jaw to the zygomatic region of the ear.

INTERVENTIONS
Due to the fact that TOS is a lifelong injury, patients must be instructed in chronic management of the
condition. Nerves need three condition so to optimize healing: Space, Time, and Minimal
Tension/Strain. Teach patients using a neural mobility assessment where safe boundaries of motion
are so they do not irritate the injured plexus. Gliding and stretching exercises can help to regain plexus
mobility and will allow the plexus to improve to increase ROM and improve ADL function. Clients can
regain scapular proprioception using mirror therapy while performing scapular motions, targeting
points on the clock. Stretching of scalenes, pectoralis mm., can add more space for the brachial plexus,
but can temporarily lead to an increase in pain symptoms.
Operative: Most surgical outcomes have been disappointing, but surgery is reserved for patients with
the most sever symptoms. Most common surgeries include transaxillary first rib resection and
supraclavicular scalenectomy (surgical removal of anterior scalene) with neurolysis.

PRECAUTIONS
Avoid overstretching the brachial plexus during treatment. Be careful with overhead exercises, such as
wall pulleys. Use of an upper body ergometer (UBE) is not recommended. Progress strengthening
exercises cautiously. Watch exercise patterns to avoid overstressing the brachial plexus.
FROZEN SHOULDER/ ADHESIVE CAPSULITIS
Adhesive capsulitis/FS is a progressive loss of GH ROM in a pattern of ER, followed by Abduction,
Flexion, and IR. The patient MUST present with this capsular pattern to have this diagnosis. There are 2
types of FS:
1. Primary: can be idiopathic, but can be linked to immunologic, biochemical or endocrine
causes.
2. Secondary: have a precipitating event (surgery, trauma, bursitis, impingement syndrome,
tendonitis). This may not progress the same way as primary.
There are three typical stages of FS:
1: Freezing: may last 2-9 months, pain interrupting sleep and ADLs and at rest, during ROM
and palpation.
2: Frozen: may last up to 1 year, pain occurs at the end of ROM, the patient will attempt to
substitute ST motion to compensate for the lack of GH mobility.
3: Thawing: Can last up to 26 months, characterized by the return of movement, some clients
will experience full ROM return, and some will have some loss.
FS can happen either unilaterally or bilaterally.

EVALUATIONS
General assessments include an occupational profile, PMH, postural assessment, DASH/QuickDASH,
ROM/MMT, functional limitations, but assessments should also include:
1. A ROM test best completed in supine with very distinct range values.
2. Making sure the patient follows the capsular pattern of ROM loss, which is
ERabductionflexionIR

INTERVENTIONS
There is no evident to suggest that physical modalities affect the outcome of FS. Intra-articular
corticosteroid during the freezing phase has been known to be helpful in stabilizing synovial tissue to
increase tolerance in stretching. AROM is important, but overstretching can cause increased scarring
to the damaged joint capsule which will delay the healing process. Stretching exercises need to be
completed within the patient's tolerance. Activities can include assisting the patient with bilateral FS in
ADL modifications or adaptive equipment for grooming, bathing, and dressing. Patients with unilateral
FS can benefit from workstation modification to remain productive during healing. Examples of
stretching exercises include dowel-rod exercises, table rolls, or pendulum exercises.
Operative: only for cases that fail to progress non-operatively. Manipulation under anesthesia and
arthroscopic release of the GH capsule ligaments are the two most common surgical interventions,
with arthroscopic release with the strongest outcomes.

PRECAUTIONS
Do not push ROM during the freezing phase to the point of pain that lasts more than a few minutes.
This will only enhance the inflammatory and fibrosing process. These clients must avoid self-imposed
immobilization.
SHOULDER IMPINGEMENT
Shoulder impingement is an injury that
occurs when one of the tendons of the
muscles that make up the rotator cuff is
injured or impinged, which leads to a loss
of function. The most commonly
impinged muscle is the supraspinatus
muscle when it passes through the
subacromial space on the scapula. Other
muscles that can be impinged are the
infraspinatus, teres minor, and
subscapularis mm. Causes include age, long
term posture, movement patterns that require repetitive overhead motions, and high activity levels
that require repetitive overhead motions. If untreated, shoulder impingement can lead to partial or full
RTC tears. Shoulder impingement can be common due to the strong pectoralis and upper trapezius
mm, with weak neck flexors and weak lower trapezius and serratus anterior mm to offset these
muscles, leading to a forward hunched posture. A typical pathology include impingement of the
supraspinatus m, which leads to tearing and then progresses to the infraspinatus tendon. Symptoms
include pain that can radiate down UE and pain at night, weakness in shoulder ROM and limit to daily
function.

EVALUATIONS
Focus on gathering a strong occupational profile and PMH, postural evaluation, ROM/MMT, outcome
assessment (DASH, PRWE), and functional limitations. There are also specific tests:
1. Full thickness tear screen: push in on hands when arms mid flexed and pt will fight
but use the deltoid to help-- shoulder will elevate and abduct
2. Palpation of tendons: supraspinatus, infraspinatus, long head of biceps tendon,
subscapularis.
3. Hawkins-Kennedy- pt has shoulder and arm both flexed at 90, then IR arm,
+ = pain
4. Neer impingemnent- IR arm and move shoulder in full flexion w/ arm extended,
+ = pain
(first two testing for general RTC pathology, second two testing for impingements)

INTERVENTIONS
Shoulder impingement is often accompanied by a tight posterior shoulder capsule. Posterior shoulder
stretches can be conducted to improve shoulder strength and posture. Review and educate patient on
proper posture techniques. Therapeutic exercise and joint mobilizations can reduce symptoms; also
focus on ROM and modalities for pain management and loosening muscles before therapy. Include
functional activities that involve the should like putting away things in cabinets. Educate on home
exercises the patient can perform. Surgical repair can happen if clients don't respond to therapy.

PRECAUTIONS
Do not passively range the shoulder through abduction to increase impingement of the supraspinatus
m.
RADIAL HEAD FRACTURE
Radial head fractures are the most common elbow
fractures in adults. The most common mechanism of
injury is falling onto an outstretched hand with the
forearm pronated, or falling directly onto the elbow.
These fractures are more common in women.
Common symptoms include pain around the elbow,
swelling/tenderness of the joint, difficulty achieving
ROM on the elbow without pain, inability/difficulty
pronating and supinating the forearm, and limits to
functional activities. Radial head fractures could also
lead to different injuries in other ligaments in the
elbow, particularly the annular ligament that wraps
around the head of the radius.

EVALUATIONS
Fractures are diagnosed through an X-ray or a CT scan ordered by a physician. For OT's they can gather
an evaluation through a strong occupational profile and PMH, postural evaluation, ROM/MMT,
outcome assessment (DASH, PRWE), and functional limitations.

INTERVENTIONS
Operative: Complications of operative treatments are infection,
malunion, nonunion, ulnar neuropathy, and arthrosis. Most are
treated with internal fixation, radial head excision and radial head
replacement if needed.
Non-displaced, stable fractures are treated very conservatively.
Initial goals are restoring motion while protecting the elbow from
stresses that compromise healing. Early treatment can focus on
elevation of UE, cold packs, light compression wraps, and light
massage. Focus on scar management post-operatively and edema
management, and then start introducing PROM with the goal of
restoring full ROM. Later as healing progress, start to implement
gradual return to use of involved UE for functional activities.
An orthosis will be used during the early weeks to promote stability of the joint. Protective orthoses
will be discontinued except for sleep, travel, and other circumstances that might put the elbow at risk.

PRECAUTIONS
The most common complication of these fractures is elbow flexion contracture, which leads to the loss
of elbow extension. Adhere to precautions related to surgery, and phase of healing. Never sacrifice
stability for more mobility. Passive movement should be gentle and slow. Be alert for symptoms of
ulnar neuritis, such as numbness/tingling in digits 4-5, and document any reports.
RADIAL NERVE PALSY (WRIST DROP)
Radial nerve palsy is damage to the nerve due to direct trauma. Radial nerve is the most commonly
injured of the three major peripheral nerves. The most vulnerable injury site of the radial nerve is high
radial nerve palsy at the mid-humeral level, as the radial n. travels transversely around the spiral
groove of the humerus moving medially to laterally. The triceps mm is spared, but distal tissue has loss
of sensory and motor function. Supinator and brachioradialis are paralyzed but elbow flexion and
forearm supination have been spared. There is also paralysis of all wrist extensors, finger extensors at
the MP joint, and inability to extend and radially abduct the thumb. Wrist drop deformity is the name
for it due to a dropped wrist posture. Common causes are direct trauma to the nerve due to fracture,
elbow dislocation, and Monteggia fracture dislocations. Other symptoms besides paralysis include a
sensory loss on the posterior arm and weakness in triceps depending on the injury site.

EVALUATIONS
Radial nerve palsy can usually be identified in visual examination through a study of ROM and
dermatomes. Evaluations can include a a strong occupational profile and PMH, postural evaluation,
ROM/MMT, outcome assessment (DASH, PRWE), and functional limitations.

INTERVENTIONS
Some damage responds within a few days, to up to 3-4
months. Patients who fail to show improvement after 3-4
months can be considered for surgery to correct damage nerve and
nerve pathway.
A wrist immobilization orthosis with the wrist in functional
position of 30 flexion is an option. A wrist cock up orthosis is less
conspicuous than a dynamic orthosis, and it is more
comfortable without problems of an outrigger bulk when used
during sleep. A low profile mobilization orthosis that
dynamically holds MP joints in extension but allows full digit
flexion can be used to substitute for absent muscle power and
promote functional use of the injured hand, leaving the palmar
surface of the hand free for sensory input. With a Colditz
tenodesis mobilization splint, the wrist is not immobilized; it
moves with the natural tenodesis effect, but it is expensive and
takes time to fabricate.
Other interventions include adaptive equipment and
modifications, retraining sensory processing, ROM and MMT, as
well as strength exercises using daily functional activities.

PRECAUTIONS
When designing orthoses, use less dynamic extension force on fourth and fifth digits, because their
digit flexors are exceptionally powerful and needed for gross grip. Make sure normal distal palmar arch
is maintained. Do not use elbow clasp splints or straps, and be cautious with compression sleeves for
the elbow. They can further compress the nerve at the radial tunnel.
CARPAL TUNNEL SYNDROME
Carpal tunnel syndrome is a nerve compression syndrome when the median nerve is compressed when
passing through the carpal tunnel on the volar side of the wrist. This is most commonly caused by
chronic tenosynovitis of the flexor tendons in the carpal tunnel. Components of the carpal tunnel
include the 4 tendons of FDS, 4 tendons of FDP, FPL, and median n. It is the most common nerve
entrapment in the UE; 1-3% incidence rate in the U.S. Symptoms include paresthesias in the thumb
index and middle finger, loss of dexterity, weakness and decreased ROM in hand, and numbness and
tingling in the hand. Symptoms are exacerbated at night, are worsened by repetitive forceful hand
motions, and are improved after shaking or straightening the affected hand. Carpal tunnel can be
usually unilateral but can be bilateral.

EVALUATIONS
Evaluations include a occupational profile, assessment of workplace and repetitive activities,
ROM/MMT, pain measures, DASH/PRFE/QuickDASH, and assessment of limits of functional activities.
Special tests for tennis elbow include:
1. Timel's sign test- tap inside of median nerve on inside of wrist.
2. Phalen's sign test- hold arms out and flex wrists and let hang for 60s, positive if symptoms of
carpal tunnel are present.

INTERVENTIONS
Carpal tunnel is optimally minimized with the wrist in 2 or wrist flexion and 3 of ulnar
deviation, so orthosis should be made with these measurements in mind. Splinting is most effective
utilized in the first 3 months of symptom onset. Wrist immobilization splint is the most effective, and
the orthosis should be worn especially at night for the best outcomes.
Other interventions can include median nerve glides, but you must avoid nerve tensioning and
stretching, because it results in venous congestion and a burning sensation. Contrast baths to reduce
inflammation and increase blood flow, kinesiotaping, iontophoresis, and proper body mechanics and a
proper workplace modification
and set up can be possible
interventions. Lumbrical exercises
can also be helpful in treating
carpal tunnel and re-
strengthening flexor muscles.
Clients should also be protective
sensation techniques and pain
management.
Surgical interventions
usually includes carpal tunnel
release, which is decompression
of the carpal tunnel to ease
symptoms. Focus on scar
tenderness as well if surgery
occurs.
CUBITAL TUNNEL SYNDROME
Cubital tunnel syndrome, also known as ulnar neuropathy, is a nerve compression syndrome on the
ulnar nerve as it passes in the cubital tunnel over the posterior elbow. It is the second most common
peripheral compression neuropathy in the UE. It is more likely to develop if a patient repeatedly leans
on their elbow, especially on a hard surface, and if they bend their elbow for sustained periods, such as
while talking on a cell phone or sleeping with your hand crooked under your pillow. Other repetitive
activities that require sustained elbow flexion can induce compression. Fractures and dislocations in these
sections can also lead to compression. Symptoms can include sharp and aching pain at the site or down the
ulnar side of the arm, decreased sensory input, decreased function and sensory input, paresthesias, feeling
of coldness, muscle weakness and atrophy in digits 4-5.

EVALUATIONS
Evaluations include a occupational profile, assessment of workplace and repetitive activities,
ROM/MMT, pain measures, DASH/PRFE/QuickDASH, and assessment of limits of functional activities.
Special tests for cubital tunnel syndrome include:
1. Froment's sign- pt attempts lateral pinch and will try to compensate by flexing the IP
joint of the thumb with the FPL due to a weak adductor pollicis and FPB.
2. Wartenberg's sign- sign is present if 5th digit is postured/held in an abducted position
from the 4th digit. The indicates interosseous muscle weakness.
3. Elbow flexion test- test designed to reproduce the symptoms of ulnar nerve
compression. The elbow is fully flexed, and the wrist is held in neutral for up to 5
minutes. Positive test is a reduction of symptoms.

INTERVENTIONS
The orthosis created should focus on making an anti-claw orthosis, making sure the MP joints
do not buckle out of the splint when the client attempts digit extension. Nocturnal elbow splinting to
restrict elbow from acute elbow flexion is common. The best literature indicates a long arm orthosis,
with the elbow positioned at 30-70 flexion,
forearm and wrist in neutral, and digits free. If
necessary, make a long arm orthosis on the
volar aspect of the arm/forearm.
Other interventions can include
education on ergonomics and proper body
mechanics, as well as avoidance of elbow flexion
stress during healing. Nerve gliding exercises,
stretching and PAMs such as heat, cold or
ultrasound can also be effective.

PRECAUTIONS
In advanced cases, there can be an imbalance of
extrinsic and intrinsic muscles, which leads to a
flattening of arches in the hands. An unopposed
extensor digitorum can lead to a claw hand
deformity.
COLLES' FRACTURE
Colles' fracture is a fracture that occurs due to
dorsal displacement of the distal fragment of the
radius. Its opposite, the Smith's fracture, is a
fracture with volar displacement of the distal
fragment. Both occur due to a FOOSH, but Smith's
occurs with the wrist in flexion, while the Colles'
occur with the FOOSH in wrist extension, so the
Colles' fracture is much more common. It is the most common fracture seen in the human body. Radius
shortening usually also occurs in this injury. It is usually extra-articular, minimally displaced and stable,
so the fracture will stay reduced in a brace/cast. It is most common in older women with osteoporotic
bone.

EVALUATIONS
Starting with the evaluation should include an occupational profile, AROM of UE joints, with specific
attention to wrist flex/ext and RD/UD, sensory testing of the dorsal sensory radial n., dynamometer
and pinchmeter, and any diagnostic imaging or testing from the physician that can assist with the
diagnosis.

INTERVENTIONS
Non-operative: usually treated with closed reduction and casting for 2-8 weeks, with wrist in moderate
wrist flexion and ulnar deviation to use the surrounding intact soft tissue to maintain the fracture
reduction.
Operative: treated with percutaneous pinning alone, or in conjunction with casting, external fixation,
or arthroscopic reduction. This stability can sometimes be enough to begin early AROM after the first
week post-op. Therapists can work on edema control, wound care and scar management, pain
management, restoration of digit motion, along with return of wrist and forearm motion during first 2
months of therapy. There is a new trend to use internal fixation methods instead of traditional external
fixators. If use of an external fixator, the client may have an easier time performing AROM without a
bulky cast, but education of fixator care is
important. After 4-6 weeks, risk of loss of
reduction is minimized, and wrist ROM can
begin. Examples of wrist exercises can
include prayer stretch, towel stretch, and
tendon gliding exercises .

PRECAUTIONS
Immobilization in moderate wrist flexion and ulnar deviation can cause or aggravate carpal tunnel
syndromes, because wrist flexion in prolonged periods increase pressure to carpal tunnel to potentially
dangerous levels. It is important to monitor client's sensory complaints during the period of cast
immobilization and promptly report concerns to the physician. Make sure to discuss proper pin care
with the patient if external fixation is a part of treatment. Be cautious of the many other complications
that could arise, including tendinopathies, CRPS, infections, nerve compressions, and soft tissue
complications.
SCAPHOID FRACTURE
Scaphoid fracture is the second largest carpal bone, and the
most commonly fractured bone in the wrist. It has a
proximal and distal pole, and the blood supply enters
through the distal pole. Scaphoid fractures can disrupt
blood supply to the bone which leads to a delay in bone
union, which is known as Avascular Necrosis (AVN). The
cause of a scaphoid fracture is usually due to a FOOSH with
the wrist extended and radially deviated. Usually, the stress
will most often center at the middle of the bone. It is an
injury that will often go unreported for a while, and is most
common in young males. This injury presents with pain,
tenderness near the scaphoid, limited strength and ROM (particularly wrist extension), and swelling.
Distal pole fractures (8-10 weeks) typically heal much faster than proximal pole fractures (12-24
weeks).

EVALUATIONS
Scaphoid fractures can not always be identified with an x-ray. Palpation of the anatomical snuffbox
leading to pain is a large identifier. The most common test for the diagnosis is the Watson's Test. Also
known as scaphoid shift test, it involves the therapist moving the patient's wrist from ulnar deviation
and slight extension to radial deviation and slight flexion. Pain elicited is a (+) test. Other tests that can
be performed is an overview of the FOOSH or injury, occupational
profile, ROM and pinch test, and DASH or QuickDASH.

INTERVENTIONS
Non-Operative: involves 6 weeks of immobilization using a short arm
splint that leaves the thumb completely free. Other recommend a
thumb spica splint leaving only the IP joint of the thumb free to
move. Once cast is removed, a forearm-based thumb spica orthosis
with the IP joint free will be continue to be moved. Treatments will
include edema management, AROM, frequent exercises every hour
to prevent stiffness, and performance of functional household tasks.
Operative: usually treated with internal fixation. Immobilization
following surgery usually depends on location of fracture, method of
internal fixation, whether or not a bone graft was used, and stability
of fracture. Patients with casting will most likely have stiffness, which needs to be treated with static
progressive splinting starting at 6 weeks post-op to regain mobility, and then similar hand therapy
interventions can begin to be utilized after medical clearance.

PRECAUTIONS
Acute scaphoid fractures may not be evident upon initial x-rays. Therefore, if there is a history of
FOOSH and pain with axial compression of the thumb, treat this injury as a fracture (with
immobilization) until symptoms have resolved and there is repeat radiographic or MRI evidence to the
contrary.
SKIER'S THUMB
Skier's thumb is an injury of the hand caused by damage to the ulnar collateral ligament (UCL) of the
thumb. The cause of this is usually due to a FOOSH with the thumb in abduction, which is a common
skiing injury (ski pole causes the thumb to abduct). This injury usually involves detachment of the
ligament from its proximal phalanx insertion. It is also common to have damage to the ACL, the VP or
the dorsal capsule. This injury can also be called "gamekeeper's thumb" if the injury occurs over time,
because long term tear and repetitive stress leads to instability of the UCL at the thumb MP joint. In
most of these injuries, Stener's lesions can also occur, which is when the adductor aponeurosis
becomes interposed between the ruptured UCL and its site of insertion at the base of the proximal
phalanx. Partial tears are treated with therapy; complete tears require surgical correction and therapy.

EVALUATIONS
Skier's thumb/ UCL damage can be detected by an x-ray. Ways to assess for a skier's thumb include an
occupational profile, DASH or QuickDASH, test of ROM and pinch strength. and an assessment of
symptoms in performance of daily functional tasks.

INTERVENTIONS
Full tears of the UCL require surgery for repair. Only
partial tears require immobilization of the joints using
a thumb spica splint. Both surgical and non-surgical
approaches will utilize a hand-based thumb spica
splint for treatment. After a period of immobilization,
AROM are initiated with medical clearance. Typically,
flexion, extension, and radial abduction started first,
then progress to gentle palmar abduction and
opposition. Light key pinch exercises can also start
early, but tip pinch and thumb tip loading exercises
are not performed until medically approved. Some
restriction is necessary to prevent stress to the
ligament, so later exercises should wait until about 8
weeks. Other practices include edema and scar
management after surgery and hand exercises. An
example of an occupation is moving a glass across a
table with the dorsal thumb.

PRECAUTIONS
Be alert for and take steps to prevent development of a thumb web-space contracture. Although a
typical approach is to splint in overcorrection (slight ulnar deviation), don't allow tightness in the web-
space to occur. Avoid tip loading and resistive pinching. Assess and problem-solve ADLs to protect
injured structures. Try building up girth of implements (like construct padded pens) to reduce load on
thumb MP joint. Instruct clients to avoid painful use of thumb.
BENNETT'S FRACTURE
Bennett's Fracture is a common intra-articular fracture at
the first CMC joint. This fracture occurs when there is
forced first CMC abduction and an axial blow along the
MC shaft when the MC is slightly flexed. The beak
ligament which stabilizes, causes an avulsion fracture of
the ulnar aspect of the 1st MC base. This can also lead to
dislocation or subluxation of the trapezio-MC joint. These
fractures tend to be stable due to multiple muscle and
ligament attachments. Signs and symptoms of this
condition include pain, swelling, tenderness to touch, and
weakness to the ability to grasp or pinch objects. It is very
treatable.

EVALUATIONS
Diagnosis of this fracture is completed through an X-Ray evaluation by a physician. Evaluations that can
be conducted by the OT or CHT include an occupational profile, pain and edema assessments, DASH or
QuickDASH, a list of symptoms that can aggravate the site, ROM and a visual examination of the area
for skin integrity, inflammation and color.

TREATMENTS
In most cases, surgical intervention is required due to intraarticular nature of injury. Internal fixation
can only occur is bony fragments are >25% of the joint surface or simply irreducible. Surgical repair is
usually completed via Kirschner wires. After surgery, the are is immobilized for 4-6 weeks in a forearm-
based thumb spica orthosis. IP joint AROM is allowed usually after 2-3 weeks of immobilization, but the
orthosis should be worn for another 3-6 weeks. If internal fixation has been used, mobilization can
begin after 1 week. Maintaining web space is
important. Other techniques for therapy can include
maintenance of skin integrity, edema and scar
management, and education on AROM and proper
elevation of the affected UE. Once strength is
allowed, one can start using functional activities to
add strength to hand muscles, like gripping towels
or pegs. Exercises can focus on thumb flexion and
extension, abduction and adduction, and pinch
strengthening.

PRECAUTIONS
ROM exercises need to be avoided until the
physician approves of it. Resistive exercises need to be avoided until there is radiographic evidence of
stable fracture healing, which is typically done after 3 months.
TRIGGER FINGER
Trigger finger, also known as digital stenosing
tenosynovitis, is a condition that develops from a
discrepancy that exists between the volume of the
flexor tendon and the size of the pulley lumen.
The site that this is most common is A1 , lying
volar to MCP joint near the distal palmar crease.
This can be due to nodules that are within the
flexor tendon sheath, which blocks the tendon's
ability to glide. Symptoms are the inability to
perform smooth digit flexion to extension. Trigger
finger has a high association with RA or DM. Many
clients describe a painful snapping making a fist
and an inability to extend the finger, as well as pain with palpation, diffuse inflammation, and swelling.
It is more common in women. The thumb, ring, and middle fingers are the most commonly affected
fingers.

EVALUATIONS
Trigger finger can be seen visually with pain and limited ROM during thumb flexion and extension.
Other important tests to conduct include an occupational profile, pain measures, edema, PRFE, DASH
or QuickDASH, and trying to rule out differential diagnoses.

TREATMENTS
Most people that have a trigger finger injury longer than 6 months
or more severe cases require surgical release of the pulley, then
sent to hand therapy for edema and scar management, ROM, and
orthoses. Corticosteroid injections can also be done to decrease
pain and help with symptoms. Clients must be educated to refrain
from any activities that aggravate symptoms. A hand-based volar
orthosis that supports the involved MCP joint/s at 0 degrees is
used. The orthosis must allow full IP flexion, and client is taught to
stretch with a hook fist exercises Hand exercises and fist motions
are used to prevent further locking and triggering, and other
techniques include massaging flexor tendon sheath, and functional
activities using finger joints. Avoid composite fist exercises. Finger
abduction/adduction exercises are also encouraged.

PRECAUTIONS
Warn the client to avoid any activities that could result in triggering for 6 weeks. Modify place and hold
exercises so that no triggering occurs; this can mean limiting these exercises to less than full composite
digital flexion initially. Watch for and manage skin maceration related to orthotic use.
LATERAL EPICONDYLITIS
Lateral Epicondylitis is a condition due to irritation, damage or strain to the extender tendons
connected to the lateral epicondyle of the humerus. It is commonly referred to as tennis elbow. This
condition is more common in people who are >35 years old, participate in repetitive occupational or
sports activities, use forceful or demanding hand/wrist postures, and have inadequate physical fitness
levels. Common symptoms include pain during ROM in wrist and finger extension radial deviation or
supination, and that can be through either active, passive, or ROM with resistance Other symptoms
include point tenderness, aching at night with elbow stiffness in the morning, and increased pain
gripping, grasping, twisting, and pushing. It is very treatable.

EVALUATIONS
Evaluations include a occupational profile, assessment of workplace
and repetitive activities, ROM/MMT, pain measures,
DASH/PRFE/QuickDASH, and assessment of limits of functional
activities. Special tests for tennis elbow include:
1. Cozen's test- stabilize pt's elbow with thumb on pt's lateral
epicondyle. Advise pt to actively make a fist and
pronate and extend wrist while therapist resists motion.
pain = + (top-right)
2. Grip Strength test- pt tests grip strength with humerus adducted,
forearm in neutral and elbow at 90. Record force on both
sides to test difference on arms, and also with arm
extended, and measure pain scales (test can be subjective)
(bottom right)
3. Handshake test- place pt's affected arm in handshake with
therapist. The pt will try to supinate against the therapist's
resistance. The elbow will flex the elbow and perform the
same motion, and record the difference.

INTERVENTIONS
Various surgical interventions can be performed to treat tennis elbow if the damage is more
severe.
A wrist immobilization orthosis will be made to be worn during periods of acute pain (10-21
days), with the orthosis positioned the wrist in 20-45 of extension. A volar wrist cock-up orthosis can
be used. After pain subsides, initiate gentle flexor and extensor forearm stretches. Once symptoms are
managed and pain is not exacerbated easily, initiate strengthening exercises. Eccentric exercises are a
good example of strengthening extensors without shortening the muscles. Ice can be used for pain
relief, as well as ultrasound and high-voltage pulse current.

PRECAUTIONS
Do not use heat if site is inflamed/swollen. Caution with eccentric exercises because they are more
forceful. Do not apply a counterforce tightly, it can cause nerve compression. No painful exercises.
DEQUERVAIN'S DISEASE
DeQuervain's disease is a tendinopathy that involves the pain over the radial styloid process with
tendons that make up the lateral border of the anatomical snuffbox (EPL, EPB, APL). The EPL EPB and
APL all share a common tendon sheath that can degenerate or become inflamed. This results in pain
with resisted thumb extension or thumb abduction, caused by repetitive or forceful thumb abduction
with ulnar and radial deviation. Activities that can provide this include typing, knitting, wringing out
rags, opening/closing jars, piano, racquet sports, and needlepoint. More common in women, ages 35-
55yrs, pregnant women in the third trimester. Symptoms include thickening and swelling, difficulty
making a fist, pain induced in extension and abduction of the thumb, and limited strength or ROM. The
pain can radiate either proximally or distally. It can also be called stenosing tenovaginitis or stenosing
tenosynovitis.

EVALUATIONS:
Important evaluations can
include an Occupational
Profile, DASH, and the
Finkelstein's test.
Finkelstein's test is a screen
that the therapist ulnarly
deviates the hand thumb
tucked into a fist. It is a
passive test; the test is positive if pain is elicited at lateral border of anatomical snuffbox.

TREATMENTS: If conservative treatments fail, surgical release of the first dorsal compartment is an
option. After surgery, orthosis is worn for a few weeks with isolated AROM, scar management,
desensitization, and strengthening exercises.
For nonoperative treatment, a forearm-based thumb spica orthosis that leave the IP joint free is
used to prevent painful motion. Position wrist in neutral and thumb in radial abduction for orthosis.
Some recommend wrist is slight extension. A radial or volar orthosis can be used. Other treatments can
include pain free ROM, and isometric exercises including wrist flexion and extension, as well as isolated
thumb IP flexion and extension.
Other therapies include ice, injections, anti-inflammatories, and identification and avoidance of
activities that can incite symptoms.
An example of a therapeutic task is sliding a cup across a table while extending and abducting
the thumb to increase strength and ROM.

PRECAUTIONS: Monitor for signs of superficial radial nerve irritation; modify orthoses if these
symptoms appear.
DUPUYTREN'S DISEASE
DuPuytren's disease is a benign connective tissue disorder that affects the palmar fascia that can lead
to flexion contracture of the MP joints and PIP joints. This condition is most commonly seen in older
men, and increases in advancing age. It is common to be affecting the hands bilaterally. It is
characterized by the presence of nodules and cords. The first symptoms include skin pits and
discolorations of the distal palmar crease, usually near the ulnar side, paired with itching and burning.
The nodules may remain constant, or and rapidly or slowly enlarge. With more sever PIP joint
contractures, the DIP joints can become hyperextended, a condition called Landsmeer's oblique
retinacular ligament (ORL). DuPuytren's has an association with DM-2, Alcoholism, Trauma and
Epilepsy. Contractures can be caused by the presence of nodules and cords which cause excess
collagen in the connective tissue. Surgical is very typical for this condition, and it is treatable.

EVALUATIONS: DuPuytren's disease can be identified by a physical examination of the fingers,

including tenderness/pain in palpation of firm nodules; skin blanching in active finger extension;
painless cords proximal to nodules; atrophic grooves/pits in skin; tender knuckle pads; presence of
contractures. Other evaluations can include an occupational profile DASH/QuickDASH, assessment of
limit of daily functional activities, and ROM test.

TREATMENTS: Surgically interventions include

Percutaneous Needle Aponeurotomy- making lacerations with needle in palmar fascia to
weaken the cord.
Fasciotomy- making a stab wound over the pretendinous cord to create a small longitudinal
incision to divide the cord. The tissue is not resected.
Fasciectomy- (gold standard) generous skin incisions and careful dissection and excision of just
the involved diseased fascia. Incisions are sutured and possibly closes with flaps and skin grafts.
Non-operative treatments include corticosteroid injections, dimethylsulfoxide injections, topical
vitamin A/E, topical verapamil, and antimetabolics
(5-FU).
Non-operative treatments include corticosteroid
injections, dimethylsulfoxide injections, topical vitamin
A/E, topical verapamil, and antimetabolics (5-FU).
Therapeutic interventions that can occur in the first week
include gentle AROM exercises, like making a fist. In weeks
2-3, continue ROM, measure ROM, and assess and treat
scar. In 3 weeks and after, focus on scar management, any
joint stiffness, and continue AROM. Orthoses are typically
worn continuously for the first 3 weeks. Not all surgical
patients will require an orthosis.

PRECAUTIONS: Be careful and observant of signs for CRPS.

Clients will naturally posture their hands protectively, so
discuss sleep patterns, pain management and anxiety with
the patient.
SWAN NECK DEFORMITY
Swan neck deformity is a condition in which the pt presents with PIP hyperextension and DIP flexion.
Lateral bands shift dorsally, which creates
unwanted PIP hyperextension. This can usually be
caused by mallet finger, which occurs when the tip of a
digit experience forced trauma; the result is a
ruptured terminal extensor tendon, which causes
a more forceful extensor pull proximally. This leads
to hyperextension of the PIP. This condition can also be
caused by RA in inflammation of the PIP or MCP joints.
Symptoms are detected visually, and patient's will
also have pain, limited AROM, swelling, and limits
to daily functional activities. Swan neck is very
treatable.

Evaluation: Swan neck deformity can be

diagnosed visually by seeing the hyperextension and flexion of the digits while the finger is at rest. The
following evaluations for more information regarding the patient's condition can also be conducted:
QuickDASH or DASH
Visual Analog Pain Scale

Treatment: Surgical interventions include soft tissue repair (involving the surrounding skin, tendons
and ligaments), PIP joint arthroplasty, and finger joint fusion. Swan neck deformity is treated through a
swan neck orthosis or an 8-
oval orthosis. Stretching for
pain free AROM, edema
management, scar
management, hand
strengthening exercises,
massage, or the use of
modalities as needed can be
used in therapy. Taping can
also help with edema and
stability. An example of a
functional therapy task would include stacking cups.

Precautions: Isotonic hand strengthening for the terminal extensor tendon is not recommended;
isometric strengthening is adequate. To avoid extensor lag at the DIP joint following a mallet injury,
encourage composite flexion and extension of the digit instead of blocked flexion and extension. Do
not sacrifice PIP joint extension for full PIP joint flexion. Educate the patient on cleaning pins if they are
exposed.
BOUTONNIERE DEFORMITY
Boutonniere deformity is a condition which presents in the digit has flexion in the PIP and
hyperextension on the DIP. This condition is caused
by forceful flexion of the PIP joint. Inflammation or
trauma on a digit causes a rupture of the central
band of the extensor tendon. This causes the lateral
bands to slip volarly. This condition can also be
caused by inflammation due to RA. This is
considered to be an injury to the extensor tendon
zone 3/4. Symptoms are detected visually, and
patient's will also have pain, limited AROM, swelling
and limits to daily functional activities. Boutonniere
deformity is very treatable.

Evaluations: Boutonniere deformity can be

diagnosed visually by seeing the hyperextension and
flexion of the digits while the finger is at rest. The following evaluations for more information regarding
the patient's condition can also be conducted:
QuickDASH or DASH
Visual Analog Pain Scale

Treatments: This can be treated either surgically or non-surgically. The goal of rehabilitation is to
achieve full passive PIP extension using dynamic, static progressive, serial static splints or casts. The
finger must be held in extension for 6 weeks prior to remobilization. Other techniques include edema
management, AROM that is pain free, hand
exercises, and functional tasks involving
hands that can be tolerated by the patient.
Taping can also help with edema and
stability An example of a functional therapy
task would be stacking cups.

Precautions: Isotonic hand strengthening

for the terminal extensor tendon is not
recommended; isometric strengthening is
adequate. To avoid extensor lag at the DIP
joint following a mallet injury, encourage composite flexion and extension of the digit instead of
blocked flexion and extension. Do not sacrifice PIP joint extension for full PIP joint flexion. Educate the
patient on cleaning pins if they are exposed.
OSTEOARTHRITIS (of the Hand)
Osteoarthritis, also known as "wear and tear" disease, is the breakdown in articular cartilage due to
mechanical and chemical factors. Changes in articular cartilage are caused by chondrocytes failing to
maintain in balance of cellular matrix, and this degradation leads to decrease in the articular cartilage
to act as a shock absorber" in joints. Abnormal loading of joints (trauma, heavy labor, joint instability,
obesity), being older than 50, especially females, and genetic susceptibility are all possible causes or
factors. Signs and symptoms include crepitus (grating/popping as digit flexes and extends),
inflammation and pain, decreased strength, limited AROM, triggering or locking of tendons, and new
bone formation (osteophytosis) leading to the formation of bone spurs and nodules. There is currently
no cure for OA.

Evaluation: It is important to develop an Occupational Profile of the patient, assessing:

pain (Visual Analog Scale)
active ROM (goniometry)
Hand strength (dynamometry, pinchmeter)
Observe inflammation, palpation on hands and joints
Observe hands side by side and compare joint changes; watch how they handle objects
9 Hole peg test (testing dexterity)
Moberg pick up test (testing sensory/manipulation)
Canadian Occupational Performance Measure (ability to perform ADLs)
AIMS (Arthritis Impact Measurement Scales)
Grind Test (compression of CMC jt. while rotating MCP at the CMC) - (+) if pain or crepitus
Observe tip pinch for ligament stability (signs of hyperextension)
Document fixed deformities

Treatment: Treatment for OA and managing symptoms can include the following techniques:
Joint protection principles (Respect pain, Balance rest and activity, Exercise (pain free range),
Avoid positions of deformity, Reduce the effort and force, Use larger/stronger joints)
Modalities: paraffin baths, warm baths, Hot packs/hand mitts (microwave), Non- thermal
ultrasound, Fluiodotherapy, Electrotherapy, Cryotherapy, Low level laser therapy
Exercise (general AROM while avoiding pain, stretching/massaging 1st web space, thumb
hollowing, thumb abduction, isometrics, strength of 1st dorsal interosseous pushing glass
across table, Thera-putty, tendon gliding exercises)
Orthoses
o Thumb cool neoprene orthosis
o Thumb Spica custom fit (hand based or wrist based)
o Finger (PIP, DIP) oval-8 splints
o include night-time positions and education on importance of splints and rest
Adaptive Equipment and home modifications
Ex. therapy with patient with opening jars with Dycem or using an adaptive opener.

Precautions: Avoid any pain when performing AROM exercises, and strengthen with caution to not
aggravate any hand deformities. PROM is not recommended due to a possible lack of joint stability.
Many clients enjoy benefits of heat modalities, so educate proper use so the clients avoid possibility of
burns.
REFERENCES

Cooper, C. (2014).Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for
common diagnoses of the upper extremity (2nd ed.). St. Louis, MO: Elsevier Mosby.

Demott, L. (2017). Management of Peripheral Neuropathy [PowerPoint Slides]. Retrieved from

https://osu.instructure.com/courses/21046/modules

Grace, A. (2017) Overview of Arthritis [PowerPoint Slides]. Retrieved from

https://osu.instructure.com/courses/21046/modules

Juckett, L. (2017). Management of Tendinopathies [PowerPoint Slides]. Retrieved from

https://osu.instructure.com/courses/21046/modules

Juckett, L. (2017). Management of the Elbow [PowerPoint Slides]. Retrieved from

https://osu.instructure.com/courses/21046/modules

Juckett, L. (2017). Management of the Hand and Fingers [PowerPoint Slides]. Retrieved from
https://osu.instructure.com/courses/21046/modules

Juckett, L. (2017). Management of the Shoulder: An OT Perspective [PowerPoint Slides]. Retrieved from
https://osu.instructure.com/courses/21046/modules

Juckett, L. (2017). Management of the Wrist [PowerPoint Slides]. Retrieved from

https://osu.instructure.com/courses/21046/modules