Arm, Elbow, and Wrist Pain
Falls and overuse plague the lower arms. Although mindfulness and attention are needed to lower the risk of falls, proper posture and form can help prevent and, when inflamed, treat the symptoms related to overuse. The financial and personal costs of treating carpal tunnel syndrome alone makes successful care of the lower arm, including the elbow and wrist, a critical component of clinical practice. Simple interventions can improve outcomes by simply applied nonsurgical treatment.
ELBOW PAIN
Differential Diagnosis
Lateral or medial epicondylitis
Pronator teres syndrome (tenderness or decreased ability to supinate, with referred symptoms of median nerve compression)
Cubital tunnel syndrome (ulnar nerve impingement)
Shoulder impingement
Angina (left-sided)
Cervical radiculopathy
Physical Examination
Palpate and percuss to identify areas of discomfort (lateral epicondyle, medial epicondyle, pronator teres). (Figure 9-1) If you cannot palpate the area of discomfort, consider the etiology referred pain.
ALERT: Referred pain can be due to angina (left arm), cervical radiculopathy, shoulder impingement syndrome, and cubital tunnel syndrome. Figure 9-1 • Right arm, anterior view. |
Diagnosis
Medial epicondylitis (Golfer’s elbow): Pain to palpation and percussion over medial epicondyle, made worse with extended elbow and resisted wrist flexion and/or pronation.
Lateral epicondylitis (Tennis elbow): Pain to palpation and percussion over lateral epicondyle, made worse with extended elbow and resisted wrist extension and/or supination.
Pronator teres syndrome: Tenderness over pronator teres muscle; compression at this site may cause pain or paresthesias radiating to the palm and/or digits within 30 seconds of compression; can mimic carpal tunnel syndrome; pain with supination and numbness over the anterior wrist and thenar eminence.
Physical Examination for Pronator Teres Syndrome
The patient holds the elbow in 90 degrees of flexion and is asked to keep the elbow relaxed.
The clinician holds the elbow to stabilize and grasps the patient’s lower arm.
The patient attempts to pronate their forearm as the clinician holds resistance (forcing the patient to contract pronator teres) and extends the elbow (Figure 9-2).
If the patient’s symptoms are reproduced, the median nerve is likely being compressed by the pronator teres.
Figure 9-2 • Tests for pronator teres syndrome. (Reprinted from Palmer ML, Epler M. Fundamentals of Musculoskeletal Assessment Techniques. 2nd ed. Philadelphia: Wolters Kluwer; 1998 with permission.)
Cubital tunnel syndrome: Impingement of the ulnar nerve as it traverses the medial elbow; often due to sleeping with elbow bent, leaning forward on elbows, cell phone use (called “cell phone elbow”), or trauma; symptoms include waking from sleeping with numbness and tingling over fourth and fifth digits with decreased grip strength
Remember the Rules
1. Move to a position of less pain and apply trigger point care
2. Stretch the SHORTENED muscle
3. Treat the region (above and below the pain)
4. Tape to support neutral position
5. Support definitive treatment (physical therapy, orthopedics, neurosurgery)
Treatment
Forearm Mobilization (for all forearm symptoms)
With the patient’s wrist in neutral (not flexed) and their arm supported by your thigh, place pressure downward and gently rock to the patient’s tolerance on the patient’s flexor tendons in the forearm to loosen adhesions of the tendon along the tendon sheath, from distal to proximal.
Repeat 10 times and assess for patient response.
Treatment for Lateral Epicondylitis and Pronator Teres SyndromeThis treatment is as effective as corticosteroid injection for lateral epicondylitis.
Use your hand to stabilize the patient’s elbow.
Supinate the patient’s hand with your other hand until the endpoint is reached.
Ask the patient to pronate the forearm against your resistance, using 10% effort.
Have the patient take three belly breaths, then relax.
As the patient relaxes, supinate to a new endpoint.
Repeat these steps for a total of three cycles.
Treatment for Medial Epicondylitis
Stabilize the patient’s elbow with your hand.
Pronate the patient’s hand with your other hand until the endpoint is reached.
Ask the patient to supinate the forearm, using 10% effort, against your resistance for three belly breaths, then relax.
Pronate to new endpoint.
Repeat these steps for a total of three cycles.
Cubital Tunnel Syndrome
Massage the medial aspect of proximal forearm to relax muscles. Do not massage over the cubital tunnel or nerve.
With their elbow wrist and fingers extended and their palm pointing away (“stop” gesture), ask the patient to gently flex and extend their wrist 10 times; if no symptoms, have them make a fist and repeat.
Treatment
Have the patient keep the elbow straight and extend their wrist and fingers.
With one hand supporting their and the other on the fingers, and forearm, hold resistance while asking the patient to flex their wrist, using 10% effort and take three belly breaths, then relax.
As the patient relaxes, move the wrist into further extension.
Repeat for three stretch-relax cycles.
WRIST PAIN
Differential Diagnosis
Carpal tunnel syndrome
Wrist sprain
Bone dislocation
Osteoarthritis
History and Diagnosis
Carpal tunnel syndrome: Waking with numbness over median nerve distribution (Figure 9-3) in hand/wrist (anterior thumb, index, middle, and fourth fingers, in contrast to cubital tunnel syndrome, which causes numbness over fingers 4 and 5), thenar wasting, and weakened grip strength
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