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ANTERIOR VIEW. RIGHT

Long thoracic N Serratus ant

POSTERIOR VIEW. RIGHT

Subclavian N.

Subclavias

Ut and Med. pectoral Ns I Pectorals major I Pectorals minor

Accessory Ml (cran. XI) Sternocle id om astoid. Mid. & low. trap Upper trapezius

Suprascapular IM.

_Supraspinatus

Infraspinatus

Axillary N

ANTERIOR VIEW. RIGHT

Long thoracic N Serratus ant

POSTERIOR VIEW. RIGHT

Subclavian N.

Subclavias

Ut and Med. pectoral Ns I Pectorals major I Pectorals minor

Suprascapular IM.

_Supraspinatus

Infraspinatus

Axillary N

inter, branch

© 2005 Florence P. Kendall. Author grants permission to reproduce for personal use but not for sale.

inter, branch

© 2005 Florence P. Kendall. Author grants permission to reproduce for personal use but not for sale.

CASE 3: PROBABLE C5 LESION

NECK, DIAPHRAGM AND UPPER EXTREMITY

Dale

Dale

NAME

NAME

•The patient's breathing seemed to be slightly labored. The patient stated that breathing was difficult for about a week after onset © 2005 Florence P. Kendall. Author grants permission to reproduce for personal use but not for sale.

CASE 4: LATERAL AND MEDIAL CORD 351 LESION

NECK, DIAPHRAGM AND UPPER EXTREMITY

Dale

Dora! Prim. Ramus

Dale

Dora! Prim. Ramus

Case 4: A manual muscle test was done before surgery, and the findings indicated the following:

© 2005 Florence P. Kendall. Author grants permission to reproduce for personal use but not for sale.

Case 4: A manual muscle test was done before surgery, and the findings indicated the following:

Slight involvement of the muscles supplied by the radial nerve below the level of innervation to the triceps.

Moderate involvement of the lateral cord below the level of the lateral pectoral nerve.

Probably complete involvement of the medial cord above the level of the medial pectoral nerve, interrupting the C8 and Tl supply (i.e., inferior trunk).

That the pectoralis minor, flexor carpi ulnaris, and flexor digitorum profundus III and IV show some strength can mislead one to assume that C8 and Tl are intact. These muscles, along with some of the intrinsic muscles of the hand, also receive C7 innervation, and there may be slight evidence of power in these muscles from C7 without the medial cord being intact.

At surgery, it was found that the medial cord had been interrupted by a bullet above the level of the medial pectoral nerve, as had been indicated by the muscle testing.

© 2005 Florence P. Kendall. Author grants permission to reproduce for personal use but not for sale.

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A 30-year-old male fell from a moving automobile and was unconscious for approximately 20 minutes. He was treated in the emergency room of a local hospital for minor abrasions and then released. During the next 3 weeks, he was seen and treated by several physicians because of paralysis and edema of the right arm and pains in the chest and neck.

Twenty-two days after the accident, he was admitted to the University of Maryland Hospital. A neuro-muscular evaluation, including a manual muscle test and an electromyographic study, was performed at that time and showed extensive involvement of the right upper extremity.

The decision was made to defer surgical exploration and treat the patient conservatively with an airplane splint and follow-up therapy in the outpatient clinic. Unfortunately, the patient did not report to the outpatient clinic until 5 months later. Subsequently, a detailed manual test (see facing page) as well as elec-trodiagnostic and further electromyographic studies were made.

SENSORY AND REFLEX TESTS

Sensation to pinprick was absent over the area of sensory distribution of the axillary, musculocutaneous, and radial nerves. No deep tendon reflexes of the biceps or triceps muscles were observed.

MANUAL MUSCLE TEST

The chart on the facing page indicates, at a glance, that the muscles supplied by the ulnar nerve were graded as normal, those by the median as either normal or good, and those by the radial, musculocutaneous, and axillary as either poor or zero. At the level of the brachial plexus, the involvement was more complicated, as noted by the grades ranging all the way from normal to zero. Concurrent charting of the involved peripheral nerves and spinal segments, however, furnished additional information and provided the basis for determination of the sites of lesions as follows:

1. A lesion of the posterior cord of the brachial plexus: The muscles supplied by the upper and lower sub-scapular, thoracodorsal, axillary, and radial nerves, which arise from the posterior cord, show complete paralysis or major weakness. Involvement of the subscapularis muscle places the site of lesion proximal to the point where the upper subscapular nerve arises ("c" in figure below).

2. No involvement of the medial cord of the plexus: The muscles supplied by the ulnar nerve, which is the terminal branch of the medial cord, graded normal. The sternal part of the pectoralis major and the pectoral is minor (C5-T1) and some muscles receiving median nerve supply (C6-T1) graded good. It is logical to assume that the slight weakness is attributable to the C5 and C6 deficit and not to any involvement of the medial cord.

DORSAL SCAPULAR SUPRASCAPULAR

LAT. PECTORAL

MUSCULOCUTANEOUS AXILLARY

MEDIAN ULNAR RADIAL

FROM 1-2 LONG THORACIC

M E D PECTORAL UPPER SUBSCAPULAR THORACODORSAL LOWER SUBSCAPULAR

Brachial plexus with possible sites of lesions (a, b, and c). U = upper; M = middle; L = lateral trunks; A = anterior divisions; P = posterior divisions; * = to longus coli and scaleni; LAT = lateral cord; MED = medial cord; POST = posterior cord. Reprinted from (33); with permission.

3. A lesion of either the upper trunk (formed by C5 and C6 roots ofthe plexus) or the anterior division of the upper trunk before it joins with the anterior division ofthe middle trunk (C7) to form the lateral cord: Confirmation of this statement requires an explanation of how it is ascertained that the lesion is in this area and that it is no more proximal than "a" or more distal than "b" in the figure on the previous Page.

The complete paralysis of the biceps and brachialis (from C5 and C6) raises the question of the level of involvement of these muscles—musculocutaneous nerve (C5, C6, C7), lateral cord (C5, C6, C7), trunk, or spinal nerve root?

That the coracobrachialis showed some strength rules out complete involvement at the musculocutaneous level. A complete lesion at the level of the lateral cord (CS, C6, C7) is refuted by several findings that indicate the C7 component is not involved.

The flexor digitorum superficialis, flexor digitorum profundus I and II. and lumbricales I and II, which have C7, C8, and Tl supply through the median nerve, graded normal. Other muscles supplied by the median nerve, which have C6, C7, C8, and Tl supply, graded good and, undoubtedly, would have exhibited more weakness had C7 been involved.

The sternal part of the pectoralis major and pec-toralis minor, which are supplied chiefly by the medial pectoral (C8 and Tl) and, to some extent, by the lateral pectoral (CS, C6, and C7), graded good and good+. Had C7 been involved, the weakness would undoubtedly have been greater.

The presence of some strength in the coraco-brachialis is thus explained on the basis of the C7 com ponents being intact, and it further confirms that such is the case. The stretch weakness, superimposed on this muscle by the shoulder joint subluxation and the weakness of the deltoid and biceps, could account for the coracobrachialis grading as no more than poor.

Thus, with C7 not involved, the most distal point of lesion may be considered as "b" in the figure on the previous page.

The possibility of CS and C6 being involved more proximal than "a" (see Figure, p. 353) at the level of the roots of the plexus is ruled out, because the rhomboids and serratus anterior muscles graded normal. Whether the lesion is proximal or distal to the point where the suprascapular nerve arises depends on whether involvement of the supraspinatus and infraspinatus muscles is on a neurogenic or a stretch-weakness basis.

The supraspinatus and infraspinatus (C4, CS, C6) graded fair, and if this partial weakness resulted from a neurological deficit, the lesion must be proximal to the point where the suprascapular nerve arises. Most logically, the presence of fair strength would then be interpreted as a result of regeneration during the 7 months since onset.

On the other hand, the weakness in these muscles may be of a secondary stretch-weakness type and not neurogenic. The patient had not worn the airplane splint that was applied 23 days after injury, and subluxation of the joint and stretching of the capsule were found. Additionally, the weakness was not as pronounced as in the other muscles supplied by CS and C6, a fullness of contraction could be felt on palpation, and these muscles had been subjected to undue stretch. If the weakness had resulted from stretch, the initial site of lesion would have been distal to the point where the suprascapular nerve arises.

The following is an example of stretch weakness superimposed on a peripheral nerve injury:

A woman was lifting a heavy rock while she was gardening. Her hands were in supination. The rock suddenly fell, turning her forearms into pronation. She felt a sharp pain in her right upper forearm. Weakness developed in the muscles supplied by the radial nerve below the level of the supinator. She was examined by several doctors, including a neurosurgeon who said that he had seen some cases, and knew of others reported in the literature, in which the radial nerve had been similarly involved at the level where it passes through the supinator.

The patient was first seen by a physical therapist 18 months after onset. The wrist extensors and the extensor digitorum showed marked weakness, but not complete paralysis, grading poor and poor+. A splint was applied, and in 2 weeks, the strength had improved to grades of poor+ and fair-h Then the condition reached a stalemate. The patient had started doing more work with the hand, and she left the splint off most of the time. Three months went by, but rather than give up, it was decided by the patient, the doctor, and the physical therapist that a period of more complete immobilization be tried. A plaster cock-up splint, including extension of the metacar-pophalangeal joints, was applied. This protected the wrist extensors and the extensor digitorum but allowed use of the interphalangeal joints in flexion and exten sion. The splint was removable, but the patient was cautioned to keep it on as much of the 24 hours in a day as possible and not to move the wrist and fingers into full flexion whenever the splint was off. After 2 weeks, the wrist and finger muscles were much improved. The patient played the piano and typed for the first time in 2 years.

A central nervous system lesion with superimposed stretch weakness is exemplified by the following case:

A child who had a right hemiplegia at birth was seen at the age of 12years for a "wrist drop." The hand was put into a cock-up splint and left for several months in that position, day and night, except for treatment periods. The muscles showed excellent return of strength. The following data taken from her records are especially interesting, because this patient was seen occasionally over a long period of time.

Age (years)

Grades off Muscle Strength

Extensor Carpi Radialis

Extensor Carpi Ulnaris

12

Poor-

Fair

13

Good+

Good+

16

Normal

Normal

20

Normal

Normal

24

Good

An overuse injury may be defined as damage caused by repetitive movements performed for a length of time that is beyond the tolerance of the tissues involved. The time involved may be short if the load lifted or the force required is excessive in relation to the ability of the subject. Overuse injuries often extend over a prolonged period of time with the activity causing an irritation or breakdown of muscle, tendon, or capsule and subsequent pain and inflammation.

The joints and muscles of the upper extremity are very vulnerable to overuse injuries. Repetitive hand and arm movements associated with a person's occupational or recreational activities give rise to a variety of strains, inflammatory processes, or nerve involvements that result in mild to debilitating conditions.

Overuse injuries cause numerous problems for over 2.3 million individuals in the United States who have disabilities requiring the use of a manual wheelchair (34). These wheelchair users depend on their upper extremities for mobility, transfers, pressure relief, and a variety of other daily functional activities. The most commonly occurring pathology is shoulder impinge-

ment syndrome involving the rotator cuff, biceps tendon and/or the subacromial bursa.

For overuse injuries such as tennis elbow (i.e., lateral epicondylitis), golfer's elbow (i.e., medial epicondylitis), swimmer's shoulder (i.e., impingement syndrome), repetitive strain injury from excessive keyboard or computer use, or push-ups done to excess, appropriate treatment depends, in part, on the specificity provided by manual muscle testing.

For example, accurate testing may help to avoid diagnoses such as carpal tunnel syndrome when the problem is, in fact, a pronator teres syndrome. A Mayo Clinic study showed that 7 of 35 patients who were operated on for carpal tunnel were later found to have pronator teres syndrome (35).

The aim of conservative treatment is to relieve pain, reduce excessive use, and alleviate further strain. Periodic use of appropriate wrist, arm, shoulder, or upper back supports can help minimize the debilitating effects of overuse injuries and restore more optimal functioning of the muscles involved.

Below is an outline of the areas of most concern for the upper extremity.

Wrist joint extension, extensor muscles, radial nerve (C5, 6, 7, 8) Wrist joint flexion, flexor muscles, ulnar nerve (C7, 8, Tl)

Wrist joint flexion, flexor muscles, median nerve (C6, 7, 8) Carpal tunnel syndrome

Radioulnar joint (forearm), pronator teres, median nerve (C6, 7) Pronator teres syndrome

Elbow joint, flexor muscles, musculocutaneous nerve (C4, 5, 6) Lateral epicondylitis (tennis elbow) Medial epicondylitis (golfer's elbow)

Shoulder joint, abductor: supraspinatus, musculocutaneous nerve (C4, 5, 6)

Shoulder joint, lateral rotation: supraspinatus, infraspinatus (C4, 5, 6)

Shoulder joint, medial rotation: subscapularis, teres major (C5, 6, 7)

latissimus dorsi (C6. 7, 8)

CORRECTIVE EXERCISES: UPPER 357

EXTREMITY

Exercises in the lying position should be done on a firm surface (e.g., a board on the bed, a treatment table, or the floor, with a thin pad or folded blanket placed on the hard surface for comfort).

Stretching exercises should be preceded by gentle heat and massage to help relax tight muscles. (Avoid using heat on weak, overstretched muscles.) Stretching should be done gradually, with a conscious effort to relax. Continue until a firm, but tolerable "pull" is felt, breathing comfortably while holding the stretch, then return slowly from the stretched position.

Strengthening exercises should also be done slowly, with an effort to feel a strong "pull" by the muscles being exercised. Hold the completed position for several seconds, then relax and repeat the exercise the number of times indicated by your therapist.

Wall-Sitting Postural Exercise Sit on a stool with back against a wall. Flatten low back against wall by pulling up and in with lower abdominal muscles. Place hands up beside head. Straighten upper back by pulling shoulder blades down and back and pull elbows back against wall. Keep arms in contact with wall and slowly move through the patterns below.

Shoulder Adductor Stretching With knees bent and feet flat on table, tilt pelvis to flatten low back on table. Hold the back flat, place both arms overhead, and try to reach arms to the table with elbows straight. Bring upper arms as close to sides of head as possible. (Do NOT allow the back to arch.) Progress to other movement patterns below.

Assisted Stretching of Pectoral is Minor With subject in back-lying position (knees bent, feet flat), assistant stands on side of shoulder to be stretched and places cupped hand between the neck and the shoulder joint. Press shoulder back and down with firm, uniform pressure that helps to rotate the shoulder back. Hold for 60 seconds.

Stretch Upper Trapezius by Strengthening Latissimus Dorsi

Sit on table with padded block beside hips. Keep body erect with shoulders in good alignment. Press downwards, straightening the elbows, and lift buttocks directly upward from the table. Return slowly to starting position.

References

1. Goss CM, cd. Gray's Anatomy of the Human Body. 28th Ed. Philadelphia: Lea & Febiger. 1966.

2. Bremner-Smith AT. Unwin AJ. Williams WW. Sensory pathways in the spinal accessory nerve. J Bone Joint Surg [BR] 1999:8 l-B:226-228.

3. Dorland WA. The American Illustrated Medical Dictionary. Philadelphia: W. B. Saunders. 1932.

4. Johnson JYH, Kendall HO. Isolated paralysis of the ser-ratus anterior muscle. J Bone Joint Surg I Am] 1955:37-A:567; Ortho Appl J 1964:18:201.

5. Taber CW. Taber's Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis. 1969, pp. 1-25, Appendix 45-50.

6. Dorland - Illustrated Medical Dictionary. 27th Ed. Philadelphia: W.B. Saunders. 1988:1118-1125.

7. O'Neill DB. Zarins B. GelbeimaenRH. Keating TM, Louis D. Compression of the anterior interosseous nerve after use of a sling for dislocation of the acromioclavicular joint. J Bone Joint Surg [Am] 1990:72-A(7) 1100.

8. Hadley MN, Sonntag VKH. Pittman HW. Suprascapular nerve entrapment. J Neurosurg 1986;64:843-848.

9. Post M, Mayer J. Suprascapular nerve entrapment. Clin Orthop Realt Res 1987; 223: 126-135.

10. Conway SR. Jones HR. Entrapment and compression neuropathies. In: Tollison CD. ed. Handbook of Chronic Pain Management. Baltimore: Williams & Wilkins, 1989.

11. Sunderland S. Nerve Injuries and Their Repair: A Critical Appraisal. London: Churchill Livingstone, 1991, p. 161.

12. Nakano KK. Neurology of Musculoskeletal and Rheumatic Disorders. Boston: Houghton Mifflin, 1978. pp. 191, 200.

13. Geiringer SR. Leonard JA. Posterior interosseus palsy after dental treatment: case report. Arch Phys Med Re-habil 1985-.66.

14. Dawson DM. Hallett M, Millender LH. Entrapment Neuropathies. 2nd Ed. Boston: Little, Brown, 1990.

15. Conway SR, Jones HR. Entrapment and compression neuropathies. In: Tollison CD, ed. Handbook of Chronic Pain Management. Baltimore: Williams & Wilkins,

1989.

16. Agur AMR. Grant's Atlas of Anatomy. 9th Ed. Baltimore: Williams & Wilkins. 1991.

17. Palmer ML, Eppler M. Clinical Assessment Procedures in Physical Therapy. Philadelphia: JB Lippincott Co.,

18. Reese NB. Bandy WD. Joint Range of Motion and Muscle Length Testing. Philadelphia: W.B. Saunders, 2002, p. 403.

19. Clarkson HM. Musculoskeletal Assessment. 2nd Ed. Baltimore: Lippincott Williams & Wilkins. 1989, p. 403.

20. AAOS American Academy of Orthopedic Surgeons. As cited in Reese NB. Bandy WD. Joint Range of Motion and Muscle Length Testing. Philadelphia: W.B. Saun-ders. 2002. p. 404.

21. A M A American Medical Association. As cited in Reese NB, Bandy WD. Joint Range of Motion and Muscle Length Testing. Philadelphia: W.B. Saunders. 2002. p. 404.

22. American Society of Hand Therapists, Fess EG, Movan C, ed. Clinical Assessment Recommendations. 2nd Ed. Gamer, NC: The American Society of Hand Therapists, 1992, p. 51.

Dirckx JH, ed. Stedman's Concise Medical Dictionary. 4th Ed. Baltimore: Lippincott Williams & Wilkins, 2001, p. 76.

Inman VT, Saunders JB, de CM. Abbott LC. Observations on the function of the shoulder joint. J Bone Joint Surg 1944;26:1.

25. Spinner M. Management of nerve compression lesions of the upper extremity. In: Omer GE, Spinner M. Management of Peripheral Nerve Problems. Philadelphia: W.B. Saunders. 1980.

Sunderland S. Nerves and Nerve Injuries. 2nd Ed. New York: Churchill Livingstone, 1978. Kendall HO, Kendall FP, Boyton D. Posture and Pain. Baltimore: Williams & Wilkins, 1952.

28. Stein, I. Painful conditions of the shoulder joint. Phys Ther Rev 1948:28(6).

29. Cahill BR. Quadrilateral space syndrome. In: Omer GE Spinner M. Management of Peripheral Nerve Problems. Philadelphia: W.B. Saunders, 1980, pp. 602-606.

30. CD Denison. Orthopedic Appliance Corporation, 220 W. 28th St. Baltimore, Maryland.

31. Burstein D. Joint compression for treatment of shoulder pain. Clin Man 1985;5(2):9.

32. Brown LR Niehues SL, Harrah A, et al. Upper extremity range of motion and isokinetic strength of internal and external rotators in major league baseball players. In: McMahon PJ. Sallis RE. The Painful Shoulder, Postgraduate Medicine. 1999; 106(7).

33 Coyne JM, Kendall FP, Latimer RM. Payton OD. Evaluation of brachial plexus injury. J Am Phys Ther Assoc 1968;48:733.

34. Trends and differential use of assistive technology devices: United States, 1994. The National Health Interview Survey on Disability, 1999.

35. Hartz Cr, Linscheid RL, Gramse RR, Daube JR. The pronator teres syndrome: compression neuropathy of the median nerve. J Bone Joint Surg, 198l;63A;885-890.

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