It is winter time here in Colorado which means, skiing, snowboarding, cross country skiing, and snowshoeing, in additional to all the normal running and biking people do. It also means snow with slippery parking lots and sidewalks. All of these things can create a nightmare situation for your upper extremities, should you fall and catch yourself on an outstretched hand.
Which brings me to the topic of today’s injury discussion. Let us take a few moments to discuss a pathology that is often initially overlooked but can create long term chronic elbow (and more widespread) pain if left untreated.
FOOSH or “fall on outstretched hand” as it is known, can cause both wrist and elbow pain. After a person falls and catches themselves on their outstretched hand they are often concerned as to if they broke a bone. Once they have discovered that nothing is broken they go on with their daily lives, assuming that the soreness will dissipate. However, with this pathology once the initial soreness and bruising is gone the patient is often left with lingering elbow or wrist pain which can progress into entire forearm pain the longer it is left untreated.
When a person falls and reaches out to catch themself, the elbow is extended and pronated and the ulna is abducted. The force of the fall can cause the elbow to become fixated in this position. When the forearm is pushed into abduction the pressure from the capitulum pushes the radius inferiorly. If the radius is pushed distally the hand is pushed into ulnar deviation. When this happens you wind up with increased tension in the extensor carpi radialis muscles to bring the hand back to functional neutral, which means they need to move into a radial deviation motion. The movement that goes with radial deviation is extension. The extensors wind up working overtime to keep the hand in “neutral”; however, the carpel bones are still suck in radial deviation. Because the extensors are working overtime to keep the hand in functional neutral the wrist extensors become painful and the patient now has a pain that seems like “tennis elbow” in their lateral elbow. The patient will complain of lateral elbow pain and they might also get tingling in the hand from the ulnar nerve. If you have a patient that is a waitress or someone that has to do passive wrist extension during the day, such as carrying a tray, you can get a subluxed carpel as well. So now this patient is complaining of wrist pain as well.
The above injury, at the elbow, is then termed an ULNAR ABDUCTION LESION. The pain from this problem can often mimic tennis elbow pain. The exam of the elbow would show:
- Restriction of elbow flexion and supination.
- Increased carrying angle
- With the abd/adduction stress test you will lose the adduction movement. You should have 2xmore abduction then adduction.
- Loss of ulnar deviation. There should be a 2:1 ratio of ulnar deviation to radial deviation.
If this lesion is confirmed through the above profile, the only treatment is a manipulation. In order to perform a manipulation you first need to make sure the patient is an appropriate candidate for manipulation and that they have given their verbal permission as well as have a negative pre-manipulative hold. Should the clinical scenario meet the previous mentioned requirements, the manipulation is a quick and effective treatment modality that will provide immediate results.
Stacy SoappmanPT, DSc, COMT, FAAOMPT