SPECIAL TESTSHOULDER

TEST INDICATION POSITION/MANUEVER RESULT

Anterior apprehension and relocation tests

Anterior glenohumeral joint instability

supine, shoulder abd 90*, elbow flx 90*Ex-ER & apply anterior directed force on the humeral head

(+) pt indicates a feeling of impending anterior dislocation

Posterior apprehension test

Posterior glenohumeral joint instability

Shoulder flx 90*, maximally IRPosteriorly directed force is applied on pt elbow

(+) 50% or greater posterior translation of humeral head/feeling of apprehension

Sulcus sign Inferior glenohumeral joint instability

Sitting/standing with arms at adductedExaminer apply a distal traction force

(+) sulcus between the humeral head and the acromion

O’Brien’s test

Acromioclavicular joint/labral abnormalities

Shoulder flex, add.,IRElbow extendedEx – downward force against a resisted armShoulder EREx –downward force against a resisted arm

(+) pain on 1st manuever in the acromioclavicular area-acromioclavicular pathologyPain or painful clicking deep inside the shoulder –labral pathology

SPECIAL TESTSHOULDER

TEST INDICATION POSITION/MANUEVER RESULT

Neer-Walsh impingement test

Rotator cuff pathology

Shoulder IR at sideEx-passively flx to 180*maintaining IR

(+) pain in the subacromial area

Hawkins-Kenedy impingement test

Rotator cuff pathology

Shoulder/elbow passively flx 90*, stabilize scapulothoracic jt, IR humerus

(+) pain at subacromial region with IR

Drop arm test

Rotator cuff tear

Ex-passively abd 90*Pt slowly lower the arm back to the side

(+) pain and inability to slowly lower the arm to the side

Speed’s test Biceps tendinitis

Shoulder flx90*, elbow extPalm facing upEx-downward force against pt resistance

(+) pain in the bicipital groove

SPECIAL TESTSELBOW

TEST INDICATION POSITION/MANUEVER RESULT

Cozen’s test Lateral epicondilitis

Fully extend elbow, pronate forearm and make a fistEx- resists patients attempt to ext and radially deviate the wrist

(+) pain on lateral epicondyle

Ligamentous instability test

Radial/ulnar collateral ligament

Elbow flx 20-30*, stabilize pt’s armEx-apply a valgus/varus force across the elbow

SPECIAL TESTWRIST AND HAND

TEST INDICATION POSITION/MANUEVER RESULT

Finkelstein’s test

Tenosynovitis of EPB & APL(De Quervain tenosynovitis)

Patient make a fist w/ thumb inside the fingerEx-passively ulnar deviates the wrist

(+) pain on the affected tendon

Watson’s test Scapholunate stability

Ulnarly deviates positionEx-dorsal force against the proximal volar pole os the scaphoid;radially deviates the wrist

(+) pop or subluxation of the scaphoid

Tinel’s sign Carpal tunnel syyndrome

Ex-taps over the carpal tunnel (+) paresthesia into the thumb, index and middle fingers

Phalen’s test Carpal tunnel syndrome

Ex-flexes pts wrist and holds them for one min.

(+) paresthesias in the median sensory distribution of the heand

MUSCULOSKELETAL PROBLEMS OF THE UPPER LIMBSHOULDER

Sternoclavicular sprainGrade Definition Signs

1 mild; w/o instability or significant ligamental disruption

Tenderness to palpation w/o joint laxity

2 Moderately severe ligamentous sprain w/ asso. subluxation of the sternoclavicular joint

Tenderness to palpation w/ joint laxity but a good end point

3 Complete disruption of sternoclavicular ligament w/ anterior or posterior dislocation

Tenderness to palpation w/ joint laxity and no end point

ShoulderSternoclavicular spraino Anterior dislocation – 2/3 of sternoclavicular

joint dislocation- Medial end of clavicla becomes prominent- Trauma

o Posterior dislocation – 1/3 of sternoclavicula dislocation

- More pain, less prominent medial clavicular end.

- Asso. w/ vascular compromise to the ipsilateral limb, neck,upper limb venous congestion difficulty of breathing/swallowing.

ShoulderSternoclavicular spraino Treatment- Grade 1 and 2

> ice (24-48 hours)> sling immobilization> NSAIDs and analgesics> return to activity 1-2 weeks (gr.1), 4-6 weeks (gr.2)

- Grade 3> anterior/posterior dislocation – reduction; surgical intervention

shouldero Radiologic – serendipity view

ShoulderClavicular fracturetype definition

1 Interligamentous with minimal displacement

2 Medial to coraco-clavicular ligaments; displaced

3 Intra-articular fractures of the distal clavicle in the acromio-clavicular joint

ShoulderClavicular fracture- Common in children and adult under 25 years

old.- 80% middle/3rd; 15% lateral/3rd; 5% medial/3rd

- Radiologic: o Proximal third – serendipity view, APo Lateral third – Zanca view, axillary lateral view,

AP

- Treatment> partial immobilization w/ sling, figure of eight bandage

ShoulderAcromioclavicular joint spraintype definition Radiologic findings

1 Mild; coracoclavicular and acromioclavicular ligaments are intact

(N) findings

2 Complete disruption of the acroclavicular ligament, intact coracoclavicular ligament

(+) clavicular elevation; < 25% displacement

3 Complete disruption of acromioclavicular and coracoclavicular ligamnet; deltotrapezial fascia intact

25-100% coracoclavicular interspace relative to normal shoulder

4 Complete disruption of acromioclavicular and coracoclavicular ligaments;

Posterior displacement of distal clavicle into trapezius muscle

5 Coracoclavicular and acromioclavicular fully disrupted, rupture of deltotrapezial fascia

> 100% coracoclavicular interspace of a (N) shoulder

6 Complete disruption coracoclavicular, acromioclavicular and deltotrapezial muscular attachment

Displacement of the distal clavicle below the acromion or the coracoid process

ShoulderAcromioclavicular joint spraino Treatment:- Type 1,2 and 3

> non-operative> immobilizaton with sling, ice, analgesics> if pain subsides – ROME, strengthening ex> indication for surgery in type 3 – persistent pain, unsatisfactory cosmetic results

- Type 4,5 and 6- > surgical treatment

ShoulderOsteolytic of the distal clavicleo Repetitive overload of the distal clavicle

o Young weight lifters – bench press/ military press lifter

o Gradual onset of acromioclavicular joint pain that is increased with bench press

o Bilateral

ShoulderOsteolytic of the distal clavicleo Radiographic findings:- Pathologic changes: distal clavicular

subchondral bone loss and cystic changes- Widening of acromioclavicular joint – late

stage

o Treatment :- Avoidance of aggravating activities- Ice, NSAIDs, corticosteroid injection- Distal clavicular resection

ShoulderScapulothoracic crepituso “snapping scapula” or scapular crepitus.

o 3 primary types of sounds:1.Gentle friction sound - physiologic2.Loud grating sound – soft tissue disease

(bursitis,fibrotic muscle etc)3.Loud snapping sound – bony pathology

(osteophyte, rib or scapular oateochondroma)

o Treatment> correction of biomechanical deficits> mobilization> NSAIDscorticosteroid injection

ShoulderRotator cuff injuryStages

1 Inflammation and edema in the rotator cuff

2 Fibrosis and tendonitis

3 Partial/complete rotator cuff tear

ShoulderPectoralis major strainoSudden pain in the pectoral region during

a forcrful activity employing shoulder adduction or internal rotation.

oEdema and ecchymosis on chest wall/proximal anterior arm region

oAxillary fold –visible defect when shoulder is abducted

oWeakness and pain with shoulder adduction and internal rotation

ShoulderPectoralis major strain o Treatment:- Grade 1 and 2

> ice, NSIDs, mild analgesics, sling> gentle passive range of motion = active ROME = strengthening ex.

o Radiologic findings- x-ray – normal- MRI

ShoulderGlenohumeral joint instabilityGrade Signs

Subluxation Humeral head extends to the edge of glenoid fossa w/o dislocation, followed by spontaneous reduction

Dislocation Humeral head becoms fully dislodge fom the glenoid fossa; manual reduction

Microinstability Repititive microtraumaor congenital laxity of the glenohural ligament

ShoulderAdhesive Capsulitis

o Codman -“frozen shoulder”

o Painful restriction in shoulder ROM with normal radiographs.

o Neviaser – “adhesive capsulitis”

o Occur in 2-5% of general populationo Women

o 40-60 years of age

ShoulderAdhesive Capsulitiso Causes:- Idiophatic- Diabetes mellitus- Inflammatory arthritis

o Pathologic evaluation- Perivascular inflammation- Fibroblastic proliferation with increased

collagen and nodular band formation

ShoulderAdhesive Capsulitis

Stages of adhesive capsulitis

Stage Duration (m0nths)

Signs and symptoms

1 1-3 Painful shoulder movement, minimal restriction in motion

2 (freezing)

3-9 Painful shoulder movement, progressive loss of glenohumeral joint motion

3 (frozen)

9-15 Reduced pain w/ shoulder movement, severely restricted glenohumeral joint motion

4 (thawing)

15-24 Minimal pain, progressive normalization of glenohumeral joint motion

ShoulderAdhesive Capsulitiso Treatment:- Hannafin et al – recommend early use of intra-

articular corticosteroid injection for stages 1 & 2> decrease the initial inflammatory stage> reduce the development of fibrosis

- NSAIDs

- ROME, shoulder girdle strengthening ex.

Restoration of normal function – 14 months

ShoulderAdhesive Capsulitiso Treatment:- Manipulation of shoulder under anesthesia

- Hydrodilatation of the glenohumeral joint

- Surgical management: arthroscopic capsular release

ShoulderSuperior labral anterior to posterior

lesionso SLAP lesion – injuries to superior labrum and

biceps tendon

o MOI:- Fall on outstretched arm – causes superior

translation of the humeral head and compression of the superior glenoid labrum.

- Deceleration phase of overhead throw – traction force of the by the biceps on the superior labrum

- Traction injuries

ShoulderSuperior labral anterior to posterior

lesionsClassification of SLAP

Type Description

1 Injury to superior labrum w/o detachment of the biceps tendon.

2 Biceps tendon is detached from the supraglenoid tubercle

3 Bucket handle tearing of the superior labrum w/o detachment of the bicep tendons

4 Tear of the superior labrum that extends into the biceps tendon.

ShoulderSuperior labrum anterior to posterior lesionso Classification of SLAP

ELBOW JOINT

Elbow jointLateral Epicondylitiso “tennis elbow”

o Repetitive stress on the lateral forearm musculature.

o >35 years old (peak 40-50 years old)

o Male

o Degenerative changes

o vascular granulation in the damaged tissue>angiofibroblastic hyperplasia

Elbow jointMedial epicondylitiso “golfer’s elbow”

o Risks factors: Training errors, faulty equipment, repetitive activities requiring wrist flexion and forearm supination, poor strength, flexibility imbalance and joint instability

o Degenerative changes are most frequently found in the pronator teres and flexor carpi radialis origin.

o Weaknes in grip strength

Elbow jointMedial epicondylitisoRadiographic findings:- Punctuate calcifications in the region of

the flexor tendon origins

oNon-operative management:- Anti-inflammatory medications- Cryotherapy- Galvanic ES / iontophoresis- Corticosteroid- ROME, strengthening ex, endurance and

flexibility ex.

Elbow jointDistal biceps tendinitiso (+) pain in the antecubital fossa

o Physical findings: tenderness, pain w/ resisted elbow flexion

o Radiologic findings: Normal

Elbow jointRupture of the distal biceps tendono 30 – 50 years old

o Men

o MOI: heavy lifting activities w/ elbow at 90* flexion

o Acute pain, popping or tearing sensation in the ante-cubital fossa

o PE – ecchymosis, edema, eruthema absence of distal biceps brachii tendon

Elbow jointDistal triceps tendonitiso Symptoms: aching and burning pain in the

distal triceps.

o PE: tenderness over the distal triceps tendon and pain w/ resisted elbow extension

o Radiologic evaluation: Normal

Elbow jointTriceps tendon ruptureo MOI: fall on outstretched hand, direct blow

to the triceps tendon

o Most common site of disruption: insertion site on the olecranon

Elbow jointSnapping triceps tendono Pathologic band over the medial side of the

distal triceps can cause a snapping sensation over the medial epicondyle during elbow flexion and extension

o Treatment : deep tissue massage, stretching of the triceps muscle, corticosteroids

Elbow jointOlecranon bursitiso Aseptic bursitis - Seen football/hockey player1.Acute hemorrhagic bursitis

> due to macrotraumatic insult to the bursa2.Chronic bursitis

> due to repetitive microtraumao Septic bursitis- Due to localized or systemic infectiono PE: edema, erythema, hyperthermia in the

area of infected bursa w/ systemic symptoms

Elbow jointUlnar collateral ligament spraino Due to valgus stress to the elbow – associated

with throwing activities

o PE: -5* elbow flexion contracture- tenderness over the ulnar collateral ligament- (+) pain w/ valgus stress to a slightly flexed

elbow.

Elbow jointValgus extension overload of the elbowo Common in overhead throwing athletes

o Pain noted at the medial lip of the olecranon

o Radiograph: olecranon osteophytes or intraarticular loose bodies.

Elbow jointsMedial epicondylar traction apophysitis and

stress fracture.o “ liitle leaguer’s elbow”

o Dominant hand of a throwing athletes between the ages of 9 – 12 years old.

o Medial epicondylar apophysis closes at 14 years old in females and at 17 years old in male.

o Radiologic findings”- Medial epicondylar enlargement,

fragmantation, beaking and avulsion of the medial epicondyle

Elbow jointOsteochondrosis of the capitellumo “Panner disease”

o 7 – 10 years old

o Degeneration or necrosis of the capitellum and regenration and calcification of this area.

o Etiology: unknown

o Due to endochondral ossification in association with trauma or vascular impairment.

o Dull, aching lateral elbow pain aggravated by throwing activities

o (+) effusion, ROM are usually restricted

Elbow joint

Osteochondrosis dissecan

Osteochondritis dissecans

age 7 – 9 years old 9 – 15 years ols

lesion Focal capitellum Entire capitellum

pain Dull, aching lateral elbow pain

Insidous onset of lateral elbow pain

Leads to loose body formation

Self-limited, resolving w/ rest and time

Elbow jointElbow dislocationo Involves the ulna and distal humerus,

frequently occur in posterolateral direction

o MOI: fall on outstretched arm w/ elbow in hyper extension.

o May injure brachial artery, or the median, ulna, radial nerve

o Treatment: - reduction- Sling or posterior long arm splint (2 – 3 days)- ROME

FOREARM and WRIST

Forearm and wristFlexor carpi ulnaris tendonitiso Due to repetitive microtrauma from activities

requiring wrist flexion and ulnar deviation

o Associated with pisotriquetral compression syndrome, may lead to osteoarthritis.

o Pain on the volar ulnar aspects

o Treatment:- wrist-hand orthosis with wrist in 25* of volar

flexion

Forearm and wristFlexor carpi radialis tendinotiso MOI: repetitive gripping w/ wrist flexion and

radial deviation

o (+) radial wrist pain when gripping and forceful wrist flexion with radial deviation.

o Treatment:- Ice- Anti-inflammatory medication - Splinting – wrist-hand orthosis with 25* wrist

flexion- ES and iontophoresis

Forearm and wristFlexor carpi radialis tendinotiso Treatment:- Correct strength, endurance and flexibility

deficits

Forearm and wristDe Quervain’s syndromeo Most common tendonitis of the wrist

o Abductor pollicis longus and extensor pollicic brevis

o MOI: forceful gripping w/ radial deviation of the wrist/ repetitive use of the thumb.

o (+) finkelstein’s test – pathognomonic

o Thumb spica

De Quervains syndrome

De Quervain’s syndrome

Finkelstein’s test

Forearm and wristIntersection syndromeo The APL and EPB tendons cross the ECRL

and ECRB causes friction 4-6cm proximal to Lister’s tubercle.

o (+) pain on dorsoradial distal forearm aggravated by activities requiring repetitive wrist extension

o PE: mild edema, acute tenderness , crepitation during flexion and extension

Forearm and wristScapholunate instabilityo Most common type of ligamental injury in the

wrist

o MOI: fall on pronated outstretched hand w/ wrist extension and ulnar deviation.

o DISI – scaphoid moves into a flexed position, lunate and triquetrum become extended (dorsal intercalated segmental instability)

o (+) Watson’s test

Forearm and wristScapholunate instabilityo Treatment:- Acute scapholunate instability > surgical - chronic scapholunate

> arthrodesis- Scapholunate advance collapse

> proximal row carpectomy

Forearm and wristScaphoid fractureo 70% of carpal fracture

o MOI: fall on extended wrist

o Anatomic snuff box – tenderness

o Prone to avascular necrosis and non-union if the fracture is on the proximal or middle third.

Forearm and wristDistal radial fractureo One of the most frequently fracured areas –

postmenopausal women and children.

o MOI: fall from extended wrist

o Treatment- Type 1 or 2 – close reduction and

immobilization w/ double sugar tong splint-wrist in slight flexion and ulnar deviation, forearm in neutral position, elbow flexed at 90*

Forearm and wristDistal radial fractureoTreatment:- Frykman 3 and higher - surgery

Frykman classification of distal radius fracture

Type 1 -2 Exra-articular fracture

Type 3 -4 Intraarticular fracture involving the radiocarpal joint

Type 5 - 6 Intraarticular fracture involving radioulnar joint

Type 7 - 8 Intraarticular fracture involving both radioulnar and radiocarpal joint

Forearm and wristKienbock diseaseo Resulted from repetitive compressive forces to

the wrist causing microfracture in the lunate

vascular compromise

avascular necrosis

collapse of the lunateo Pain and stiffness in the wrist

o Radiologic: Ulnar minus

Forearm and wristKienbock disease

o Treatment: early - immobilization to allow revascularization

Forearm and wristExtensor carpi ulnaris tendonitis and

subluxationo Second most frequent tendonitis

o Dorso-ulnar wrist pain during forceful or repetitive wrist extension and ulnar deviation.. (+) “pop”

o Treatment:- Rest, ice, antiinflammatory medications and

neutral wrist-hand orthosis.- ES/ iontophoresis- Local peritendinous corticosteroid injection

Forearm and wristExtensor tendon slip disruptiono Rupture at the base of middle phalanx

o “Boutonniere injury” – inability o actively extend the PIP joint but can maintain full PIP joint extension.

o MOI: rupture of the central slip or avulsion fracture at the distal insertion on the proximal aspect of the distal phalanx.

o treatment:- Continous extension splinting of PIP x 5-6 wk

Forearm and wristExtensor tendon slip disruptiono Treatment:- Chronis – serial splinting- Displaced avulsion fracture PIP – surgical

intervention

Forearm and wrist> boutonniere’s

deformity

Forearm and wristTerminal extensor tendon ruptureo “Mallet” fingero MOI: tendon rupture or an avulsion fracture

of the dorsal proximal distal phalanx- Hyperflexion force to an extended DIP joint

- treatment:>splinting of DIP in extension 24/day x 6-8 weeks.

Forearm and wristMallet finger

Forearm and wristFlexor digitorum profundus ruptureo “jersey finger” oMOI: vigorous gripping activities

oTreatment:oSurgery

Forearm and wristProximal interphalengeal joint dislocations