Assessment and special tests of upper limb Flashcards
special questions for the upper limb
red flags (non mech pain, cancer, sudden loss of ER, pancrose tumour), trauma (fracture, cuff tear), age (arthritis, capsulitis), PMH (diabetes- capsulitis), steroid use, previous capsulitis, previous dislocation/instability, clicking/ locking with pain- labral
pain pattern
night pain= RC pathology, arc of pain 60-100 RC problem, arc of pain>100- AC joint, EOR pain- OA/instabiity, global pain- early frozen shoulder
PMH
Screen for systemic disorders e.g. DM/Ca/RA/ ASA
special questions
clunking/clicking, giving way, neck pain, altered sensation, functional activities, hand dominance
OA capsular pattern shoulder
LR>ABD>MR
mechanism of onset
injury (FOOSH), insidious (frozen shoulder) repetitive (degenerative)
social history- age of onset shoulder
RC degeneration>35 years, secondary impingement >25 years, calcification 40-60 years, frozen shoulder 45-60 years, atraumatic instability 10-35 years
occupation and hobbies related to shoulder pain
occupation- sustained neck-shoulders postures/repetitive arm movements
hobbies- swimming/cross country skiing/racket sports/throwing sports
observation what to look for
scapular position, scapular orientation, HOH- affected by tightness of pecs=pulls forward, cervical position, thoracic spine, muscle tone
winged scapula
can be due to nerve issue with true wining- long thoracic nerve, protruding shoulder blade= muscle imbalance
isometric testing findings
RC tear= weak and painful or just painful/weak- depending on grade of tear, secondary instability= NAD/ painful or/& weak/ apprehension, OA of GHJ- NAD and weak, primary impingement- weakness and pain
accessory movements of shoulder
patient in supine, shoulder abducted and LR, holding onto therapist humerus, apply force AP and PA
soft tissue lengthening test- pec major
supine lying, stabilize thorax, clavicular fibres- Abd 90° and ER, sternal fibers abd 150° and ER, slowly lower arm to bed
soft tissue lengthening test- pec minor
supine lying view from head down, assess the height of the shoulder from the bed, >2cm is normal, then stabilize sternum and push down on coracoid
soft tissue lengthening test- lat dorsi
lying supine with knees flexed at 90°, maintain lumbar neural (flex lumbar spine to push down on bed) , full flexion of shoulder, should reach treatment couch if not tight
RC pain tests- Hawkins-Kennedy test
passive shoulder flexion to 90°, passively MR humorous, +ve= pain/symptoms,
sensitivity- 58-80%, speceficity- 57%
weak clinical value
RC pain tests- Neers test
fix scapula, MR arm, passively flex, +ve= pain reproduction, reduced sub acromial space- greater tubercle leads to compression
59-72 sensivity, 60 speceficity
weak clinical value
RC pain tests- full can/empty can
90° in scap plane, full MR, maintain position whilst therapist pushes down, +ve= weakness/pain or both, weakness is more accurate for tears,
empty can test- sensitivity- 74%, speceficity 30%
WEAK CLINICAL VALUE
instability test- apprehension test
supine lying, abd arm to 90°, ER arm, +ve= apprehension (fear, muscle spasm, conscious limitation of movement, not pain), repeat test with AP glide to HOH, +ve increased ROM/ reduction in apprehension
sensitivity- 65.6
speceficity- 95.4
instability test- load and shift test
test ant and post stability, stabilize scapula, mild compression into glenoid, apply AP force to humeral head, movement 25%= N, up to 50% is G1, over 50% GII, checks for inferior instability
instability test- inferior instability (sulcus sign)
sit/st or lying, arm by side, elbow at 90°, caudad mobilisation, assessing for excessive movement, use fingers to palpate between the HOH and acromion
instability test- lift off test
standing position, patient lifts arm up back, must maintain this position, problems if lack of movement or pain will reduce contraction
sensitivity- 35, speceficity- 75
medial epicondylitis tests
passive test- palpate medial epicondyle, supinate forearm, extend wrist, extend fingers, +ve= pain over medial epicondyle
can also test by resisting strength
lateral epicondylitis- Mill’s test
same starting position- passive stretch test, pronate forearm, flex wrist, extend elbow +ve= pain reproduction,
also test by resisting strength
lateral epicondylitis- cozens test
active contraction of extensor tendons, elbow 90°, active resisted forearm pronation, wrist extension, wrist radial deviation, +ve=pain, can palpate for pain
concave convex rule- concave joint sliding
concave joint surfaces slide in the same direction as the bone movement, if concave joint is moving on stationary convex surface- glide occurs in the same direction as the role
concave convex rule- convex surface
convex joint surfaces slide in the opposite direction of the bone movement, if convex surface is moving on stationary concave surface- gliding occurs in opposite direction to roll
finkelstein test
for DeQuervains- thickening of tendon sheath around abd pol longus and ext pol brevis, Pt grips own thumb, ulna deviates, +ve test= pain
Tinel’s sign
ext wrist and tap over carpal tunnel, +ve test= pain, paresthesia, median nerve test, carpal tunnel syndrome
weak clinical valjue
phalens test
flex pt wrist maximally against each other, hold for 1 mins, +ve test= tingling in thumb, index finger and 1/2 ring finger
sensitivity- 85, speceficity- 89
treatment- pain
joint mobilisations (grades affected by SIN), education- pain relief (may be MDT), soft tissue mobilisations (pain gate theory and descending inhibition), potentially TENs
treatment- stiffness
joint mobilisation, exercises- may start with active assisted/passive physiological movement, stretching, look at scapula for shoulder movement (e.g. 4 point push up- work serratus anterior and scapula muscles and shoulder flexion)
treatment- weakness
strength exercises- may start with lower weight and higher reps
treatment- instability
strengthening of muscles, closed chain exercises- weight bearing movements, shoulder flexion exercises (can add LR along side flexion)
treatment- options
education (pain relief, advice about the condition, timescales, healing, scan, beliefs), activity modification, exercise (strength, load tolerance, endurance, control, stretching), functional demo, mannual therapy, soft tissue treatments
exercise ideas- flex, abd, LR, MR, isometric
ROM flex= with bed/table= slide hand across table, ROM abd- use yoga ball, LR- hand on door frame, isometric exercises- using other hand for resistance
