Musculoskeletal UE Flashcards
Bicipital Tendonitis
- Repeated full ABDuction and ER of the humeral head can lead to irritation and produces inflammation , edema, microscopic tears within the tendon, and degeneration of the tendon itself.
- Often caused by repetitive overhead activity and motion.
- Symptoms: Deep ache directly in front and on top of the shoulder. Worse with overhead activies or lifting heavy objects; pn to palpation of bicipital groove and resisted flexion
- Special tests: Yergason’s or Speeds test
- Therapy is typically no initiated immediately….Referred should educate on pendulum, TENS, pathology, and restrictions (no lifting, overhead movements, or reaching)
- Once out of acute phase – stretch and strengthen
- Time to PLOF 6-8 weeks.
- Surgical intervention if fail from conservative treatment for 6 months
Hill sachs lesion
most likely to occur with an anterior dislocation that created a compression fracture on the posterior humeral head.
Bankart lesion
avulsion of anterior/inferior labrum off of glenoid at attachment of inferior GHJ ligament
avulsion of the anterior-interior capsule and glenoid labrum
Cubital tunnel syndrome
- tenderness over the course of the ulnar nerve through the cubital tunnel
- elbow instability
- impaired sensation of the ring and little finger weakness
- atrophy of the ulnar-innervated intrinsic m of the hand.
Congenital Torticollis
- Unilateral contracture of the SCM.
- S&S: lateral flexion to the same side as the contracture, rotation toward the opposite side, and facial asymmetries.
- Treatment: conservative with emphasis on stretching, AROM, positioning, and caregiver education.
- Surgical management is indicated when conservative options have failed and the child is over 1 year old
Colles Fracture
- From FOOSH
- Transverse fracture of the distal radius – dorsal displacement of the radius. (talking proximal segment)
- Can also cause damage to ulnar collateral ligament or styloid process.
- “dinner fork” deformity
DeQuervain’s Tenosynovitis
- Inflammatory process of the tendon and synovium:
- Abductor pollicis longus (APL) & extensor pollicis brevis (EPB) at base of thumb
- Due to repetitive activities involving thumb abduction and extension (racquet or heavy lifting)
- Localized pain and tenderness in the area of the anatomical snuffbox that may radiate down forearm
- Improves with rest and worsens with activity
- More prevalent among women higher among newer mothers
- Finkelstein’s test
Impingement syndrome
- Repetitive microtrauma from UE activity performed above horizontal plane
- S&S: painful arc of motion, positive impingement sign, tenderness over the greater tuberosity in the bicipital groove
- RTC strengthening and scapular stability, pain control, activity modification
Primary impingement vs secondary impingement
Primary impingement: bony abnormality, hooking of the acromion
Secondary impingement: Functional abnormality, RTC dysfunction
GHJ Subluxation
joint laxity, allowing for more than 50% of the humeral head to passively translate over the glenoid rim without dislocation
“popping” out and back into place, pain, paresthesias, sensation of the arm feeling “dead’, positive apprehension test, capsular tenderness, swelling
Glenohumeral Dislocation
- Anterior dislocation is most common
- complete separation of the articular surfaces of the glenoid
- Most common between 18-25 y/o; or among the elderly secondary to a fall.
- Severe pain (decreases once reduced), paresthesias, limited ROM, weakness, visible shoulder fullness, arm supported by contralateral limb
- Affected limb will typically be positioned inslight abduction and lateral rotation with the pt unable to touch opposite shoulder
- Initial immobilization with sling for 3-6 weeks.
- PT after immobilizations – strengthening focus on ISOM, gradually progressive resisted activity emphasizing shoulder stabilizers.
- Decreased or absent radial pulses are suggestive of vascular injury and should be addressed immediately.
- Positive apprehension sign.
Juvenile Rheumatoid Arthritis
- Most common chronic rheumatic disease in children. Consists of inflammation of the joints and connective tissues
- Etiology – virus, infection or trauma that triggers an autoimmune response
- 3 types – Systemic JRA, Polyarticular JRA, Oligoarticular (pauciarticular JRA) (most common type)
- PT – PROM/AROM, positioning, splinting, strengthening, endurance, WB activites, postural training, and functional mobility.
Systemic JRA
- least common.
- Acute onset, high fevers, rash, enlargement of spleen and liver, and inflammation of the lungs and heart
Polyarticular JRA
- More common
- High female incidence,
- Significant rheumatic factor
- Arthritis in more than 4 joints with symmetrical involvement
- Involves hands, feet, as well as larger joints.
- Potential for severe destruction
Oligoarticular (pauciarticular) JRA
- Most common type of JRA
- Affects less than 5 joints with asymmetrical joint involvement.
- Girls under 8 most likely to get this
Lateral epicondylitis
- Irritation or inflammation of the common extensor muscles
- From throwing or racquet sports (aka tennis elbow)
- Caused by eccentric loading of the wrist extensor m (usually extensor carpi radialis brevis)
- Most common 30-50 y/o. More in men
- Manage pain, increase strength, flexibility, endurance of wrist extensors.
- Counter force bracing to reduce degree of tension in the region of the muscle attachment (must wean prior to finishing therapy)
Medial epicondylitis
- Aka golfers elbow
- Forearm pronator, wrist, finger flexors (most common the flexor carpi radialis and pronator teres)
- Pain and tenderness at medial epicondyle and with resisted wrist flexion, pronation, and with gripping
- PT – massage, stretching, counterforce brace (to limit muscular strain). Once pain subsides: strengthening (eccentric)
- Cortisone injection can help alleviate symptoms
Which is golfers elbow/swimmers elbow?
Medial epicondylitis
What is tennis elbow?
Lateral epicondylitis
Lateral has a “t” and so does “tennis”
Rotator cuff tear
- > 50 are susceptible
- Pain c/o are worse with partial due to increased tension on remaining m fibers and associated neural tissue.
- Other S&S – stiffness, feeling of instability, GH grinding with mobility, crepitus, night pain, and discomfort with lying on affected side.
- PT – primary focus is to prevent adhesive capsulitis, and strengthen the UE musculature. Follow the protocol
- Timeline – regain function use of shoulder 4-6 months; dynamic overhead activities may be restricted for up to 1 years. Return to sport may be longer than 1 year
Tempromandibular Joint Dysfunction (TMJ)
- Risk factors: chewing on one side, eating tough foot, clenching, or grinding.
- S&S: pain, m spasm, abnormal or limited jaw motion, HA, tinnitus, “clicking or popping”, locking, reduced motion of the unaffected side
- Treatment – splint for realignment of joint and guard/bite plate to maintain proper positioning at night and avoid grinding.
Wartenberg Syndrome
entrapment of the superficial radial sensory nerve.
- Test – tapping the index finger over the superficial radial nerve on the posterior and radial side of the wrist.
- Positive test is local tenderness and paresthesia with the test.
Radial Tunnel syndrome
- pain, cramping, and tenderness in the proximal posterior (dorsal) forearm without muscle weakness.
What limitation of movement would be most anticipated in a patient with a frozen shoulder?
ER > ABD > IR
What stage of idiopathic frozen shoulder is most likely to present with intact rotator cuff strength and night pain?
Stage 1
characterized by the gradual onset of pain with decreased movement and night pain. The patient typically presents with a loss of external rotation motion with intact rotator cuff strength. The duration of this stage is usually less than three months.
A child with right torticollis would most likely present with plagiocephaly in the area of the:
left occipitoparietal bone
Right torticollis results from shortening of the right sternocleidomastoid causing the head to bend to the right and rotate to the left. With the child lying supine, pressure is placed on the left occipitoparietal bone.
Which 2 tendons/muscles are associated with DeQuervain’s tenosynovitis
(APL) abductor pollicis longus
(EPB) extensor pollis brevis
Which muscle is most commonly associated with lateral epicondylitis
extensor carpi radialis brevis
In severe cases of De Quervain’s tenosynovits, edema may cause entrapment of which nerve?
Radial nerve
Condition in which the patient is born with a mutation in the dystrophin gene Xp21
Duchenne Muscular dystrophy
Glenohumeral Joint Loose Packed Position
55º abduction
30º horizontal adduction
Glenohumeral Joint Close Packed Position
90-90 (abduction and ER)
Glenohumeral Joint Capsular Pattern
ER > abduction > IR
Sternoclavicular Joint Loose Packed Position
arm resting at side
Sternoclavicular Joint Close Packed Position
maximum arm elevation and protraction
Sternoclavicular Joint Capsular Pattern
pain at end range
Acromioclavicular Joint Loose Packed Position
arm resting at side
Acromioclavicular Joint Close Packed Position
arm abducted to 90º (per Giles study book)
(Smith lecture stated undetermined)
Acromioclavicular Joint Capsular Pattern
pain at end range
Humeroradial Joint Loose Packed Position
full extension and supination
Humeroradial Joint Close Packed Position
90º flexion
5º supination
Humeroradial Joint Capsular Pattern
flexion > extension > supination > pronation (per Giles study book)
(Smith lecture states no true capsular pattern)
Humeroulnar Joint Loose Packed Position
70º flexion
10º supination
Humeroulnar Joint Close Packed Position
full extension
Humeroulnar Joint Capsular Pattern
flexion > extension
Proximal Radioulnar Joint Loose Packed Position
70º flexion
35º supination
Proximal Radioulnar Joint Close Packed Position
5º supination
Proximal Radioulnar Joint Capsular Pattern
supination > pronation
Radiocarpal Joint Loose Packed Position
neutral with slight ulnar deviation
Radiocarpal Joint Close Packed Position
extension with radial deviation
Radiocarpal Joint Capsular Pattern
flexion = extension
List the dislocation special test for the shoulder
Apprehension test
Sulcus sign
List Biceps Tendon special tests for shoulder
Ludington’s test
Speed’s Test
Yergason’s test
List the RTC pathology/impingement special tests
Drop arm test
Hawkins-Kennedy impingement test
Infraspinatus test
Lateral rotation lag sign
Lift off sign (medial rotation)
Neer impingement test
Supine impingement test
Supraspinatus test
List the Thoracic Outlet special test
Adson maneuver
Allen test
Costoclavicular syndrome test
Roos test
Wright test (hyperabduction test)
List the ligamentous instability tests for elbow
Valgus stress test
Varys stress test
List the epicondylitis special tests for elbow
Cozen’s test
Lateral epicondylitis test (Maudsley’s test)
Medial epicondylitis test
Mill’s test
List the ligamentous instaiblity special tests for wrist
Ulnar collateral ligament instability test
List the vascular insufficiency special tests for wrist
Allen test
Capillary refill test
List the special tests for neurological dysfunction of the wrist/hand
Carpal compression test (median nerve compression test)
Froment’s sign
Phalen’s test
Tinel’s sign
Apprehension Test for anterior instability of GHJ
● Use when you suspect an anterior instability.
● Position: supine
● Therapist: Placing pts in the close pack position for GHJ (90/90 position)
● Start with 90* abduction with 90* elbow flexion→then move into full ER. Stop if they have apprehension.
● Results:
o Positive = apprehension with movement (not pain – if they have pain you have to stop but it isn’t positive)
o Them not wanting to go in the position. Reflex to protect, watch their face.
Apprehension Test for anterior instability of GHJ
supine with arm at 90 flexion and lateral rotation
PT applies posterior force through the long axis of humerus
(+) = look of apprehension or facial grimace
Apprehension Test for posterior instability of GHJ
supine with arm at 90 flexion and medial rotation
PT applies posterior force through the long axis of humerus
(+) = look of apprehension or facial grimace
Sulcus sign
● Looking for instability due to laxity of superior GH and coracohumeral ligaments.
● Position: 20-50* of abduction and neutral rotation. Apply longitudinal traction to the arm. (in sitting or standing)
● Positive test = depression greater than fingerbreadth (the pts finger) b/n lateral acromion and head of humerus
Different grades:
1+ <1cm
2+ 1-2 cm
3+ >2 cm
Speeds Test
- Position – shld flexion → full ER → Full elbow extension → full supination.
- Resist elbow flexion.
- Results: For LHB tendon. They will have anterior pain at the bicipital groove.
- Can also do a dynamic version of the Speed’s test resisting both shld and elbow flexion.
Biceps stretch test
- Position: standing
- Therapist: Stand behind pt.; loosely stabilize scapula
- elbow flexion → full forearm pronation → shld extension → then straighten elbow.
- Positive = most painful. (Bicipital tendinopathy)
Ludington’s test
Clasp both hands behind the head with fingers interlocked
Pt is asked to alternately contract and relax the biceps m.
(+) = absence of movement in the biceps tendon
Indicative of rupture of the long head of biceps tendon
Yergason’s test
- 90 deg of elbow flexion and the forearm pronated.
- Humerus is stabilized against thorax. Places one hand on pts forearm and other hand over the bicipital groove.
- Pt direct to actively supinate and ER against resistance
(+) = pain or tenderness in bicipital groove
Indicative of bicipital tendonitis
torn transverse humeral ligament, bicipital tendonitis or tendinosis
Drop arm test (Codman’s Test)
- Rotator cuff integrity assessment (specifically the supraspinatus)
- Position: Pt is standing (or sitting).
- Therapist: passively abducts pts arm to 90*
- Pt is asked to slowly lower arm with palm down
- If at any point in the descent the pts arm drops it indicates a RTC injury….doesn’t really tell PT much.
Hawkins Kennedy Test
- Position: Put in position to impinge the subacromial space (~90* elevation)
- 90* shld flexion and overpressure into IR
- Positive test = pain (not just discomfort)
Indicative of shld impingement involving supraspinatus tendon
Infraspinatus test
- elbow flexed to 90 deg and shld 45 deg of IR.
- pt resists a IR force from PT. (So testing the ER portion of the infraspinatus m.)
(+) = pn or weakness
Indicates infraspintus strain/tear
Lateral rotation lag sign
- therapist passively moves shld to 20 deg of scaptions and near ER.
- Pt asked to hold position
(+) = unable to hold position
Indicated supraspinatus/infraspinatus pathology (or teres minor)
Hornblowers sign
- Testing the teres minor
- Arm at 90 deg abduction in scap plane and elbow flexed at 90 (therapist supported)
- Pt attempts to ER forearm against resistance
*(+) = Pt can’t ER
Lift off sign (IR lag sign) - aka Gerbers test
- Position: pt in sitting or standing with involved arm behind back with palm facing outward.
- Therapist: Grasp pts shoulder with on hand and wrist with other. Lift pts arms off back.
- Pt has to maintain this position (when clinician lets go)
- Positive test - inability of the pt to maintain his or her arm off of back….or substitution.
*When suspecting subscapularis tear
Neer Test
- Therapists places one hand on posterior aspect of pts scapula and other on elbow.
- Therapist elevates the pts arm through flexion
- Stabilize scapula and take into flexion. Resist/overpressure into medial and posterior direction.
- Results: positive it reproduces symptoms or has pain.
Impingement on the greater tuberosity (from a scorebuilders question)
Painful Arc sign (test)
- Subacromial impingement, AC joint.
- Pt moves through full abduction
- Results:
Pain at 60-120 = Subacromial impingement syndrome
Pain at 170-180 = AC joint
Supine impingement test
- Therapist passively moves shld into full flexion
- Then ER and adducts shld so that the arms is near pts head
- Therapist IR the shld
- (+) = pt experiences a significant increase in pn with IR.
Supraspinatus Test (Empty Can & Full can)
- Position: sitting or standing with arm elevated in the scapular plane to 60-90
Empty can: with IR resist flexion in position.
Full can: full external rotation in scapular plane - Results: reproduce symptoms…..doesn’t really tell much (+) = weakness or pain.
- Could be indicative of tear of the supraspinatus tendon, impingement, or subscapularis involvement.
Adson maneuver
- pt in sitting or standing
- therapist monitors radial pulse and asks the pt to rotate their head TOWARDS the test shoulder.
- pt then asked to extend their head while therapist ER and extends the pts shoulder
● (+) = absent or diminished radial pulse
Could be indicative of thoracic outlet syndrome (specifically the cervical rib or 1st thoracic rib)
Allen Test (for thoracic outlet syndrome)
● sitting or standing with test arm in 90 deg of abduction, ER, and elbow flexion
● pt asked to rotate their head AWAY from test shoulder and therapist monitors the radial pulse
● (+) = absent or diminished pulse when head is rotated away from test shoulder
Indicative of thoracic outlet syndrome (specifically the cervical rib or 1st thoracic rib)
Costoclavicular syndrome test
● pt in sitting
● therapist monitors the radial pulse and assists pt to assume military posture (extension and ER)
● (+) = absent or diminished pulse =
may be indicative of thoracic outlet syndrome caused by compression of the subclavian artery between the rib and the clavicle
Roos Test
● positioned in sitting or standing with arm in 90 deg in abduction, ER, and elbow flexion.
● pt asked to open and close their hands for 3 mins.
● (+) = inability to maintain test position, weakness of the arms, sensory loss or ischemic pain.
indicative of thoracic outlet syndrome (secondary to neurovascular compromise)
Halstead Maneuver
- Sitting, 90 deg of abduction, ER, elbow flexion to 90 deg, and head AWAY.
- The patient is sitting or standing. The therapist continuously palpates the radial pulse on the side being tested. While still palpating the radial pulse, the therapist abducts the arm to 45 degrees, extends the shoulder to 45 degrees, and externally rotates the upper extremity while applying a downward distraction to the arm. The patient is then asked to fully turn her head away from the side being tested and extend the cervical spine.
Wright test (hyperabduction test)
● pt in sitting or supine
● pts arm overhead in frontal plane (so…abduction) while monitoring the radial pulse
● (+) = diminished radial pulse and may be indicative of compression in the costoclavicular space.
Crossover impingement (ACJ) or Acromioclavicular crossover test
● Purpose: To test for the presence of AC joint dysfunction
● Position: standing or sitting
● Therapist: flex the pts shoulder to 90* & horizontal abduction across body
● Results: Positive = reproduction of pain at AC joint (C4 region)
● Horizontal adduction with overpressure.
Obrien Test aka Active compression test
● Use for a suspected Labral tear or AC joint. The response differentiates them
● Position: Pt in standing with involved shoulder to 90* flexion→ 10 (to 15)* horz. Add → IR → elbow extension.
● Resist flexion in IR– if painful– then test ER. If no pain in IR don’t continue test.
● Results:
o Positive = pain with resisted flexion in IR position and resolves with resisted flexion in ER
▪ Labral – deep pain in shld joint
▪ AC joint – on top of shoulder (C4)
o It is negative if has pain for both resisted motions.
Clunk Test aka Glenoid labrum tear test
● Position: Supine
● Therapist: One hand is placed on posterior aspect of shld over humeral head; other hand grasps humerus above elbow.
● Clinician fully GH abducts shoulder. Push the humeral head anterior while simultaneously pushing into ER
● Positive = a clunking sensation may be felt if a free labral fragment is caught in joint
Jerk Test
● To detect posterior/inferior labral compromise
● Position: Pt in sitting
● Therapist: Stabilize the scapula from superior direction behind pt. with one hand and with other hand grasps pts elbow and positions into 90* abduction with elbow flexed (facing forward). Load joint (axial compression) and then horizontally adduct (also with IR). This loads the posterior capsule
● Results: Positive = pain
Abd with axial pull
● Do this test if they have pain with regular abduction with resistance – will determine b/n bursa and tendon
● Position: Supine or standing
● Therapist: Grasp pts epicondyles with hand and block lateral epicondyle with hip.
● Axial pull (distraction) to open up the subacromial space and resist abduction.
● Results:
o If pain stays the same or gets worse = tendonitis (supraspinatus)
o It the pain goes away or improves significantly = bursa
ER with axial pull
● Do this test if they have pain with resisted ER – will determine bursa or tendon.
● Position: pt supine or standing with elbow flexed to 90*
● Therapist: Grasp pts epicondyles with hand
● Apply distraction and resist ER
● Results:
o If with distraction reproduces symptoms = infraspinatus tendonpathy
o If distraction decreases symptoms = bursitis
IR with axial pull
● Do this test if they have pain with resisted IR – will determine bursa or tendon.
● Position: pt supine or standing with elbow flexed to 90*
● Therapist: Grasp pts epicondyles with hand
● Apply distraction and resist IR
● Results:
o If with distraction reproduces symptoms = infraspinatus tendonpathy
o If distraction decreases symptoms = bursitis
Belly press sign
● If you can’t get their arm behind their back (alternative to the IR lag sign) – so also for subscapularis tear
● Position: sitting or standing with elbow flexed to 90*
● Pt is asked to IR shoulder which causes palm to be pressed into belly
● Results:
o Watch position of elbow…it shouldn’t change
o Positive test: elbow drops behind body into extension
Biceps Load Test
● Position: Supine, shoulder is at 120* abduction and maximally ER, and supinated (palm towards head). Therapist supporting elbow.
● Resist elbow flexion
o Long head of biceps attached at the superior labrum.
● Results:
o Positive = looking for signs of pain.
▪ Could be an indicative of a SLAP lesion.
Crank Test
● Position: Pt in supine → 160* elevated in scapular plane → axial loading while→ put in ER and then IR.
● Positive test = reproduction of a painful click in the shoulder.
Coracoid Impingement Sign
● Same as Hawkins – Kennedy with with horz. Adduction 10-20* before IR. (this compresses the coracoid)
o Impinges: subscapularis, supraspinatus, etc.
● Shld flexion to 90* → Horizontal adduction (close to end range) → Overpressure with IR.
● Results: Positive = pain
IRRST (Internal Rotation Resisted Strength Test) (Zaslav Test)
● Differentiates b/n outlet impingement vs. non outlet impingement. Do this one if you have a positive Neer test
o Outlet impingement (External) - subacromial
o Non-outlet impingement (Internal) – posterior glenoid
▪ athletes getting to much motion.
● Position: Pts shld at 90* abduction and 80* ER with elbow at 90*.
● Therapist: Resist/MMT into ER & IR
● Results:
o Positive = ER >IR (IR strength is weaker ER)—non-outlet (so it is non-outlet, from the posterior aspect of the glenoid)
o Negative = ER weaker than IR (not a positive) – shows it is outlet impingement
Posterior Internal Impingement Test
● For non-outlet impingement
● Position: supine
● Therapist: passively abducts shld to 90* and maximum ER.
● Results:
o Positive = localized pain in posterior should elicited.
▪ Pain in the deep posterior shoulder indicative of an RC tear and/or a posterior labral tear.
● Will most often found in overhead athletes or those with similar activities/positions of the shoulder. Impingement is between the humeral head and labrum and the posterior glenoid.
Relocation Test
● Position: Supine in 90/90 position. If they have apprehension with this then apply a posterior force to the humeral head.
● If they apprehension goes away it is a positive test.
Load and Shift Test
● To check instability of the GHJ in different directions
● Position: supine or sitting.
● Therapist: Keep humerus in neutral rotation. Grasp proximal humerus. Stabilize the scapula from superior direction (acromion, coracoid process, and scapular spine).
● Load anteriorly, back to neutral, posterior back to neutral. Should have some motion but not much (compare to involved and uninvolved.
● Results: Not about pain but about the amount of perceived motion.
Valgus Test
- Place elbow at 30* of elbow flexion
- Stabilize humerus and other hand on the distal forearm.
- Give a passive valgus load. (frontal plane motion)
- Pain provocation test
o (+) if pain at end range
o Also just assessing the amount of motion available
(MCL)
Varus Stress test
(LCL)
* Place elbow at 30* of elbow flexion
* Stabilize humerus and other hand on the distal forearm.
* Give a passive varus load.
* Pain provocation test
o (+) if pain at end range
o Also just assessing the amount of motion available
Moving valgus stress test
- 90* abduction of abduction & 120-140* flexion
- Placing valgus load through elbow (from distal forearm) as elbow is moving from flexion to extension. (it will feel like ER of the humerus but you are blocking the movement of the humerus)
- Pain provocation:
o Helping for throwing athletes that have MCL symptomology
o (+) – for chornic MCL tear of elbow is reproduction of symptoms. Will feel around 120-170*
Lateral Pivot Shift Apprehension Test (PLRI: posterolateral rotatory instability)
- ER load of the forearm where the LCL complex will tear. Leads to a posterolateral instability
- Supine position. Full supination. Valgus. Axial compression on radial side.
- Hold forces as move
Lateral Pivot Shift Apprehension Test (PLRI: posterolateral rotatory instability)
- ER load of the forearm where the LCL complex will tear. Leads to a posterolateral instability
- Supine position. Full supination. Valgus. Axial compression on radial side.
- Hold forces as move
Cozen’s Test (pg. 702) - resistance
Elbow flexion, pronation, wrist extension, radial deviation.
Resist extension
Positive - (+) pain with resistance at lateral epicondyle
for lateral epicondylitis
Mill’s Test
Elbow flexion, wrist flexion, finger flexion (stretching elbow extensors)
For lateral epicondylitis
Maudsley’s test
Pts hold their fingers straight
Resist middle finger flexion
For lateral epicondylitis
Elbow Flexion Test
pt fully flexes both elbows while extending their wrists and holds this position for 3-5 min.
(+) = tingling or paresthesia is noted in the ulnar nerve distribution of the forearm and hand
for cubital tunnel syndrome
Froment’s Sign
o Hold piece of paper between thumb and fingers
o Wanting them to fire adductor pollicus
o Try to pull the paper out. Watch for accommodation.
o Testing for ulnar nerve
Tinel’s Sign
o At any area of peripheral nerve that is sensitized through entrapment
o Looking for reproduction of symptoms.
Cubital tunnel compression test
o Tapping or compression over ulnar nerve (for around 60 seconds)
o Not looking for “feeling”….looking for reproduction of symptoms
Pinch Grip test
pinch the tips of teh index finger and tumb together
(+) = pushes the pads of fingers together and not the tips. (More like the Froment so they use the ulnar nerve)
This test a pathology of the anterior interosseous nerve (median nerve)
Finklestein’s Test
- Purpose: to detect stenosing tenosynovitis of the APL and EPB
- Therapist: Pt makes light fist grasping thumb with wrist in neutral. Therapist grasps fist, stabilizes forearm with one hand and deviate the wrist to the ulnar side of the hand.
- Results:
o (+) = reproduction of symptoms/paresthia.
o For DeQuervains disease – will be positive in neutral, supination, or pronation
o Wartenburg syndrome – will only be positive in pronation.
According to scorebuilders test for a postiive will get a thumb spica
Wartenberg’s Test
- Purpose: test with complaint of pain over the distal radial forearm associate with paresthesias over the posterior (dorsal) radial hand
- Therapist: Tapping index finger over the superficial radial nerve on posterior and radial side of wrist.
- Positive test: Reproduction of symptoms (paresthesia and tenderness)
Ulnar Impaction Test
- Purpose: test articulation between ulnar carpus and TFCC
- Position: Pt in sitting with elbow flexed to 90*, ulnar deviation, and fingers in a slight fist.
- Therapist: loads wrist with compressive force through the ring and small metacarpals (4th and 5th)
- Results:
o (+) = Pain with this test → possible tear of the TFCC OR ulnar impaction symdrome
FDS Test
- Purpose: integrity of the FDS tendon.
- Therapist: Holds the pts fingers held in extension except for finger being tested. Pt is instructed to flex the finger at the PIP joint.
- Results:
o If pt flexes finger at PIP joint the FDS in intact.
o If pt cannot flex finger at PIP joint….potential integrity issue/rupture of FDS tendon.
FDP Test
- Purpose: test integrity of FDP tendon
- Therapist: stabilizes over the MCPs of the finger and asks pt to extend the test finger at the DIP.
- Results:
o If pt is able to flex at DIP joint the FDP is intact
o If pt is unable to flex at DIP indicates possibility of tendon is severed or m denervated
Extensor Hood Rupture
- Purpose: checking the integrity of the extensor hood
- Patient position: Pt flexes finger to 90* at the PIP over the edge of the table. Therapist stabilizes the proximal portions. Pt asked to extend the PIP joint.
- Results:
o If able to extend at the PIP the extensor hood is intact.
o Absence of extension at PIP indicates complete rupture of the central slip.
Froment’s Sign
- Purpose: Testing for deep branch of the ulnar nerve entrapement by testing the strength of AP and short head of the FPB m
- Patient position: sitting with paper held between index finger and thumb
- Therapist: sitting in front of patient. Gently pulls paper away while the pt attempts to hold
- Results:
o (+) – pt is unable to hold paper or if DIP or MCP flexion occurs at the FPL compensating for weakness of the adductor pollicis from ulnar nerve compromise.
Phalen’s
- Purpose: testing for Carpal Tunnel Syndrome (by applying compressive forces to carpal tunnel region)
- Position: Pt puts dorsal aspects of hand together with elbows flexed and holds position up to 45 seconds
- Results:
o (+) – reproduction of paresthesia, pain/discomfort in the median nerve distribution
Reverse Phalen’s
- Purpose: testing for Carpal Tunnel Syndrome (applying tensile load to carpal tunnel.)
- Position: Palmar side of hands together in wrist extension and holding position for 60 seconds
- Results:
o (+) – reproduction of paresthesia, pain/discomfort in the median nerve distribution.
Allen Test (for wrist)
- Purpose: test patency of the radial and ulnar nerve supplying hand
- Therapist: compresses both radial and ulnar arteries at the wrist. Ask pt to open and clench first 3-4 times (to drain the venous blood from hand). Then release pressure on ulnar artery and then radial artery. Fingers and palm should regain their normal pink color
- Results:
o (+) – distinct different in filling time suggest dominance of one artery filling the hand.
o Normal filling time should be less than 5 seconds.
Piano Key Test
- Purpose: test the stability of the ulnomeniscotriquetral joint.
- Position: firmly stabilizes the distal radius with one hand and grasps the head of the ulna between thumb and the index finger of the other hand.
- Therapist: depresses the ulnar head in an anterior direction
- Results:
o (+) – for TFCC tear or triquetral instability is excessive movement anteriorly is present.
Radioulnar Ballottement Test
- Purpose: used to assess DRUJ instability.
- Position: pts elbow is flexed
- Therapist: uses thumb and index finger to stabilize the radius radially and the ulnar head ulnarly. Stress applied in an anterior-posterior direction.
- Results:
o (+) – pain or mobility noted is suggestive of a radioulnar instability
o Typically not supposed to be much movement anterior or posterior direction in supination or pronation maximally.
Radioulnar Ballottement Test
- Purpose: used to assess DRUJ instability.
- Position: pts elbow is flexed
- Therapist: uses thumb and index finger to stabilize the radius radially and the ulnar head ulnarly. Stress applied in an anterior-posterior direction.
- Results:
o (+) – pain or mobility noted is suggestive of a radioulnar instability
o Typically not supposed to be much movement anterior or posterior direction in supination or pronation maximally.
Lunatotriquetral Shear (Reagan) Test
- Purpose: Assess the integrity of the lunotriquetral ligament (Testing for a VISI)
- Therapist: Grasp over the triquetrum (last of the proximal row on the ulnar side) between thumb and the second finger of one hand and the lunate with the thumb and second finger of the other hand. Lunate (just medial to the triquetrum) is moved posteriorly (dorsally) with thumb of one hand while triquetrum is pushed palmarly.
- Results:
o (+) – crepitation, clicks, or discomfort in this area suggests injury to the ligament.
Scapholunate (Watson)
- Purpose: Testing for the DISI (this is more common)
- Begin by positioning the patient’s wrist in UD.
- Block proximal pole scaphoid with your thumb. (Find by Flexing and radial deviating and feeling on palmar side)
- Reinforce this position by placing your other thumb over the thumb.
- While blocking the scaphoid, take wrist into radial deviation.
- Positive test is painful click/pop and possible dead hand.
Pisotriquetral Shear Test
- Purpose: assess the integrity of the pisotriquetral articulation.
- Therapist: stabilize the wrist with fingers posterior (dorsal) to triquetrum and thumb over pisiform. Pisiform is rocked back and forth in M<>L direction.
- Results:
o (+) – pain during this maneuver
o Sesamoid bone the the FCU goes around. (so if you have a tendonopathy if may be tender with this.)
Bunnel-Littler test
in sitting with MCP in slight extension
Therapist attempts to move the PIP into flexion.
If the PIP doesn’t flex with the MCP extended there may be tight intrinsic muscle or capsular tightness
If the PIP joint fully flexes with MCP joint in slight flexion , there may be instrinsic m tightness without capsular tightness.
Tight retinacular ligament test
PIP in neutral whil therapist attempts to flex DIP.
If unable to flexion the DIP, the retinacular ligament or capsule may be tight
If able to flex the DIP with the PIP in flexion the retinacular ligaments may be tight and the capsule may be normal.
Murphy sign
in sitting or standing and asked to make a fist
(+) = pts third metacarpal remaining level with the 2nd and 4th metacarpals.
Indicative of dislocated lunate.
How to improve shld ER?
Anterior joint mob
When applying grade II and IV mobs to a pts shld. The pts shld has some mild discomfort that goes away by morning. Should you do the mobs again?
Yes since the discomfort resolved and it isn’t uncommon for pts have have some level of discomfort.
Salter Harris Classifications
I - THROUGH PHYSIS displacing epiphyseal plate – by shearing, torsion or avulsion – good prognosis
II - Entire PHYSIS + METAPHYSIS – shear or avulsion with angular for (Most common type) – decreased bone growth, but good long term prognosis
III - Portion of PHYSIS + EPIPHYSIS – portion of epiphysis displaced. partial growth arrest is possible and surgical fixation potentially
IV - PHYSIS+EPIPHYSIS+METAPHYSIS – similar to type III. Seen in distal humerus – may lead to premature focal fusion causing deformity in joint – partial growth arrest is possible and surgical fixation may be necessary
V - COMPRESSION of PHYSIS – compression or crush – growth disturbances at physis and generally have poor functional prognosis. Difficulty to dx acutely. eventual growth arrest may be the only clue.
AVN and infection are 2 non traumatic causes
SALTER (works in relation to a femur for above and below to work out)
S - straight across
A - Above
L - Lower
TE - Through everything
R - cRush
Claw hand
From ulnar nerve palsy (C8-T1)
hand at rest the 4th and 5th digit are in finger flexion (so they stay straight for the most part)
MCP hyperextension, PIP and DIP flexion at rest
Ape hand or Benedict hand
Median nerve palsy (C5-T1…from the PTFE lecture)….the PTFE exam says C6-C8
The 1st -3rd digits don’t flex when attempting a fist.
Swan Neck Deformity
Flexion of the MCP
Extension of PIP
Flexion of DIP
From trauma…tearing of the volar plate
Could also occur with RA
Boutonniere Deformity
Extension of the MCP
Flexion of PIP (to fit knuckly through buttonhole)
Extension of DIP
Rupture extensor hood
Trauma or could also occur with RA
What will be seen with a brachial plexus injury
pain is more localized to the shoulder with some radiation up to the neck and the face. There will also be a decrease in the deep tendon reflexes for the biceps tendon C5-6.
What exercise is the best for maximum depression of the scapula and isolation of the lower trapezius from the middle and upper portions
External rotation in the prone position with shoulder positioned at 120 degrees abduction and the elbow flexed to 90 degrees
When doing a wall push and the inferior angle tilts away from the chest wall what does this indicate?
Weakness of the serratus anterior, latissimus dorsi, and/or lower traps
Cubital tunnel syndrome
- tenderness over the course of the ulnar nerve thorugh the cubital tunnel
- elbow instability
- impaired sensation of the ring and little finger weakness
- atrophy of the ulnar-innervated instrinsic m of the hand.
What type of end-feel does adhesive capsulitis have?
Hard endfeel
