Upper Extremity Exam: Subjective Review

• Upper extremity examination
• By Michael Garrison, PT, DSc
• Board-Certified Clinical Specialist in Sports Physical Therapy
• Board-Certified Clinical Specialist in Orthopedic Physical Therapy
• Clinical Associate Professor
• Physical Therapy - East Carolina University

Subjective Examination Review

• Age and onset should be reviewed
• Location of pain should be noted
• Relevant past medical history is important
• Aggravating and easing factors of the condition are important
• Pain behavior and pain description
• Functional impact of the condition should be considered to determine patient goals
• Any imaging or other specialists seen for the condition
• Patient-reported outcome and body chart

Subjective Examination

• Build the therapeutic alliance with the patient
  • Face to face, seated, show genuine interest to the patience
  • Use open-ended questioning and practice active listening
  • Guide the conversation and elicit the patient's agenda
• Maximize non-specific effects of Rx
• Understand the functional impact
  • This can help to define improvement
  • Basis for patient-centered goals
  • Shows need for supervised rehab

Patient Agenda

• The provider role includes empathy and responsiveness
• Expectations of the patient and the provider need to be understood
• Important pillar of patient-centered care
• How to elicit the patient's agenda:
  • "What can I do for you today?"
  • "What is your main concern?"
  • "Tell me what brings you in today?"
  • "What are your goals for this therapy visit?"

Objective Examination Goals

• Reproduce comparable sign
• Rule in/out differential diagnoses
• Ensure patient is appropriate for physical therapy
• Identify impairments
• Develop interventions
• Continue building therapeutic alliance
• Continue maximizing non-specific effects

Scenarios

• Example cases:
  • 52-year-old female with right arm and shoulder pain
  • 22-year-old male with acute medial elbow pain
  • 25-year-old female with numbness and tingling (N&T) of the hand
• Must do the following:
  • Differential diagnoses
  • Approach to your exam
  • Identify impairments
  • Rehab appropriate for functional goals

Objective Examination

• Observation, to include:
  • Expose the area to be examined
  • Anterior inspection for deformity, atrophy, swelling, posture
  • Posterior inspection for scapular position, thoracic curvature
  • Lateral inspection for head position, cervicothoracic spine
• Begin the examination from the waiting room to observe the patient:
  • In a position of comfort
  • Gait evaluation

Objective Examination

• Range of motion
  • Quality and quantity – SH rhythm, painful arc
  • Active and passive if needed; accessory motions
  • Eliminate gravity when appropriate
• Strength assessment
  • Painless weakness – most concerning
  • Painful weakness – most common
  • Compare to unaffected side

Special Tests

• Special tests are only a part of the examination
• Sensitivity vs. specificity (SPIN vs. SNOUT)
• Highly sensitive tests to screen
  • Can deal with false positives
  • Do not want false negatives to sneak through
• Issues with gold standard for a positive result
• Not all structural findings are symptomatic
• Special tests do not guide physical therapy interventions
• Still need to know the basics

Objective Examination

• Upper quarter screen
  • Strength
  • Reflexes
  • Sensation
• Clear C-spine and elbow
• Thoracic outlet
  • Adson's
  • Costoclavicular
  • Hyperabduction, Wright, Roos
  • Tinel

Practice

• Practice the clinical examination:
  • Upper quarter screen
  • Joint clearing
  • ROM and overpressure
  • Compression, quadrant, spurling
  • Thoracic outlet special tests
  • Wright, Roos, Hyperabduction
  • Adson's, costoclavicular, Tinel's
  • Gillard cluster of 5

Rotator Cuff Evaluation

• Supraspinatus
  • Initiation of abduction (ABD)
  • Empty can of Jobe
  • Open can
• Infraspinatus
  • External rotation
  • ERLS
• Teres minor
  • External rotation (ER) in 90 ABD
  • Hornblowers
• Subscapularis
  • Internal rotation
  • Bear hug
  • Subscap lift-off

Suspect Rotator Cuff Tear

• Subjective
  • Age and MOI
  • Pain when laying flat
  • Better with rest, worse with movement
  • Pain location – lateral arm
• Objective
  • Painful arc
  • Drop arm
  • Lag sign
  • Lift-off

Acromioclavicular Joint

• Perform:
  • Cross arm adduction
  • AC resisted extension
  • Active compression
  • Paxinos sign

Instability / Laxity

• Understand the difference between instability and laxity
• Laxity is assessed
• Instability is reported – related to function
• Perform:
  • Load and shift – ant and post
  • Relocation
  • Apprehension
  • Sulcus sign

Biceps / SLAP / Labrum

• Active compression
• Speeds test
• Yergasons
• Biceps load (apprehension position)
• Crank test – McMurray's of the shoulder
• Jerk test – Posteroinferior labral lesion
• Location of pain

Subacromial Pain Syndrome Subacromial Pain Syndrome

• Hawkins-Kennedy
• Neers
• Painful arc
• Location of pain
• Internal impingement
  • Pain with apprehension position
  • SICK scapula

Shoulder Palpation

• Palpate:
  • SC and AC joints
  • Clavicle
  • Coracoid process
  • Acromion
  • Intertubercular groove
  • Spine of scapula
  • Infraspinous fossa
  • Supraspinous fossa
  • Medial border of scapula
  • Inferior medial angle

Exam Practice

• Systematic approach
• Consistent subjective exam
• Structured objective exam
• Is the patient appropriate for PT
• Document the negative
• Skilled and medically necessary care
• Interventions applied to impairments
• Patient-centered functional goals

Documentation

• Grade I AC Sprain example documentation:
  • Patient presents to the clinic in no acute distress. The source of the most pain is the left superior shoulder. Shoulder muscle girth and position are symmetrical.
  • Active range of motion of the left shoulder is within normal limits, (+) GH painful arc
  • Special Tests: (+) Obriens for acromioclavicular joint pain, (-) Speeds, equal ant/post load and shift, (-) apprehension, (-) sulcus, (+) Hawkins, (+) Neers, (+) Cross arm adduction, (+) acromioclavicular shear
  • Palpation: TTP along the left acromioclavicular joint
  • Rotator cuff: Abduction: 5/5, External rotation: 5/5, Internal rotation: 5/5, (-) hornblowers, (-) bear hug, (-) lift off
  • Full active range of motion of the cervical spine, no pain at end range
  • (-) cervical compression, (-) cervical quadrant, (-) spurlings

Elbow Examination

• Observation
  • Carrying angle – 5 in males, 10-15 in females
  • Cubitus varus – gunstock deformity
  • Cubitus valgus – increased angle
• Begin from the waiting room
  • Position of comfort
  • Arm swing and motion

Biceps Tendon – Distal

• Age and MOI
• Swelling, ecchymosis, deformity
• Hook test
  • Elbow flexed to 90, full supination
  • Attempt to hook tendon
• Positive test
  • Can't hook the tendon
  • Unsure if you can hook tendon

Ulnar Nerve Entrapment

• Elbow Flexion Test
  • Seated, elbows flexed, wrists extended
  • Up to 3-minute hold
  • Reproduction of symptoms
• Pressure Provocation Test
  • Slight flexion, pressure proximal to cubital tunnel
  • Hold for up to 60 seconds
  • Reproduction of symptoms
• Tinel's sign

Ulnar Nerve Entrapment

• Froment's sign – Ulnar nerve
  • Strong pinch between thumb and index finger
  • Examiner attempts to pull object
  • Weakness of ADP leads to FPL substitution
• OK sign – AIN (Median)
  • OK sign with IP joints flexed
  • Weakness of FPL leads to IP extension

Elbow Fracture

• Use of ROM as a screen for fracture
• Full ROM = 100% sensitive to r/o fracture
  • Assess motion
  • Determine if an X-ray needed if motion is limited
• Compare to contralateral side, all 4 motions
• An X-ray may be normal, but motion still limited
  • Could be an occult fracture
  • Fracture still part of differential
  • Look for healing on repeat X-rays

Elbow Instability

• Varus stress
  • Patient seated, 20-30 of flexion, varus stress
  • Palpate RCL, pain and/or laxity indicates a positive finding
• Valgus stress
  • Patient seated, 20-30 of flexion, valgus stress
  • Palpate UCL, pain and/or laxity indicates a positive finding
• Moving valgus stress
  • Patient seated, shoulder 90, elbow 120
  • Valgus stress as the elbow is extended
  • Pain reproduction indicates a positive finding

Elbow Palpation

• Palpate:
  • Medial epicondyle
  • Olecranon and olecranon fossa
  • Triceps tendon
  • Lateral epicondyle
  • Capitellum
  • Radial head
  • UCL/RCL
  • Flexor mass – PT, FCR, PL, FCU – 3 median, 1 ulnar
  • Mobile wad of 3 – BR, ECRL, ECRB – radial n

Wrist and Hand ROM

• Assess:
  • 90 / 90 pronation / supination
  • Wrist flexion – 90, extension – 70
  • Radial deviation – 15, ulnar deviation – 45
  • Finger extension
    • MCP – 45
    • PIP – 0, DIP – 10 – 20
  • Finger Flexion
    • MCP – 90
    • PIP – 100, DIP – 90
• Strength assessment

Thumb Testing

• Gamekeeper's or Skier's Thumb
  • Patient seated, 1st MCP stabilized
  • Apply valgus stress
  • 35-degree increase = positive test
• Finkelstein's Test
  • 1st extensor tenosynovitis – DeQuervain's
  • Patient makes fist with thumb inside fingers
  • Apply ulnar deviation
  • Pain along AbPL and EPB = positive test

Scaphoid Fracture

• Anatomic snuff box tenderness
  • AbPL and EPB – radial border
  • EPL – ulnar border
• Axial loading of the thumb
• Extension of the wrist
• Thumb to index finger pinch
• Reproduction of pain indicates a positive test

Scapholunate Dissociation

• Watson Test
  • Position palm up
  • Grasp the palmar surface of the scaphoid with the thumb
  • Move from UD and extension into RD and slight FLEX
  • Subluxation over the thumb indicates a positive test

Carpal Tunnel

• Thenar atrophy - AbPB
• Phalen's
  • Forearms vertical, wrists in flexion, hold 60 sec
  • Reproduction of symptoms = positive
• Reverse Phalen's
  • Forearms vertical, wrists in extension, hold 60 sec
  • Reproduction of symptoms = positive
• Carpal compression test
• Hand elevation test – 2 minutes
• Tinel's

Wrist and Hand Evaluation

• Central slip injury
  • Boutonniere deformity
  • PIP flexion, DIP extension
  • Dorsal proximal middle phalanx tenderness
• Mallet finger
  • Terminal extensor tendon disruption
  • Can lead to swan neck deformity
• Jersey finger – FDP rupture off the DIP
• Swan neck – volar plate injury

Bunnell Littler Test

• For identifying causes of proximal interphalangeal(PIP) Flexion Restriction
  • Add MCP Flex, if PIP Flex Improves, there is Intrinsic tightness
  • Add MCP Flex, if PIP Flex remains Unchanged, there is Capsular tightness

Wrist and Hand Palpation

• Palpate:
  • Distal radius, Listers tubercle, ulnar styloid
  • Scaphoid
  • TFCC
  • Proximal carpal row – S,L,T,P
  • Distal carpal row – T,T,C,H
  • Metacarpals, MCP joint
  • Proximal, middle, distal phalanges
  • IP joints

This lesson covers the subjective examination of the upper extremity, including age, pain location, medical history, and aggravating factors. It emphasizes the importance of building a therapeutic alliance through active listening and open-ended questions.