Upper Extremity Examination - Physical Therapy PDF

Upper Extremity Examination 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 Un...

Upper Extremity Examination 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 Exam Review Age and onset Location of pain Relevant past medical history Aggravating and easing factors Pain behavior, pain description Functional impact – patient goals Imaging or other specialists seen Patient reported outcome and body chart Physical Therapy - East Carolina University  Subjective Exam Build the therapeutic alliance – Face to face, seated, be interested – Open ended questioning, active listening – Guide the conversation, elicit patient’s agenda Maximize non-specific effects of Rx Understand the functional impact – Can help you define improvement – Basis for patient centered goals – Need for supervised rehab Physical Therapy - East Carolina University  Patient Agenda Provider role – empathy and responsiveness Expectations of the patient and provider Pillar of patient centered care How to elicit the patient 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 Physical Therapy - East Carolina University  Objective Exam Goals Reproduce comparable sign Rule in/out differential diagnoses Ensure patient is appropriate for PT Identify impairments (* sign) Develop interventions Continue building therapeutic alliance Continue maximizing non-specific effects Physical Therapy - East Carolina University  Scenarios 52 y/o female right arm and shoulder pain 22 y/o male with acute medial elbow pain 25 y/o female with N&T of the hand Differential diagnoses Approach to your exam Identify impairments Rehab appropriate for functional goals Physical Therapy - East Carolina University  Objective Exam Observation – Expose the area – Anterior – deformity, atrophy, swelling, posture – Posterior – scapular position, thoracic curvature – Lateral – head position, cervicothoracic spine Begin from the waiting room – Position of comfort – Gait evaluation Physical Therapy - East Carolina University  Objective Exam Range of motion – Quality and quantity – SH rhythm, painful arc – Active and passive if needed, accessory motions – Eliminate gravity as needed Strength assessment – Painless weakness – most concerning – Painful weakness – most common – Compare to unaffected side Physical Therapy - East Carolina University  Special Tests Not That Special Only part of your exam Sensitivity vs specificity (SPIN vs SNOUT) Highly sensitive tests to screen – Can deal with false positives – Don’t want false negatives sneaking through Issues with gold standard for a positive Not all structural findings are symptomatic Special tests don’t guide PT interventions Still need to know the basics Physical Therapy - East Carolina University  Objective Exam Upper quarter screen – Strength – Reflexes – Sensation Clear C-spine and elbow Thoracic outlet – Adson’s – Costoclavicular – Hyperabduction, Wright, Roos – Tinel Physical Therapy - East Carolina University  Thoracic Outlet Tests Wright Test Adson Test Roos Test Physical Therapy - East Carolina University  Practice 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 Physical Therapy - East Carolina University  Rotator Cuff Evaluation Supraspinatus Teres minor – Initiation of ABD – ER in 90 ABD – Empty can of Jobe – Hornblowers – Open can Subscapularis Infraspinatus – Internal rotation – External rotation – Bear hug – ERLS – Subscap lift off Physical Therapy - East Carolina University  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 Physical Therapy - East Carolina University  Acromioclavicular Joint Cross arm adduction AC resisted extension Active compression Paxinos sign Paxinos Sign Active Compression Physical Therapy - East Carolina University  Instability / Laxity Understand the difference Laxity is assessed Instability is reported – related to function Load and shift – ant and post Relocation Apprehension Sulcus sign Apprehension Sulcus Sign Physical Therapy - East Carolina University  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 Physical Therapy - East Carolina University  Biceps Speeds Test Yergasons Biceps Load Physical Therapy - East Carolina University  Subacromial Pain Syndrome Hawkins-Kennedy Neers Painful arc Location of pain Hawkins Internal impingement Neers – Pain with apprehension position – SICK scapula Physical Therapy - East Carolina University  Shoulder Palpation SC and AC joints Clavicle Coracoid process Acromion Intertubercular groove Spine of scapula Infraspinous fossa Supraspinous fossa Medial border of scapula Inferior medial angle Physical Therapy - East Carolina University  Exam Practice Systematic approach Consistent subjective exam Structured objective exam Is patient appropriate for PT Document the negative Skilled and medically necessary care Interventions applied to impairments Patient centered functional goals Physical Therapy - East Carolina University Documentation Grade I AC Sprain Physical Therapy - East Carolina University  Elbow Exam 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 Physical Therapy - East Carolina University  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 Physical Therapy - East Carolina University  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 Physical Therapy - East Carolina University  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 (AIN) OK sign – AIN (Median) – OK sign with IP joints flexed – Weakness of FPL leads to IP EXT Physical Therapy - East Carolina University  Elbow Fracture Use of ROM as screen for fracture Full ROM = 100% sensitive to r/o fracture – Assess motion (highly sensitive) – Determine if Xray (highly specific) indicated Compare to contralateral side, all 4 motions Xray normal but motion still limited – Can be occult fracture – Fracture still part of differential – Look for healing on repeat Xrays Physical Therapy - East Carolina University  Elbow Instability Varus stress – Patient seated, 20-30 of flexion, varus stress – Palpate RCL, pain and/or laxity is positive Valgus stress – Patient seated, 20-30 of flexion, valgus stress – Palpate UCL, pain and/or laxity is positive Moving valgus stress – Patient seated, shoulder 90, elbow to 120 – Valgus stress as elbow is extended – Pain reproduction is positive Physical Therapy - East Carolina University  Elbow Palpation Medial epicondyle Olecranon and olecranon fossa Tricep 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 Physical Therapy - East Carolina University  Wrist and Hand ROM 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 Physical Therapy - East Carolina University  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 Physical Therapy - East Carolina University  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 = positive test Physical Therapy - East Carolina University  Scapholunate Dissociation Watson Test – Position palm up – Grasp palmar surface of scaphoid with thumb – Move from UD and EXT into RD and slight FLEX – Subluxation over the thumb = positive test Physical Therapy - East Carolina University  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 Physical Therapy - East Carolina University  Carpal Tunnel Phalen’s Test Hand Elevation Test Reverse Phalen’s Test Physical Therapy - East Carolina University Acute Mallet Finger Physical Therapy - East Carolina University  Wrist and Hand Eval 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 Physical Therapy - East Carolina University  Bunnell Littler Test Identify cause of PIP Flex Restriction Add MCP Flex Add MCP Flex PIP Flex Improves PIP Flex Unchanged Intrinsic tightness Capsular tightness Physical Therapy - East Carolina University  Wrist and Hand Palpation 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 Physical Therapy - East Carolina University Questions Physical Therapy - East Carolina University