PPhysical hysical EExamination xamination of of the Uthe Upper pper EExtremitixtremitieses

Prof.Dr.Hidayet SarıProf.Dr.Hidayet Sarı

Physical Medicine and Physical Medicine and Rehabilitation Department Rehabilitation Department

Shoulder Examination Shoulder Examination

ANATOMYANATOMY• Bones Bones • Joints Joints • MusclesMuscles• Bursae Bursae • Nerves Nerves • Blood supply Blood supply

Bony AnatomyBony AnatomyAnteriorAnterior

Bony AnatomyBony AnatomyPosteriorPosterior

SHOULDER JOINTS SHOULDER JOINTS

1.1. Glenohumeral Glenohumeral

2.2. Scapula thoracicScapula thoracic

3.3. Acromio-clavicularAcromio-clavicular

4.4. Sterno-clavicularSterno-clavicular

Bony AnatomyBony AnatomyJoints and ArticulationsJoints and Articulations

•

STATIC STABILIZERS

Clinical AnatomyClinical Anatomy– DeltoidDeltoid– Rotator cuffRotator cuff– Teres majorTeres major

– Latissimus dorsiLatissimus dorsi– BicepsBiceps– Pectoralis musclesPectoralis muscles

Clinical AnatomyClinical Anatomy

• Rotator CuffRotator Cuff– SSupraspinatus upraspinatus

ABDABD

– IInfraspinatus nfraspinatus ERER

– TTeres minor eres minor ERER

– SSupscapularis upscapularis IRIR

Depress humeral head against glenoid to allow full abduction

Clinical AnatomyClinical Anatomy

• BursaeBursae– subacromialsubacromial– subdeltoidsubdeltoid– subscapularsubscapular

Physical ExaminationPhysical Examination

• InspectionInspection• Palpation –pressionPalpation –pression• Range of motion examination Range of motion examination • Neurological examination Neurological examination • Special tests for the shoulder Special tests for the shoulder

problems problems • Examination of the related areasExamination of the related areas

Shoulder InspectionShoulder Inspection

• Anterior side Anterior side • Posterior side Posterior side • Lateral side Lateral side • Medial side Medial side

Physical ExamPhysical ExamInspectionInspection

• Front & backFront & back• Height of Height of

shoulder and shoulder and scapulaescapulae

• Muscle atrophy, Muscle atrophy, asymmetryasymmetry

SHOULDER PALPATION SHOULDER PALPATION and PRESSIONand PRESSION

• Bones Bones • Joints Joints • MusclesMuscles• Bursae Bursae • NervesNerves• Lymph nodes Lymph nodes

SHOULDER Range Of SHOULDER Range Of MotionMotion

• Flexion-180 degreeFlexion-180 degree• Extension -45 degreeExtension -45 degree• Abduction -180 degreeAbduction -180 degree• Adduction -30 degreeAdduction -30 degree• Internal rotation -90 degreeInternal rotation -90 degree• External rotation -90 degree External rotation -90 degree

Physical ExamPhysical Exam Range of MotionRange of Motion

• Forward flexion: Forward flexion: – 00oo – 180 – 180oo

Physical ExamPhysical Exam Range of MotionRange of Motion

• ExtensionExtension– 00oo – 40 to 60 – 40 to 60oo

Physical ExamPhysical Exam Range of MotionRange of Motion

• Internal rotationInternal rotation– 80-9080-90oo

• External rotationExternal rotation– 80-9080-90oo

Speed shoulder tests Speed shoulder tests

External rotation External rotation Internal Internal rotationrotation

Neurological Examination Neurological Examination of the Shoulder of the Shoulder

Muscle tests :Muscle tests :• FlexionFlexion• Extension Extension • Abduction Abduction • Adduction Adduction • Internal rotation Internal rotation • External rotation External rotation

Muscle testing scoringMuscle testing scoring

• 0 No contraction• 1 Flicker or trace contraction• 2 Active movement, with gravity

eliminated• 3 Active movement against gravity• 4 Active movement against gravity

and resistance• 5 Normal power

Shoulder Abduction muscle Shoulder Abduction muscle test test

Shoulder flexion and Shoulder flexion and extension muscle testextension muscle test

Shoulder external and Shoulder external and internal rotation muscle internal rotation muscle

testtest

Shoulder abduction and Shoulder abduction and adduction muscle testadduction muscle test

Neurological Examination Neurological Examination of the Shoulderof the Shoulder

sensory tests :sensory tests :• C4C4• C5C5• C6C6• C7C7• C8C8• T1T1• T2T2

Special Tests for the Special Tests for the Shoulder ProblemsShoulder Problems

• Yergason test –biceps tendinitisYergason test –biceps tendinitis• Neer impingement test-acromioclavicular Neer impingement test-acromioclavicular

impingementimpingement• Drop arm test –rotator cuff tear Drop arm test –rotator cuff tear • Resisted flexion (Speed)test –biceps Resisted flexion (Speed)test –biceps

tendinitistendinitis• Resisted abduction(Supraspinatus) test-Resisted abduction(Supraspinatus) test-

supraspinatus lesion supraspinatus lesion • Aprehension test –glenohumeral joint Aprehension test –glenohumeral joint

instability instability

Yergason testYergason test• Yergason test for Yergason test for

biceps tendon biceps tendon instability or instability or tendonitis. tendonitis.

• The patient's elbow The patient's elbow is flexed to 90 is flexed to 90 degrees, and the degrees, and the examiner resists examiner resists the patient's active the patient's active attempts to attempts to supinate the arm supinate the arm and flex the elbow. and flex the elbow.

Drop Arm TestDrop Arm Test

• Passive abduction Passive abduction to 90to 90°°

• Instruct patient to Instruct patient to slowly lower armslowly lower arm

• At 90At 90°° abducted abducted arm will suddenly arm will suddenly drop, may need to drop, may need to add slight pressureadd slight pressure

• (+) drop = (+) test(+) drop = (+) test

SHOULDER PAINSHOULDER PAINSPECIAL TESTSSPECIAL TESTS

• NeerNeer– PASSIVEPASSIVE– Forced forward Forced forward

flexion of arm with flexion of arm with internally rotated internally rotated shouldershoulder

– Test is positive if Test is positive if pain occurs at same pain occurs at same point as with active point as with active forward flexionforward flexion

Speed’s ManeuverSpeed’s Maneuver

• Forward flex the Forward flex the shoulder against shoulder against resistance while resistance while maintaining the elbow maintaining the elbow in extension and the in extension and the forearm in supination. forearm in supination. Pain or tenderness in Pain or tenderness in the bicipital groove in the bicipital groove in dicates bicipital dicates bicipital tendinitis. tendinitis.

Rotator Cuff Strength Rotator Cuff Strength TestingTesting

• Weakness on examWeakness on exam• Grade strength on 0Grade strength on 0→→5 scale5 scale• Compare to other sideCompare to other side

Supraspinatus testing

Apprehension Apprehension Test/Relocation TestTest/Relocation Test

Differantial Diagnosis for Differantial Diagnosis for shoulder painshoulder pain

• Subacromial impingement syndrome Subacromial impingement syndrome • Adhesive capsulitis –frozen shoulderAdhesive capsulitis –frozen shoulder• Biceps tendinopatiBiceps tendinopati• Bursitis Bursitis • Rotator cuff pathology Rotator cuff pathology • Glenohumeral joint pathology Glenohumeral joint pathology • Acromioclavicular joint pathology Acromioclavicular joint pathology • Sternoclavicular joint pathologySternoclavicular joint pathology• Myofascial pain syndromeMyofascial pain syndrome• Radiating or referred pain from cervical Radiating or referred pain from cervical

spine spine

Subacromial Subacromial ImpingementImpingement

• Neer proposed that 95% of rotator cuff tears are due to chronic Neer proposed that 95% of rotator cuff tears are due to chronic impingement between the humeral head and the coracoacrominal impingement between the humeral head and the coracoacrominal

arch.arch.

Subacromial Subacromial ImpingementImpingement• Stage 1 disease consists of edema and Stage 1 disease consists of edema and

hemorrhage of the tendon due to occupational or hemorrhage of the tendon due to occupational or athletic overuse, and is reversible under athletic overuse, and is reversible under conservative treatment.conservative treatment.

Subacromial Subacromial ImpingementImpingement

• Stage 2 disease shows progressive inflammatory changes of Stage 2 disease shows progressive inflammatory changes of the rotator cuff tendons and the subacromial-subdeltoid the rotator cuff tendons and the subacromial-subdeltoid bursa, and can be treated by removing the bursa and bursa, and can be treated by removing the bursa and dividing the coracoacromial ligament after failed dividing the coracoacromial ligament after failed conservative management.conservative management.

ELBOW EXAMINATIONELBOW EXAMINATION

• AnatomyAnatomy• EvaluationEvaluation• Inspection-ObservationInspection-Observation• Palpation-PressionPalpation-Pression• Range of motionRange of motion• Neurological examinationNeurological examination• Special testsSpecial tests• Examination of related areasExamination of related areas

ELBOW ANATOMYELBOW ANATOMY

• BonesBones• JointsJoints• LigamentsLigaments• MusclesMuscles

Elbow Anatomy Elbow Anatomy Medial ElbowMedial Elbow

ElbowElbow Anatomy Anatomy Lateral ElbowLateral Elbow

ELBOW ELBOW Anatomy Anatomy

EVALUATIONEVALUATION

INSPECTIONINSPECTION• Anterior –posterior sideAnterior –posterior side• Medial-lateral sideMedial-lateral side• Carrying angleCarrying angle• Swelling Swelling

PALPATION and PALPATION and PRESSION PRESSION

Bone palpation :Bone palpation :• Lateral epicondyleLateral epicondyle• Radial head Radial head • Medial epicondyleMedial epicondyle• OlecranonOlecranon

SOFT TISSUE SOFT TISSUE PALPATIONPALPATION

Medial aspect Medial aspect • Ulnar nerveUlnar nerve• Wrist flexor –pronator groupWrist flexor –pronator group• Medial collateral ligament Medial collateral ligament Lateral aspectLateral aspect• Wrist extensors (ECRL-ECRB)Wrist extensors (ECRL-ECRB)• Lateral collateral ligament Lateral collateral ligament • Annular ligament Annular ligament

SOFT TISSUE SOFT TISSUE PALPATIONPALPATION

Anterior aspectAnterior aspect• Cubital fossa Cubital fossa • Brachial arteryBrachial artery• Median nerve Median nerve • Musculo-cutaneus nerve Musculo-cutaneus nerve Posterior aspectPosterior aspect• Olecranon bursaOlecranon bursa• Triceps tendon Triceps tendon

ELBOW ROMELBOW ROM

• Flexion -135 degreeFlexion -135 degree• Extension -0 degree Extension -0 degree • Pronation -90 degree Pronation -90 degree • Supination -90 degreeSupination -90 degree

NEUROLOGICAL NEUROLOGICAL EXAMINATION EXAMINATION

Muscle tests:Muscle tests:• Flexion - Extension Flexion - Extension • Pronation - SupinationPronation - Supination Sensation tests Sensation tests • C5-C6-C7-C8-T1C5-C6-C7-C8-T1 Reflex test:Reflex test:• Biceps reflex –C6Biceps reflex –C6• Brachioradial reflex –C6Brachioradial reflex –C6• Triceps reflex-C7Triceps reflex-C7

Elbow Reflex testingElbow Reflex testing

• Biceps reflex –C6Biceps reflex –C6• Brachioradial reflex –C6Brachioradial reflex –C6• Triceps reflex-C7Triceps reflex-C7

SPECIAL TESTSSPECIAL TESTS

• Ligament tests (varus-valgus stres Ligament tests (varus-valgus stres test)test)

• Tennis elbow test Tennis elbow test • Golfers elbow test Golfers elbow test • Tinels sign for ulnar nerve Tinels sign for ulnar nerve

Ligament tests (varus-Ligament tests (varus-valgus stres test)valgus stres test)

Tennis elbow testTennis elbow test

Golfers elbow testGolfers elbow test

Tinels sign for ulnar nerve Tinels sign for ulnar nerve

COMMON ELBOW COMMON ELBOW PROBLEMSPROBLEMS

• Lateral epicondylitis Lateral epicondylitis • Medial epicondylitis Medial epicondylitis • Olecranon bursitis Olecranon bursitis • Fractures Fractures • Triceps tendinitis Triceps tendinitis • Post immbolization capsular Post immbolization capsular

tightnesstightness

(contracture)(contracture)

EXAMINATION of the EXAMINATION of the WRIST and HAND WRIST and HAND

Anatomy Anatomy • Surface anatomy Surface anatomy • Skeletal anatomy Skeletal anatomy • Fibrous anatomy Fibrous anatomy • MusclesMuscles• Nerves Nerves • Blood supply Blood supply

Bony Bony AnatomyAnatomy

• Phalanges: 14Phalanges: 14• Sesamoids: 2Sesamoids: 2• Metacarpals: 5Metacarpals: 5• CarpalsCarpals

– Proximal row: 4Proximal row: 4– Distal row: 4Distal row: 4

• Radius and UlnaRadius and Ulna

Lister’s tubercle

ANATOMY ANATOMY

• Surface anatomy Surface anatomy • Palmar surface Palmar surface • Radial border Radial border • Thenar surface Thenar surface • Thumb –index-middle-ring-small Thumb –index-middle-ring-small

fingers fingers • Hypothenar surface Hypothenar surface • Dorsal surface Dorsal surface • İnterosseus muscle İnterosseus muscle

JOINTSJOINTS

• Radio-carpal Radio-carpal • Ulna-carpal Ulna-carpal • İnter-carpal İnter-carpal • Metacarpo-phalangial (MCP)Metacarpo-phalangial (MCP)• Proximal inter-phalangial (PIP)Proximal inter-phalangial (PIP)• Distal inter-phalangial (DIP)Distal inter-phalangial (DIP)

MusclesMuscles

EVALUATION EVALUATION

• History History • Inspection-Observation (dorsum of the Inspection-Observation (dorsum of the

hand-palm of the hand )hand-palm of the hand )• Palpation-PressionPalpation-Pression• Range of motionRange of motion• Functional assessmentFunctional assessment• Neurological examinationNeurological examination• Special testsSpecial tests• Examination of related areasExamination of related areas

INSPECTIONINSPECTIONPalmar SurfacePalmar Surface

• CreasesCreases• Thenar and Thenar and

Hypothenar Hypothenar EminenceEminence

• Arched FrameworkArched Framework• Hills and ValleysHills and Valleys• Web SpacesWeb Spaces

Palpation-PressionPalpation-Pression

ROM EXAMINATION ROM EXAMINATION

• Forearm pronation-90 degreeForearm pronation-90 degree• Forearm supination -90 degreeForearm supination -90 degree• Wrist flexion (palmar flexion)-90 Wrist flexion (palmar flexion)-90

degree degree • Wrist extension (dorsal flexion )-90 Wrist extension (dorsal flexion )-90

degree degree • Wrist radial deviation -30 degree Wrist radial deviation -30 degree • Wrist ulnar deviation -20 degree Wrist ulnar deviation -20 degree

RANGE OF MOTIONRANGE OF MOTIONWristWrist

• FlexionFlexion• ExtensionExtension• Radial deviationRadial deviation• Ulnar deviationUlnar deviation

– Ulnar deviation is Ulnar deviation is greater than greater than radialradial

FINGERS ROM FINGERS ROM

MCP joint :MCP joint :• Flexion -90 degreeFlexion -90 degree• Extension -20 degree Extension -20 degree PIP joint : PIP joint : • Flexion -90 degreeFlexion -90 degree• Extension -0 degree Extension -0 degree DIP joint :DIP joint :• Flexion -80 degree Flexion -80 degree • Extension -0 degree Extension -0 degree

THUMB ROM THUMB ROM

• Flexion Flexion • Extension Extension • Abduction Abduction • Adduction Adduction • Opposition Opposition

NERVES and BLOOD NERVES and BLOOD SUPPLY SUPPLY

• Radial nerve Radial nerve • Median nerve Median nerve • Ulnar nerve Ulnar nerve

• Radial artery Radial artery • Ulnar artery Ulnar artery

COMMON PROBLEMS COMMON PROBLEMS

• Fractures Fractures • Tenosynovitis :Tenosynovitis :1.1. Thumb extensors –De Querveins diseaseThumb extensors –De Querveins disease2.2. Finger flexors tenosynovitis Finger flexors tenosynovitis 3.3. Finger extensors tenosynovitis Finger extensors tenosynovitis • Arthritis Arthritis 1.1. Rheumatoid arthritis (RA)Rheumatoid arthritis (RA)2.2. Osteoarthritis (OA)Osteoarthritis (OA)––bouchards nodes bouchards nodes -heberdans nodes -heberdans nodes - First MCP OA-Rhizarthrosis- First MCP OA-Rhizarthrosis

DeQuervain’s DeQuervain’s TenosynovitisTenosynovitis

• Inflammation of Inflammation of EXT Pollicis Brevis EXT Pollicis Brevis and ABD Pollicis and ABD Pollicis Longus tendonsLongus tendons

• Tenderness - Tenderness - 1st Dorsal 1st Dorsal CompartmentCompartment

• Finkelstein’s TestFinkelstein’s Test

Rheumatoid ArthritisRheumatoid Arthritis

• MCP swellingMCP swelling• Swan neck Swan neck

deformitiesdeformities• Ulnar deviation Ulnar deviation

at MCP jointsat MCP joints• Nodules along Nodules along

tendon sheathstendon sheaths

OsteoarthritisOsteoarthritis

• Heberden’s nodes: Heberden’s nodes: DIPDIP

• Bouchard’s nodes: Bouchard’s nodes: PIPPIP

COMPRESSION COMPRESSION NEUROPATHIES NEUROPATHIES

• Median nerve compression syndrome Median nerve compression syndrome carpal tunel syndrome (tinel and phalen test )carpal tunel syndrome (tinel and phalen test )• Pronator syndrome Pronator syndrome • Ulnar nerve compression syndromes Ulnar nerve compression syndromes compression at the elbow ulnar tunel syndrome compression at the elbow ulnar tunel syndrome Compresssion at the wrist Guyon canal Compresssion at the wrist Guyon canal

syndromesyndrome• Radial nerve compression syndromes Radial nerve compression syndromes Posterior interosseous nerve syndrome Posterior interosseous nerve syndrome Superficial radial nerve entrapment Superficial radial nerve entrapment

SPECIAL TESTSSPECIAL TESTS

• Finkelsteins test –De Quervein Finkelsteins test –De Quervein tenosynovitis tenosynovitis

• Tinel test –CTS, UTSTinel test –CTS, UTS• Phalens test –CTS Phalens test –CTS

Carpal Tunnel TestsCarpal Tunnel Tests

• Neurologic examNeurologic exam– Median nerve Median nerve

sensation and sensation and motormotor

• Phalen’s Test:Phalen’s Test:both wrists both wrists maximally flexed maximally flexed for 1 minutefor 1 minute

• Tinel’s TestTinel’s Test

EXAMINATION of the EXAMINATION of the RELATED AREAS RELATED AREAS

• Cervical spine Cervical spine • Shoulder Shoulder • Elbow Elbow • Arteries ,veins ,lymphArteries ,veins ,lymph• gallbladder stonegallbladder stone• Heart Heart