Anatomy and special tests of upper extremity
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Functional anatomy of upper extremity
Shoulder region
The primary movements of the shoulder are that are aided by the four joints of the shoulder are:
- Shoulder flexion/ extension
- Shoulder elevation/ depression
- Shoulder external rotation/ internal rotation
- Shoulder abduction/adduction
- Scapular elevation/depression
- Scapular upward rotation/ downward rotation
- Scapular abduction/ adduction
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Elbow Region
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The primary movements of the elbow that are aided by the four joints of the elbow are:
- Elbow flexion/extension
- Forearm supination/pronation
The elbow joint has other important anatomical features:
- Capsule- thin, structure that surrounds the anterior and posterior components of the joint
- Bursae- act as fluid-filled sac that provides cushioning and friction reduction between tendons, joints, muscles and bone
The ligaments that aid in movement of the elbow region are:
- Ulnar collateral ligament
- Ligament is triangle in shape running anteriorly, posteriorly, and obliquely to reinforce the medial humeroradial joint
- Radial collateral ligament
- Fan shaped ligament that runs from lateral epicondyle to annular ligament to support the humeroradial joint laterally
- Annular ligament
- Cone shaped ligament that envelopes the radial head and attaches to the medial ulna; provides protection to radial head
- Quadrate ligament
- Extends from radial notch on ulna surface to the neck of the radius; reinforces the inferior portion of the joint capsule
- Distal radioulnar ligament
- Comprised of anterior and posterior radioulnar ligament to provide strength to the capsule
Wrist and Hand Region
The primary movements of the wrist and hand region are:
- Wrist flexion/extension
- Wrist radial deviation/ulnar deviation
- Finger flexion/extension
- Finger abduction/adduction
- Intrinsic finger movement
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The wrist and hand joint has other important anatomical features:
- Capsule of wrist and hand- provide support to internal structures
- Volar plate- present on palmar aspect of MCP, PIP, and DIP to protect joints
- Extensor hood- fibrous connection on the dorsum of finger that aids in extension of the PIP and DIP
- Nerves- radial, medial, and ulnar are the primary nerves of innervation for the wrist and hand
Ligaments of the wrist:
- Dorsal radiocarpal
- Limits flexion, pronation
- Radiate
- Stabilizes hand
- Radial collateral ligament
- Limits ulnar deviation
- Ulnar collateral ligament
- Limites radial deviation
- Palmar ulnocarpal
- Limits extension and supination
- Palmar radiocarpal
- Limits extension and supination through knuckles
Ligaments of fingers:
- Collateral ligaments
- Oriented from lateral condyle to distal phalanx and lateral volar plate to each metacarparpal, PIP, and DIP
- All fibers tighten during flexion but only volar fibers tighten during extension
- Accessory
- Oriented from condylar head to volar plate
- Transverse
- Provide stability linking MCP joints and reinforcing the anterior capsule
Upper extremity range of motion normals
Shoulder range
Elbow range
Wrist range
MCP range
PIP range
DIP range
1st CMC range
1st MCP range
1st IP range
Special tests of upper extremity
Shoulder special tests
- Apprehension test (tests anterior instability)
- Patient is supine with shoulder in 90 degrees abduction; therapist attempts to externally rotate
- Positive: patient seems apprehensive about performing movement and resists motion
- Patient is supine with shoulder in 90 degrees abduction; therapist attempts to externally rotate
- Sulcus sign (tests posterior and inferior instability)
- Patient stands with arm relaxed at side; therapist pulls arm distally
- Positive: presence of sulcus inferior to the acromion with symptom reproduction
- Patient stands with arm relaxed at side; therapist pulls arm distally
- Drop arm test
- Patient seated with shoulder passively abducted to 120 degrees; patient instructed to slowly lower arm back to sign
- Positive: patient is unable to lower arm down slowly and suddenly drops to side without control
- Patient seated with shoulder passively abducted to 120 degrees; patient instructed to slowly lower arm back to sign
- Infraspinatus/supraspinatus muscle test
- Patient is seated or standing and therapist resists external rotation with arm in neutral position and adducted to trunk
- Positive: patient is unable to sustain external rotation
- Patient is seated or standing and therapist resists external rotation with arm in neutral position and adducted to trunk
- External rotation lag sign
- Patient is seated or standing with shoulder passively abducted to 90 degrees and externally rotated
- Positive: patient is unable to maintain external rotation
- Patient is seated or standing with shoulder passively abducted to 90 degrees and externally rotated
- Internal rotation lag sign
- Patient is seated with arm held behind back in internal rotation passively
- Positive: patient is unable to maintain internal rotation
- Patient is seated with arm held behind back in internal rotation passively
- Empty can test
- The patient stands or sits with their arms at their sides. The patient abducts their arm to 90 degrees, with their elbow extended. The patient internally rotates their shoulder, so that their thumbs point towards the floor. The examiner applies downward pressure on the patient’s wrist or forearm.
- Positive: Pain in the shoulder, Weakness in the arm, and The patient’s arm dropping involuntarily.
- Tests supraspinatus muscle
- Positive: Pain in the shoulder, Weakness in the arm, and The patient’s arm dropping involuntarily.
- The patient stands or sits with their arms at their sides. The patient abducts their arm to 90 degrees, with their elbow extended. The patient internally rotates their shoulder, so that their thumbs point towards the floor. The examiner applies downward pressure on the patient’s wrist or forearm.
- Neer’s
- The patient sits comfortably, and the examiner stands behind them. The examiner stabilizes the patient’s scapula (shoulder blade) with one hand to prevent scapular movement during the test. The examiner passively flexes the patient’s arm forward while internally rotating it, bringing the greater tuberosity of the humerus (the bony bump on the upper arm) under the acromion.
- Positive: The patient reports pain or tenderness during the arm movement, particularly in the anterior or lateral aspect of the shoulder.
- Tests for impingement
- Positive: The patient reports pain or tenderness during the arm movement, particularly in the anterior or lateral aspect of the shoulder.
- The patient sits comfortably, and the examiner stands behind them. The examiner stabilizes the patient’s scapula (shoulder blade) with one hand to prevent scapular movement during the test. The examiner passively flexes the patient’s arm forward while internally rotating it, bringing the greater tuberosity of the humerus (the bony bump on the upper arm) under the acromion.
- Hawkins- Kennedy
- The patient sits with their arm flexed at the shoulder and elbow to 90 degrees. The examiner stabilizes the patient’s shoulder with one hand and internally rotates the arm with the other hand.
- Positive: The test is considered positive if the patient experiences pain in the anterior shoulder during internal rotation.
- Tests for impingement
- Positive: The test is considered positive if the patient experiences pain in the anterior shoulder during internal rotation.
- The patient sits with their arm flexed at the shoulder and elbow to 90 degrees. The examiner stabilizes the patient’s shoulder with one hand and internally rotates the arm with the other hand.
- Acromionclavicilar (AC) joint
- Horizontal adduction test
- Patient standing with shoulder flexed to 90 degrees and adducted across chest
- Positive: localized pain over AC joint
- Patient standing with shoulder flexed to 90 degrees and adducted across chest
- Horizontal adduction test
- SLAP (superior labrum anterior to posterior) lesions
- O’Brien’s test
- The patient stands or sits with their affected arm flexed at 90° and adducted 10–15°; the patient internally rotates their shoulder; the examiner applies downward pressure on the patient’s arm while the patient resists; repeated with upper extremity in external rotation
- Positive: pain or clicking noise found when performing internal rotation and symptoms relieved when performing external rotation
- Differential diagnosis needs to be made to determine if AC joint vs glenoidhumeral joint dysfunction
- The patient stands or sits with their affected arm flexed at 90° and adducted 10–15°; the patient internally rotates their shoulder; the examiner applies downward pressure on the patient’s arm while the patient resists; repeated with upper extremity in external rotation
- O’Brien’s test
- Bicep tendonitis tests
- Bicep load II test
- Patient in supine with shoulder abducted to 120 degrees elbow flexed to 90 degrees, forearm supinated; shoulder fully externally rotated; if the patient demonstrates apprehension when performing then asked patient to flex the elbow against resistance
- Positive: if apprehension remains the same or shoulder becomes more painful
- Patient in supine with shoulder abducted to 120 degrees elbow flexed to 90 degrees, forearm supinated; shoulder fully externally rotated; if the patient demonstrates apprehension when performing then asked patient to flex the elbow against resistance
- Yergasons test
- Patient sitting with shoulder in neutral position against trunk, elbow at 90 degrees, and forearm pronated, resist supination of forearm and external rotation of shoulder
- Tests for transverse ligament, bicipital tendonitis, and SLAP lesions
- Positive: bicep tendon of long head will be palpable outside of bicepal groove or a reproduction of pain
- Patient sitting with shoulder in neutral position against trunk, elbow at 90 degrees, and forearm pronated, resist supination of forearm and external rotation of shoulder
- Speed’s test
- Patient sitting or standing with upper limb in full extension and forearm supination, resist shoulder flexion
- Can also place shoulder in 90 degrees of flexion and push upper limb into extension (causing eccentric contraction)
- Tests bicepetal tendonitis and SLAP lesions
- Can also place shoulder in 90 degrees of flexion and push upper limb into extension (causing eccentric contraction)
- Positive: pain in anterior shoulder
- Patient sitting or standing with upper limb in full extension and forearm supination, resist shoulder flexion
- Bicep load II test
- Neurological dysfunction
- Upper limb tension tests- assists with identifying peripheral nerve injury by placing the upper limb in positions of that will stress nerve
- Upper limb tension test 1 (ULTT1)- median and anterior interosseous nerve
- Cervical spine: contralateral lateral flexion
- Shoulder: depression and abduction to 110 degrees
- Elbow: extension
- Forearm: supination
- Wrist: extension
- Fingers and thumb: extension
- Upper limb tension test 2 (ULTT 2)- median, axillary, and musculocutaneous nerve
- Cervical spine: contralateral lateral flexion
- Shoulder: depression and abduction to 10 degrees, lateral rotation
- Elbow: extension
- Forearm: supination
- Wrist: extension
- Upper limb tension test 3 (ULTT 3)- radial nerve
- Cervical spine: contralateral lateral flexion
- Shoulder: depression and abduction to 10 degrees; internal rotation
- Elbow: extension
- Forearm: pronation
- Wrist: flexion with ulnar deviation
- Fingers and thumb: flexion
- Upper limb tension test 4 (ULTT 4)- ulnar nerve
- Cervical spine: contralateral lateral flexion
- Shoulder: depression and abduction (10 - 90 degrees) with hand to ear
- Elbow: flexion
- Forearm: pronation
- Wrist: extension and radial deviation
- Fingers and thumb: extension
- Upper limb tension test 1 (ULTT1)- median and anterior interosseous nerve
- Upper limb tension tests- assists with identifying peripheral nerve injury by placing the upper limb in positions of that will stress nerve
- Thoracic outlet syndrome- assess for structural damage of nerves and arteries that pass through the thoracic inlet
- Adson’s test (compression of the subclavian artery and/or nerves as it passes through the interscalene space)
- Patient sitting with radial nerve palpated; head rotated toward extremity being tested with shoulder extended and externally rotated; extend head
- Positive: reproduction neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
- Roos elevated arm test (nerves and/or blood vessels in the space between the collarbone and the first rib are compressed)
- Patient standing with shoulders fully externally rotated, 90 degrees abducted, elbows flexed to 90 degrees- patient then rapidly opens and closes hand for 3 minutes
- Positive: reproduction neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
- Wright test (compression at the space behind the pectoralis minor muscle)
- Patient seated with passive movement of arm into abduction and external rotation
- Positive: reproduction neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
- Costoclavicular test (compression of the neurovascular bundle between the clavicle and first rib)
- To perform the test the patient sitting, the therapist assists the patient in performing the following 4 movements: scapula retraction, scapula depression, elevation, and protraction- the patient holds each position for up to 30 seconds, while the patient rests his or her forearms on his thighs
- Positive: reproduction neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
- Adson’s test (compression of the subclavian artery and/or nerves as it passes through the interscalene space)
Elbow special tests
- Elbow extension test
- Patient in seated position attempts to fully extend elbow
- Positive: patient unable to extend due to possible fracture- imaging will be needed to confirm
- Varus/valgus test
- Patient siting or supine with elbow flexed to 20 degrees; valgus force applied to test ulnar collateral ligament and then varus force applied to test for radial collateral ligament
- Positive; joint laxity and possible pain- needs to be performed bilaterally to determine joint laxity
- Bicep rupture sign
- Observation of distal bunching of bicep muscle along with complete loss of function (unable to perform elbow flexion)
- Positive: Indicates rupture of proximal long head of biceps tendon
- Cozen’s test
- Patient can be seated or standing. Position the patient with their elbow extended, forearm in pronation, wrist in slight radial deviation, and then ask them to make a fist and resist wrist extension while the examiner palpates the lateral epicondyle.
- Positive: Pain indicates lateral epicondylitis
- Mills test
- Patient can be seated or standing. The patient extends their arm straight out in front of them with their palm facing down. The examiner then flexes the patient’s wrist and supinates their forearm, causing a stretch in the flexor tendons.
- Positive: Pain with this maneuver suggests medial epicondylitis.
- Neurological dysfunction
- Elbow flexion test
- Patient supine with shoulder in full external rotation and elbow held in maximal flexion with wrist extended for one minute
- Positive: pain present at medial elbow with hypoanesthesia n ulnar distribution of involved side
- Entrapment of ulnar nerve at cubital tunnel
- Elbow flexion test
Wrist and hand special tests
Ligamentous, capsule, and joint instability
- Watson (scaphoid shift)
- Patient seated with elbow rested on table, forearm pronated, wrist palace in full ulnar deviation, with slight extension while stabilization of metacarpals by therapist. Pressure placed on sidal side of scaphoid while radially deviating and flexing wrist
- Positive: painful shift of scaphoid with a “clunk” sound when pressure is removed (wrist placed into resting position) indicates carpal instability
- Interphalangeal joint varus/valgus tests
- Patient in seated position with fingers supported and stabilized; valgus/varus force applied to PIP and DIP joints of all digits
- Positive: joint laxity and possible pain - needs to be performed bilaterally to determine extent of laxity
Tendon and muscle
- Wrist hyperabduction and abduction of thumb test (WHAT)
- Patient in seated position with wrist hyperflexed and thumb abducted in full MCP and IP extension with resistance applied against therapist’s index finger
- Positive: reproduction of pain in wrist- needs to be performed bilaterally
- Indicates de Quervain’s tenosynovitis
- Most preferred test due to sensitivity for de Quervain’s tenosynovitis
- Indicates de Quervain’s tenosynovitis
- Eichoff’s test
- Patient seated makes fist with thumb flexed within fingers while examiner passively moves wrist into ulnar deviation
- Positive: reproduction of pain in wrist- needs to be performed bilaterally
- Indicates de Quervain’s tenosynovitis
- 2nd preferred test due to sensitivity for de Quervain’s tenosynovitis
- Indicates de Quervain’s tenosynovitis
- Finkelstein’s test
- Patient seated while therapist passively pulls the thumb and wrist into ulnar deviation and pulses in longitudinal direction
- Positive: reproduction of pain in wrist- needs to be performed bilaterally
- Indicates de Quervain’s tenosynovitis
- 3rd preferred test due to sensitivity for de Quervain’s tenosynovitis
- Indicates de Quervain’s tenosynovitis
Neurological dysfunction
- Phalen’s test (wrist flexion test)
- Patient in seated position maximally flexes both wrists while holding them together for one minute
- Positive: reproduces tingling sensation or paresthesia in median nerve distribution
- Indicates carpal tunnel syndrome
- Tinel’s test
- Patient in seated position and therapists taps peripheral nerve (can be any nerve palpable)
- Positive: reproduces tingling sensation or paresthesia nerve distribution
Vascular dysfunction
- Modified Allen’s test
- Patient in seated position has therapist palpate radial and ulnar nerve followed by patient quickly opening and closing hand several times; patient then makes a fist
- Therapist then compresses radial artery, has patient open hand, observes palm of hand, releases compressed radial artery, and observes for radial filling time; the same procedure will be done with ulnar artery
- Positive: abnormal re-filling time- needs to be performed bilaterally