Differential diagnosis with interventions of upper extremity

Shoulder differential diagnosis

• Glenohumeral dislocations and instability
  • Dislocations of the glenohumeral joint caused by traumatic or atraumatic reasons
    • Trauma is due to direct injury
    • Atramautic can be due to repetitive injury causing hypermobility
  • Types of dislocations:
    • Anterior-inferior dislocations: caused by excessive abduction and external rotation of upper extremity with subsequent disruption in inferior glenoid ligament, anterior capsule, and glenoid labrum
      • If traumatic can lead to:
        • Hill-Sachs lesion: compression fracture of posterior humeral head
        • Superior labrum, anterior to posterior tear (SLAP)
        • Bankhart lesion: avulsion of the anterior-inferior capsule and glenoid labrum
        • Axillary nerve injury: numbness, tingling, and weakness in deltoid

Image #47

https://upload.wikimedia.org/wikipedia/commons/e/e3/Shoulder_dislocation_with_Bankart_and_Hill-Sachs_lesion%2C_before_and_after_reduction.jpg

• Posterior dislocations : rare, caused by horizontal adduction and internal rotation

• Symptoms
  • Popping during movements
  • Repeated dislocations or subluxations of glenohumeral joint
• Diagnosis
  • Clinical presentation
  • Special test- apprehension test
  • X-ray
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Surgery as indicated
• Physical therapy interventions
  • Strengthening capsule and muscles directly connected to prevent further dislocations
  • Functional training
  • Avoidance of apprehension position
  • Surgical protocols if indicated
    • With anticipated return to function in 3-4 months

• Labral tears
  • Tear in the cartilage ring that surrounds the shoulder joint; divided into above the middle of the socket and below the middle of the socket
    • Above the middle of the socket is caused a SLAP (superior labral anterior-posterior) tear; can also involve the biceps tendon
    • Below the middle of the socket is caused a Bankhart lesion; can also involve the inferior glenoid ligament
  • Labral tears are associated with traumatic injury or repetitive shoulder dislocations

• Symptoms:
  • Pain increased with overhead movement or behind the back
  • Shoulder weakness
  • Shoulder instability/dislocation
  • Pain with resisted flexion of the biceps
  • Tenderness over anterior shoulder
• Diagnosis
  • Clinical presentation
  • MRI
  • Arthroscopic surgery- gold standard for diagnosis
• Medical Interventions
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Surgery if indicated
• Physical therapy interventions
  • Focus on return to function without pain
  • Restoration of muscle imbalances
  • Address underlying causes of labral tears
  • Surgical protocols if indicated
    • With anticipated return to function in 3-4 months

• Rotator cuff tendonitis
  • Caused by mechanical impingement of the distal attachment of the rotator cuff causing inflammation of the tendons
    • Increased risk for development of tendonitis due to poor vascularity at attachment sites

Image #48

https://upload.wikimedia.org/wikipedia/commons/thumb/f/fc/Shoulder_joint.svg/1920px-Shoulder_joint.svg.png

• Symptoms
  • Pain when raising or lowering the arm
  • Pain when reaching behind your back
  • Pain that worsens after lying down on the affected side
• Diagnosis
  • Clinical presentation
  • Special tests- empty can test, drop arm test, manual muscle testing of infraspinatus and supraspinatus
  • MRI
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Surgery if indicated
• Physical therapy intervention
  • Determine the phase (acute vs subacute vs chronic) and make appropriate selection of interventions based on phase of healing
  • Surgical protocols if indicated

• Impingement syndrome
  • Impingement (entrapment) of rotator cuff tendon against the acromion due to mechanical repetition

• Symptoms
  • Pain in the anterior and superior aspect of the shoulder
  • Pain and weakness that worsens with overhead movements, such as reaching, throwing, or lifting objects
  • Pain that may radiate down the arm
  • Pain that is worse at night
• Diagnosis
  • Clinical presentation
  • Special tests
    • Hawkins-Kennedy
    • Neer’s
    • Painful-arc
      • Shoulder pain that occurs when abducting an arm between 70 and 120 degrees.
    • MRI
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Surgery if indicated
  • Physical therapy intervention
    • Avoidance of shoulder elevation greater than 90 degrees to avoid subacromial decompression- acute phase
    • Postural re-education- improve forward head, rounded shoulders, and kyphotic posture
    • Correction of muscle imbalances
    • Improve joint mobility
    • Return to previous functional status
    • Surgical protocols if indicated

• Adhesive capsulitis
  • Restriction in shoulder motion due to inflammation of the joint capsule
    • Restrictions are in external rotation (greatest), abduction and flexion (capsular pattern of shoulder)
    • Reason for diagnosis can be repetitive motion, diabetes, cardiovascular disease, or thyroid disease

• Symptoms
  • Restriction in external rotation, abduction, and flexion causing functional deficits
• Diagnosis
  • Clinical presentation
  • Functional limitations
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Management of diabetes , cardiovascular, or thyroid disease if applicable
• Physical therapy management
  • Improve joint mobility in capsular pattern
  • Return to prior functional status
  • Improve muscle imbalances

• Acromioclavicular and sternoclavicular disorders
  • Occurs when fall on adducted shoulder or when with collision with another individual particularly during sporting event
    • Grades of injury
      • Type I
        • A minor sprain of the acromioclavicular ligament
        • No radiographic displacement
        • No tear of the acromioclavicular or coracoclavicular ligament
      • Type II
        • A tear of the acromioclavicular ligament, but not the coracoclavicular ligaments
        • Less than 25% increase in the coracoclavicular interspace
      • Type III
        • Tears of both the acromioclavicular and coracoclavicular ligament
        • 25% to 100% displacement of the clavicle
      • Type IV
        • Tears of both the acromioclavicular and coracoclavicular ligament
        • Posterior displacement of the distal clavicle into the trapezius fascia

• Symptoms:
  • Pain at the top of the shoulder, which may worsen when moving the arm
  • Swelling, bruising, or tenderness over the joint
  • Limited range of motion in the shoulder
  • A bump or deformity where the clavicle or scapula has moved
  • A crunching or grinding sound when moving the arm
  • The collarbone may appear to move upward
  • The shoulder may appear to droop
• Diagnosis
  • Clinical presentation
  • Subjective statement of mechanism of injury
  • X-ray
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Surgery is rare due to the increased risk of deterioration it can have on the AC joint
• Physical therapy management
  • Sling during acute phase to avoid shoulder elevation
  • Functional training and strengthening of muscles surrounding the joint
  • Manual therapy to acromioclavicular or coracoclavicular ligament as appropriate

• Subacromial/subdeltoid bursitis
  • Subacromial and subdeltoid burse become inflamed (close relationship with rotator cuff tendonitis )
    • The bursa becomes trapped (impinged) beneath the acromion arch

• Symptoms
  • Pain may worsen with overhead movements, such as reaching for objects or lifting the arm.
  • The shoulder may be tender to the touch, especially around the acromion process.
  • The bursa may become inflamed and swollen, causing a visible bulge or lump in the shoulder.
  • The shoulder may feel stiff and difficult to move. .
  • When moving the shoulder, there may be clicking or popping sounds as the bursa rubs against the acromion bone.
• Diagnosis:
  • Clinical examination - ruling in and out other diagnoses based on symptomatology as well as assessment of range of motion and muscle strength
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Determine the phase (acute vs subacute vs chronic) and make appropriate selection of interventions based on phase of healing

• Bicepital tendonitis
  • Inflammation of the long head of the biceps
    • Cases can be mechanical trapping (impingement) of the long head of biceps between acromion and bicipital groove of humerus

• Symptoms
  • Sharp, throbbing, or dull pain in the front of the shoulder that may radiate down the upper arm - pain worsens with overhead movements, such as reaching, lifting, or throwing.
  • Localized tenderness over the biceps tendon, particularly where it passes over the shoulder joint.
  • A feeling or sound of snapping or popping in the shoulder when moving the arm.
  • Weakness in the biceps muscle, making it difficult to lift or bend the arm.
• Diagnosis
  • Clinical presentation
  • MRI
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Determine the phase (acute vs subacute vs chronic) and make appropriate selection of interventions based on phase of healing

• Proximal humeral fracture
  • Occurs due to fall on outstretched arm
    • Stable fractures that do not require surgery

• Symptoms
  • Intense shoulder pain
  • Swelling and bruising,
  • Difficulty moving the arm
• Diagnosis:
  • Clinical presentation
  • Subjective statement
  • X-ray
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy interventions
  • Early passive range of motion to decrease range of motion restrictions
  • Non-weight bearing early per physician recommendations
  • Eventual active range of motion, strengthening, and coordination activities initiated once medically cleared

• Distal humeral fracture
  • Trauma causes fracture at distal humerus
    • Immediate attention must be given to if supracondylar fracture due to increased likelihood of neurovascular involvement
      • Radial nerve involvement and vascular structures may lead to paralysis and/or pulselessness
      • In children, can cause malunion due to growth plate involvement
    • Lateral epicodyle fractures will require internal fixation (rod and screws implanted in arm) for proper alignment

• Symptoms
  • Severe pain in the elbow area that may radiate to the forearm and shoulder.
  • Pronounced swelling around the elbow joint.
  • The elbow may appear bent or twisted.
• Diagnosis
  • Clinical presentation
  • X-ray
• Medical management
  • Surgery for internal fixation
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Aid in management of symptoms during inflammatory phase
  • After surgical intervention and time of immobilization has concluded, then will begin mobility and strengthening

• Thoracic outlet syndrome
  • Compression of neurovascular bundle to that includes the brachial plexus, sympathetic trunk, subclavian artery and vein, and phrenic and vagus nerves due to alteration in thoracic outlet size
  • Common areas of compression are:
    • Superior thoracic outlet
    • Scalene triangle
    • Between clavicle and first rib
    • Between pectoralis minor and thoracic wall

• Symptoms
  • Pain in the neck, shoulder, arm, or hand
  • Pain that worsens with certain activities, such as overhead reaching or holding objects
  • Numbness, tingling, or burning sensations in the arm, hand, or fingers
  • Symptoms may be worse at night or after prolonged activity
  • Weakness in the arm, hand, or grip
  • Swelling in the arm or hand,
  • Coldness or cyanosis in the fingers
• Diagnosis
  • Clinical examination
    • Special tests
      • Adson’s test
      • Roos test
      • Wright test
      • Costoclaviclavidular test
  • X-ray
  • MRI
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Surgical removal of cervical rib as indicated
  • Surgical release of Scalenes as indicated
• Physical therapy management
  • Interventions vary based on cause of thoracic outlet syndrome
  • Postural re-education
  • Joint mobility and strengthening as appropriate

Elbow differential diagnosis

• Medial epicondylitis
  • Inflammation of the pronator teres and the flexor carpi radialis tendons at the attachment of at the medical epicondyle
    • Typically due to overuse in activities that require excessive pronation at the forearm
      • Commonly referred to as golfer’s elbow

• Symptoms
  • Pain on the inner side of the elbow, often radiating down the forearm
  • Pain that worsens with activities that involve gripping, twisting, or bending the wrist
  • Tenderness to the touch on the medial epicondyle
  • Weakness in the grip
  • Numbness or tingling in the ring and little fingers
  • Stiffness in the elbow
• Diagnosis
  • Clinical presentation
    • Special test
      • Mill’s test
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Determine the phase (acute vs subacute vs chronic) and make appropriate selection of interventions based on phase of healing
  • Bracing may be indicated

• Lateral epicondylitis
  • Inflammation of the extensor carpi radialis brevis tendon at its attachment at the lateral epicondyle
    • Gradual onset occurring with repetitive wrist extension resulting in overloading of the extensor carpi radialis

• Symptoms
  • Gradual onset of pain on the outer side of the elbow, often worse with gripping, twisting, or extending the wrist
  • Localized tenderness over the lateral epicondyle
  • May be mild swelling around the elbow.
  • Pain may spread from the elbow down the forearm or into the wrist.
• Diagnosis
  • Clinical presentation
    • Special tests
      • Cozen’s test
• Medial management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Determine the phase (acute vs subacute vs chronic) and make appropriate selection of interventions based on phase of healing
  • Bracing may be indicated

• Ulnar collateral ligament injuries
  • Due to repetitive valgus stress to medial elbow causing stress to ulnar collateral ligament

• Symptoms
  • Pain at medial elbow at insertion of ligament
  • Paresthesias in ulnar nerve distribution in forearm and hand
• Diagnosis
  • Clinical presentation
    • Special test
      • Tinel test
      • Valgus elbow test
  • MRI
• Medial management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Determine the phase (acute vs subacute vs chronic) and make appropriate selection of interventions based on phase of healing
  • Taping may be indicated

• Elbow dislocation
  • Caused by trauma to the elbow causing misalignment from anatomical position
    • Posterior dislocation is the most common
      • Posterolateral dislocation occurs as a result of hyperextension from a fall on outstretched arm
      • Posterior dislocations commonly cause avulsion fracture of medial epicondyle
    • Complete dislocation will impact all of the following structures
      • Lateral collateral ligament, anterior capsule, brachialis muscle, wrist flexor muscles, and wrist extensor muscles

• Symptoms
  • Intense pain at the elbow joint, especially during movement
  • The elbow may appear visibly out of place, with the forearm at an unnatural angle
  • The elbow may feel loose or like it is going to give way.
  • Difficulty or inability to bend, straighten, or rotate the elbow.
  • Swelling and bruising around the elbow joint.
• Diagnosis
  • Clinical presentation
  • X-ray
• Medical management
  • Reduction of dislocation
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Stable elbow (easily reduced and stays in place)- initial immobilization followed by therapy to assist with regaining range of motion and strength
  • Unstable elbow (elbow continues to dislocated even after reduction)- surgery indicated

• Nerve entrapments
  • Medial nerve entrapment
    • Tightness of pronator teres muscle and under superficial head of flexor digitorum superficialis secondary to repetitive gripping activities
    • Symptoms
      • Pain, numbness, tingling, and weakness in median nerve distribution in forearm and below
    • Diagnosis
      • Clinical presentation
      • Manual muscle test of forearm muscles
      • Positive Tinel’s test in median nerve distribution
  • Radial nerve entrapment
    • Entrapment of posterior interosseous nerve within radial tunnel as a result of overhead activities and throwing
    • Symptoms
      • Lateral elbow pain
      • Pain, numbness, tingling, and weakness in radial nerve distribution in forearm and below
    • Diagnosis
      • Clinical presentation
      • Manual muscle test of forearm muscles
      • Positive Tinel’s test in radial nerve distribution
  • Ulnar nerve entrapment
    • Compression or trauma at cubital tunnel, thickened retinaculum or hypertrophy of flexor carpi ulnaris muscle
    • Symptoms
      • Medial elbow pain
      • Pain, numbness, tingling, and weakness in ulnar nerve distribution in forearm and below
    • Diagnosis
      • Clinical presentation
      • Manual muscle test of forearm muscles
      • Positive Tinel’s test in ulnar nerve distribution
  • Medial management for all nerve entrapments
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Physical therapy management for all nerve entrapments
    • Early interventions- rest, modalities to reduce inflammation/pain

• Nerve glides for appropriate nerve
  • Median glide
    • Sit or stand with your elbow bent and your hand resting on a surface.
    • Turn your palm up and spread your fingers wide.
    • Gently bend your wrist back towards your forearm.
    • Extend your arm out to the side while keeping your wrist bent.
    • Turn your palm down and bring your fingers together.
    • Repeat these steps several times.
  • Radial glide
    • Stand or sit with your arms at your sides.
    • Turn your palm towards the floor.
    • Keep your wrist flexed and your fist clenched.
    • Turn your palm towards your body.
    • Look over your opposite shoulder.
    • Repeat these steps several times.
  • Ulnar glide
    • Stand or sit with your arms at your sides.
    • Extend your arm out to the side with your palm facing up.
    • Then bend your elbow slightly while rotating your hand outward, simultaneously tilting your head away from the extended arm.
    • Repeat several times.
  • Night splinting as appropriate
  • Functional training
  • Patient education

Wrist and hand differential diagnosis

• Carpal tunnel syndrome
  • Compression of the of the median nerve at the carpal tunnel at the wrist due to inflammation of the wrist flexor tendon or inflammation of the median nerve
    • Caused by repetitive wrist motions; other causes may be pregnancy, diabetes, or rheumatoid arthritis

• Symptoms
  • Numbness and tingling in the thumb, index, and middle fingers
  • Pain, often described as burning, aching, or electric shock-like
  • Sensitivity to cold or touch
  • Weakness in the hand, especially when gripping or making fine movements
  • Clumsiness or difficulty with tasks like buttoning clothes or writing
  • Dropping objects
• Diagnosis
  • Clinical presentation
    • Special tests
      • Tinels,
      • Phalen’s
  • Electrodiagnositic testing- test if a nerve signal is moving and its speed
• Medial management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Range of motion, strengthening
  • Corrections of biomechanical causes
  • Functional exercises
  • Bracing is the most appropriate option during pregnancy

• deQuervain’s tenodsynovitis
  • Inflammation of the extensor pollics brevis and abductor pollics longus
    • Due to repetitive microtrauma or can occur during pregnancy

• Symptoms
  • Pain at the base of the thumb that radiates into the forearm.
  • Swelling and tenderness on the thumb side of the wrist.
  • A feeling of catching or snapping when moving the thumb or wrist.
  • Pain or stiffness when grasping, pinching, or extending the thumb.
  • Difficulty gripping or holding objects.
  • Numbness or tingling in the thumb or index finger.
• Diagnosis
  • Clinical presentation
    • Special tests-
      • Finkelstein’s test
      • WHAT
  • MRI
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Range of motion, strengthening
  • Corrections of biomechanical causes
  • Functional exercises
  • Bracing is the most appropriate option during pregnancy

• Colles fracture
  • Fracture causing posterior displacement of distal radius with radial shift of wrist and hand
    • Most common fracture from falling out on outstretched hand
    • Can cause median nerve damage if edema is unmanaged

• Symptoms
  • Sharp, immediate pain, especially when bending or gripping the wrist.
  • Pronounced swelling and bruising around the wrist.
  • The wrist may appear bent or crooked, often resembling a “dinner fork”.
• Diagnosis
  • Clinical presentation
  • X-ray
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Immobilization for 5-8 weeks
• Physical therapy management
  • After removal of cast
    • Range of motion, strengthening
    • Pain, edema control
    • Use of modalities as appropriate
    • Functional exercises

• Scaphoid fracture
  • Due to fall onto outstretched arm
    • This is the most common fractured carpal bone

• Symptoms
  • Pain and weakness on the thumb side of the wrist, especially when gripping or pinching objects.
• Diagnosis
  • Clinical presentation
    • Diagnosis of rule out
  • X-ray
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Immobilization for 4-8 weeks
• Physical therapy management
  • Prior to cast removal
    • Range of motions exercises to proximal and distal joints to the scaphoid to maintain pre-injury flexibility
  • After removal of cast
    • Range of motion, strengthening
    • Pain, edema control
    • Use of modalities as appropriate
    • Functional exercises

• Dupuytren’s contracture
  • Contracture of the palmar fascia leading to flexion of the digits towards the palm
    • Common in the metacarpalphalangeal (MCP and proximal interphalangeal (PIP) joints of fourth and fifth digits in nondiabetic and third and fourth in diabetic

• Symptoms
  • Small, hard lumps in the palm of the hand, often near the base of the ring or little finger.
  • Thickened bands of tissue that run from the nodules to the fingers.
  • The affected fingers are gradually pulled into a bent position, making it difficult to straighten them out.
• Diagnosis
  • Clinical presentation
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Wound care may be indicated
  • Surgery may be indicated
• Physical therapy management
  • Splinting
  • Flexibility exercises
  • Restoration of normal hand function

• Boutonnier deformity
  • Rupture of central tendon slip of extensor hood
    • Commonly occurs after trauma to hand or with diagnosis of rheumatoid arthritis
    • Deformity noted is extension of MCP and DIP with flexion of PIP

• Symptoms
  • Deformity as noted above
• Diagnosis
  • Clinical presentation
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Management of rheumatoid arthritis
• Physical therapy management
  • Splinting
  • Taping
  • Flexibility exercises

• Swan neck deformity
  • Contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons
    • Commonly occurs after trauma to hand or with diagnosis of rheumatoid arthritis
    • Deformity noted is flexion of MCP and DIP with extension of PIP

• Symptoms
  • Deformity as noted above
• Diagnosis
  • Clinical presentation
  • Possibly x-ray imaging (rarely used)
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Management of rheumatoid arthritis
• Physical therapy management
  • Splinting
  • Taping
  • Flexibility exercises

• Mallet finger
  • Rupture or avulsion of extensor tendon at its insertion into distal phalanx digit
    • Commonly occurs after trauma forcing distal phalanx into a flexed position
    • Deformity noted is flexion of DIP

• Symptoms
  • Deformity as noted above
• Diagnosis
  • Clinical presentation
  • Possible MRI (rarely used)
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Splinting
  • Taping
  • Flexibility exercises

• Ape hand deformity
  • Median nerve dysfunction causes thenar muscle weakness with first digit moving dorsally until it becomes aligned with second digit

• Symptoms
  • Inability to move the thumb in and out of the palm
  • Inability to oppose the thumb
  • Limited ability to flex and extend the thumb
  • Sensory loss or tingling in the thumb
  • Weakened forearm pronation
  • Weakened finger flexion
• Diagnosis
  • Clinical presentation
  • Electordiagnostic
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
• Physical therapy management
  • Splinting
  • Taping
  • Flexibility exercises
  • Functional strengthening and coordination activities