5.4 Differential diagnosis with interventions of upper extremity

Achievable NPTE-PT

5. Musculoskeletal system

Our NPTE-PT course is currently in development and is a work-in-progress.

Differential diagnosis with interventions of upper extremity

18 min read

Font

Discuss

Feedback

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:
      - Hills-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

alt_text

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

alt_text

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

Glenohumeral dislocations and instability

Dislocations: traumatic (direct injury) or atraumatic (repetitive injury, hypermobility)
Anterior-inferior dislocation: risk of Hill-Sachs lesion, SLAP tear, Bankhart lesion, axillary nerve injury
Posterior dislocation: rare, caused by horizontal adduction/internal rotation

Labral tears

SLAP tear: above middle of socket, may involve biceps tendon
Bankhart lesion: below middle of socket, may involve inferior glenoid ligament
Associated with trauma or repeated dislocations

Rotator cuff tendonitis

Mechanical impingement/inflammation of rotator cuff tendons
Poor vascularity at attachment sites increases risk

Impingement syndrome

Rotator cuff tendon entrapment under acromion
Pain/weakness with overhead movement, positive Hawkins-Kennedy, Neer’s, painful-arc tests

Adhesive capsulitis (Frozen shoulder)

Inflammation/restriction of joint capsule
Capsular pattern: greatest loss in external rotation, then abduction/flexion

Acromioclavicular and sternoclavicular disorders

Injury from fall on adducted shoulder or collision
Graded I-IV by ligament involvement and displacement

Subacromial/subdeltoid bursitis

Inflammation/impingement of subacromial and subdeltoid bursa
Often associated with rotator cuff tendonitis

Bicepital tendonitis

Inflammation of long head of biceps tendon
Pain worsens with overhead activity, localized tenderness

Proximal humeral fracture

From fall on outstretched arm, usually stable (non-surgical)
Early passive ROM, non-weight bearing initially

Distal humeral fracture

Trauma at distal humerus, risk of neurovascular injury (esp. supracondylar)
Surgical fixation often required, especially for lateral epicondyle fractures

Thoracic outlet syndrome

Compression of neurovascular bundle (brachial plexus, subclavian vessels)
Common compression sites: scalene triangle, between clavicle/first rib, under pectoralis minor

Medial epicondylitis (Golfer’s elbow)

Inflammation at medial epicondyle (pronator teres, flexor carpi radialis)
Pain with gripping/pronation, positive Mill’s test

Lateral epicondylitis (Tennis elbow)

Inflammation at lateral epicondyle (extensor carpi radialis brevis)
Pain with wrist extension/gripping, positive Cozen’s test

Ulnar collateral ligament injuries

Repetitive valgus stress to medial elbow
Pain at medial elbow, possible ulnar nerve symptoms, positive Tinel/valgus test

Elbow dislocation

Most commonly posterior, from fall on outstretched arm
May involve avulsion fracture, ligament/muscle injury

Nerve entrapments (elbow)

Median: pronator teres/flexor digitorum superficialis compression
Radial: posterior interosseous nerve in radial tunnel
Ulnar: cubital tunnel or flexor carpi ulnaris compression
Symptoms: pain, numbness, weakness in respective nerve distributions

Carpal tunnel syndrome

Median nerve compression at wrist (carpal tunnel)
Numbness/tingling in thumb, index, middle fingers; positive Tinel’s/Phalen’s

deQuervain’s tenosynovitis

Inflammation of extensor pollicis brevis/abductor pollicis longus
Pain at thumb base, positive Finkelstein’s/WHAT test

Colles fracture

Distal radius fracture with posterior displacement
“Dinner fork” deformity, risk of median nerve damage

Scaphoid fracture

Most common carpal fracture, from fall on outstretched hand
Pain/weakness on thumb side, risk of non-union

Dupuytren’s contracture

Palmar fascia contracture, flexion of digits (MCP/PIP)
Nodules, thickened bands, progressive finger flexion

Boutonniere deformity

Rupture of central slip of extensor hood
Extension of MCP/DIP, flexion of PIP

Swan neck deformity

Intrinsic muscle contracture, dorsal subluxation of lateral extensor tendons
Flexion of MCP/DIP, extension of PIP

Mallet finger

Rupture/avulsion of extensor tendon at distal phalanx
Flexion deformity at DIP

Ape hand deformity

Median nerve dysfunction, thenar muscle weakness
Thumb aligns with second digit, loss of opposition, sensory loss in thumb

General management strategies

Acetaminophen or NSAIDs for pain/inflammation
Physical therapy: phase-based interventions, splinting, strengthening, functional training
Surgery as indicated for severe cases or failed conservative management

Next | 5.5 Anatomy and special tests of lower extremity

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:
      - Hills-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

alt_text

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

alt_text

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

Achievable NPTE-PT

5. Musculoskeletal system

Our NPTE-PT course is currently in development and is a work-in-progress.