Special tests of upper extremity
Shoulder special tests
Below are tests to assess if this condition is present:
- Apprehension test (tests anterior instability)
- Patient is supine, the shoulder is in 90 degrees of abduction; therapist attempts to externally rotate
- Positive: patient seems apprehensive about performing movement and resists motion
- Patient is supine, the shoulder is in 90 degrees of abduction; therapist attempts to externally rotate
- Sulcus sign (tests posterior and inferior instability)
- Patient stands with arm relaxed at the side; therapist pulls the arm distally
- Positive: presence of sulcus inferior to the acromion with symptom reproduction
- Patient stands with arm relaxed at the side; therapist pulls the arm distally
Below are tests to assess if this condition is present:
- Drop arm test
- Patient seated with the shoulder passively abducted to 90 degrees and externally rotated; patient instructed to slowly lower the arm back to the side
- Positive: patient is unable to lower their arm down slowly and suddenly drops it to the side without control
- Patient seated with the shoulder passively abducted to 90 degrees and externally rotated; patient instructed to slowly lower the arm back to the side
- Infraspinatus/supraspinatus muscle test
- Patient is seated or standing; therapist resists external rotation with the arm in the neutral position and adducted to the trunk
- Positive: patient is unable to sustain external rotation
- Patient is seated or standing; therapist resists external rotation with the arm in the neutral position and adducted to the trunk
- External rotation lag sign
- Patient is seated or standing with the shoulder passively abducted to 90 degrees and externally rotated
- Positive: patient is unable to maintain external rotation
- Patient is seated or standing with the shoulder passively abducted to 90 degrees and externally rotated
- Lift off test (Gerber’s test)
- Patient is standing with the shoulder passively placed in internal rotation and the hand at waist level against the back
- Positive: patient is unable to lift off the back
- Patient is standing with the shoulder passively placed in internal rotation and the hand at waist level against the back
- Internal rotation lag sign
- Patient is seated with arm held behind the back in internal rotation, passively
- Positive: patient is unable to maintain internal rotation
- Patient is seated with arm held behind the 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, elbow extended, then internally rotates the shoulder so the thumb points toward the floor. The examiner applies downward pressure on the patient’s wrist or forearm.
- Tests the 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, elbow extended, then internally rotates the shoulder so the thumb points toward the floor. The examiner applies downward pressure on the patient’s wrist or forearm.
- Neer’s test
- The patient sits comfortably while the examiner stands behind them, stabilizing the patient’s scapula with one hand to prevent scapular movement. The examiner passively flexes the patient’s arm forward while internally rotating it, bringing the greater tuberosity of the humerus under the acromion.
- Tests for impingement
- Positive: the patient reports pain or tenderness during arm movement, particularly in the anterior or lateral shoulder
- The patient sits comfortably while the examiner stands behind them, stabilizing the patient’s scapula with one hand to prevent scapular movement. The examiner passively flexes the patient’s arm forward while internally rotating it, bringing the greater tuberosity of the humerus under the acromion.
- Hawkins-Kennedy test
- The patient sits with the shoulder and elbow flexed to 90 degrees. The examiner stabilizes the shoulder with one hand and internally rotates the arm with the other.
- Tests for impingement
- Positive: pain in the anterior shoulder during internal rotation
- The patient sits with the shoulder and elbow flexed to 90 degrees. The examiner stabilizes the shoulder with one hand and internally rotates the arm with the other.
- Acromioclavicular (AC) joint
- Horizontal adduction test
- Patient standing with shoulder flexed to 90 degrees and adducted across the chest
- Positive: localized pain over the AC joint
- Patient standing with shoulder flexed to 90 degrees and adducted across the chest
- Horizontal adduction test
- SLAP (superior labrum anterior to posterior) lesions
- O’Brien’s test
- The patient stands or sits with the affected arm flexed to 90 degrees and adducted 10-15 degrees; the patient internally rotates the shoulder while the examiner applies downward pressure on the arm and the patient resists; repeated with the arm in external rotation
- Positive: pain or a clicking noise during internal rotation, with symptoms relieved during external rotation
- A differential diagnosis is needed to distinguish AC joint dysfunction from glenohumeral joint dysfunction
- The patient stands or sits with the affected arm flexed to 90 degrees and adducted 10-15 degrees; the patient internally rotates the shoulder while the examiner applies downward pressure on the arm and the patient resists; repeated with the arm in external rotation
- O’Brien’s test
- Biceps tendonitis tests
- Biceps load II test
- Patient supine with the shoulder abducted to 120 degrees, elbow flexed to 90 degrees, forearm supinated, and the shoulder fully externally rotated. If the patient shows apprehension, they’re then asked to flex the elbow against resistance.
- Positive: apprehension remains the same, or the shoulder becomes more painful
- Patient supine with the shoulder abducted to 120 degrees, elbow flexed to 90 degrees, forearm supinated, and the shoulder fully externally rotated. If the patient shows apprehension, they’re then asked to flex the elbow against resistance.
- Biceps load II test
- Yergason’s test
- Patient sitting with the shoulder in a neutral position against the trunk, elbow at 90 degrees, forearm pronated; examiner resists supination of the forearm and external rotation of the shoulder
- Tests for transverse ligament involvement, bicipital tendonitis, and SLAP lesions
- Positive: the biceps tendon of the long head becomes palpable outside the bicipital groove, or pain is reproduced
- Patient sitting with the shoulder in a neutral position against the trunk, elbow at 90 degrees, forearm pronated; examiner resists supination of the forearm and external rotation of the shoulder
- Speed’s test
- Patient sitting or standing with the upper limb in full extension at the side and the forearm supinated; examiner resists shoulder flexion (or, alternatively, the shoulder is placed in 90 degrees of flexion and the limb is pushed into extension, causing an eccentric contraction)
- Tests for bicipital tendonitis and SLAP lesions
- Positive: pain in the bicipital groove at the anterior shoulder
- Patient sitting or standing with the upper limb in full extension at the side and the forearm supinated; examiner resists shoulder flexion (or, alternatively, the shoulder is placed in 90 degrees of flexion and the limb is pushed into extension, causing an eccentric contraction)
Elbow special tests
- Elbow extension test
- Patient in seated position attempts to fully extend the elbow
- Positive: patient unable to extend due to possible fracture — imaging will be needed to confirm
- Patient in seated position attempts to fully extend the elbow
- Varus/valgus test
- Patient sitting or supine with elbow flexed to 20 degrees; valgus force applied to test the ulnar collateral ligament, then varus force applied to test the radial collateral ligament
- Positive: joint laxity and possible pain — needs to be performed bilaterally to determine laxity
- Patient sitting or supine with elbow flexed to 20 degrees; valgus force applied to test the ulnar collateral ligament, then varus force applied to test the radial collateral ligament
- Biceps squeeze test (for biceps rupture)
- Observation of distal bunching of the biceps muscle along with complete loss of function (unable to perform elbow flexion)
- Positive: indicates rupture of the proximal long head of the biceps tendon
- Observation of distal bunching of the biceps muscle along with complete loss of function (unable to perform elbow flexion)
- Cozen’s test
- Patient seated or standing with the elbow extended, forearm pronated, and wrist in slight radial deviation; the patient makes a fist and extends the wrist against the examiner’s resistance while the examiner palpates the lateral epicondyle
- Positive: pain indicates lateral epicondylitis
- Patient seated or standing with the elbow extended, forearm pronated, and wrist in slight radial deviation; the patient makes a fist and extends the wrist against the examiner’s resistance while the examiner palpates the lateral epicondyle
- Mills test
- Patient seated; the clinician palpates the lateral epicondyle with one hand while pronating the patient’s forearm and fully flexing the wrist, elbow extended
- Positive: pain with this maneuver suggests lateral epicondylitis
- Patient seated; the clinician palpates the lateral epicondyle with one hand while pronating the patient’s forearm and fully flexing the wrist, elbow extended
- Reverse Mills test
- Patient seated or standing; the clinician stabilizes the patient’s humerus, palpates the medial epicondyle, then passively supinates the forearm, extends the wrist, and fully extends the elbow, stretching the flexor tendons
- Positive: pain with this maneuver suggests medial epicondylitis
- Patient seated or standing; the clinician stabilizes the patient’s humerus, palpates the medial epicondyle, then passively supinates the forearm, extends the wrist, and fully extends the elbow, stretching the flexor tendons
- Medial epicondylitis (golfer’s elbow) test
- Patient seated; the clinician palpates the medial epicondyle with one hand while extending the elbow and fully extending the wrist
- Positive: pain with this maneuver suggests medial epicondylitis
- Patient seated; the clinician palpates the medial epicondyle with one hand while extending the elbow and fully extending the wrist
- Neurological dysfunction
- Elbow flexion test (Wadsworth test)
- Patient supine with the shoulder in full external rotation and the elbow held in maximal flexion, wrist extended, for one minute
- Tests for ulnar nerve entrapment at the cubital tunnel
- Positive: pain at the medial elbow within the ulnar distribution of the involved side
- Patient supine with the shoulder in full external rotation and the elbow held in maximal flexion, wrist extended, for one minute
- Elbow flexion test (Wadsworth test)
Wrist and hand special tests
Ligamentous, capsule, and joint instability
- Interphalangeal joint varus/valgus tests
- Patient in a seated position with fingers supported and stabilized; valgus/varus force applied to the PIP and DIP joints of all digits
- Positive: joint laxity and possible pain — needs to be performed bilaterally to determine the extent of laxity
- Patient in a seated position with fingers supported and stabilized; valgus/varus force applied to the PIP and DIP joints of all digits
Tendon and muscle
Finkelstein’s test and Eichhoff’s test are traditional provocative tests for de Quervain’s tenosynovitis. The WHAT (Wrist Hyperflexion, Abduction of the Thumb) test has shown very high sensitivity (99%) but low specificity.
- Wrist hyperflexion and abduction of the thumb test (WHAT)
- Patient in seated position with the wrist hyperflexed and the thumb abducted in full MCP and IP extension. The examiner applies gradually increasing abduction resistance to the thumb.
- Positive: reproduction of pain in the wrist — needs to be performed bilaterally
- Indicates de Quervain’s tenosynovitis in the 1st dorsal compartment (abductor pollicis longus and extensor pollicis brevis)
- Patient in seated position with the wrist hyperflexed and the thumb abducted in full MCP and IP extension. The examiner applies gradually increasing abduction resistance to the thumb.
- Eichhoff’s test
- Patient seated, makes a fist with the thumb flexed within the fingers, then actively moves the wrist into ulnar deviation
- Positive: reproduction of pain in the wrist — needs to be performed bilaterally
- Indicates de Quervain’s tenosynovitis in the 1st dorsal compartment (abductor pollicis longus and extensor pollicis brevis)
- Patient seated, makes a fist with the thumb flexed within the fingers, then actively moves the wrist into ulnar deviation
- Finkelstein’s test
- Patient seated, makes a fist with the thumb flexed within the fingers, while the examiner passively moves the wrist into ulnar deviation
- Positive: reproduction of pain in the wrist — needs to be performed bilaterally
- Indicates de Quervain’s tenosynovitis in the 1st dorsal compartment (abductor pollicis longus and extensor pollicis brevis)
- Patient seated, makes a fist with the thumb flexed within the fingers, while the examiner passively moves the wrist into ulnar deviation
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 the median nerve distribution
- Indicates carpal tunnel syndrome
- Positive: reproduces tingling sensation or paresthesia in the median nerve distribution
- Patient in seated position maximally flexes both wrists while holding them together for one minute
- Tinel’s test
- Patient in seated position; the therapist taps a palpable peripheral nerve
- Positive: reproduces tingling sensation or paresthesia in the nerve distribution
- Patient in seated position; the therapist taps a palpable peripheral nerve
Vascular dysfunction
- Modified Allen’s test
- With the patient seated, the therapist palpates the radial and ulnar arteries, then has the patient quickly open and close their hand several times before making a fist
- The therapist compresses the radial artery, has the patient open the hand, observes the palm, releases the compression, and observes the radial refill time; the same procedure is then repeated for the ulnar artery
- Positive: abnormal refill time — needs to be performed bilaterally