Clinical presentation and interventions for upper extremity | Musculoskeletal system

Contrasting shoulder conditions

Glenohumeral dislocations and instability
- Dislocations of the glenohumeral joint caused by traumatic or atraumatic reasons
  - Trauma is due to direct injury, most commonly a fall on an outstretched hand (FOOSH) mechanism of injury
  - Atramatic can be due to repetitive injury causing hypermobility
- Types of dislocations:
  - Anterior-inferior dislocations: Most common type (95%). Mechanism is a combination of motions including: excessive horizontal abduction, abduction, external (lateral) rotation, and extension/hyperextension of upper extremity.
    - If traumatic can lead to: Disruption anterior glenohumeral/capsular ligament ligament, subscapularis, and anterior/inferior glenoid labrum Sulcus sign: a depression or groove appears between the acromion and the humeral head.
      - Hills-sachs lesion: compression fracture of posterior humeral head
      - Bankhart lesion: avulsion of the anterior-inferior glenoid labrum
      - Axillary nerve injury: numbness, tingling, and weakness in deltoid

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

Symptoms
- Popping during movements
- Repeated dislocations or subluxations of glenohumeral joint
Diagnosis
- Clinical presentation - Sulcus sign
- Special test- apprehension test (Gold Standard)
- 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 called a Bankart lesion; can also involve an avulsion fracture of the anterior/inferior lip of the glenoid (bony Bankart)
- 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

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 compression- acute phase
  - Postural re-education- improve forward head, rounded shoulders, and kyphotic posture (Upper cross syndrome)
  - Correction of muscle imbalances
  - Improve joint mobility
  - Return to previous functional status
  - Surgical decompression if indicated

Rotator cuff tear/damage
- Causes acute tear from a fall on outstretched hand (FOOSH) sudden heavy lifting, shoulder in an awkward position
- Partial and degenerative damage from an Increased risk for development of tendonitis due to poor vascularity at attachment sites
Symptoms
- Pain when raising or lowering the arm
- Pain when reaching behind your back
- Pain that worsens after lying down on the affected side
- Pain that is worse at night
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
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.
- Empty endfeel joint’s passive movement stops due to the patient’s pain, not because of a physical blockage
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

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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, positive Speed’s, Yerguson, and bicep load II test.
- 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

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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
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 epicondyle fractures will require internal fixation (rod and screws implanted in arm) adults, percutaneous removal pins for non skeletally mature fractures) 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-eeducation
- Joint mobility and strengthening as appropriate

Contrasting elbow conditions

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

Contrasting conditions of wrist and hand

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 hand
  - 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
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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