P P hysical hysical E E xamination xamination of of the U the U pper pper E E xtremiti xtremiti es es Prof.Dr.Hidayet Sarı Prof.Dr.Hidayet Sarı Physical Medicine and Physical Medicine and Rehabilitation Department Rehabilitation Department
Jan 12, 2016
PPhysical hysical EExamination xamination of of the Uthe Upper pper EExtremitixtremitieses
Prof.Dr.Hidayet SarıProf.Dr.Hidayet Sarı
Physical Medicine and Physical Medicine and Rehabilitation Department Rehabilitation Department
Shoulder Examination Shoulder Examination
ANATOMYANATOMY• Bones Bones • Joints Joints • MusclesMuscles• Bursae Bursae • Nerves Nerves • Blood supply Blood supply
Bony AnatomyBony AnatomyAnteriorAnterior
Bony AnatomyBony AnatomyPosteriorPosterior
SHOULDER JOINTS SHOULDER JOINTS
1.1. Glenohumeral Glenohumeral
2.2. Scapula thoracicScapula thoracic
3.3. Acromio-clavicularAcromio-clavicular
4.4. Sterno-clavicularSterno-clavicular
Bony AnatomyBony AnatomyJoints and ArticulationsJoints and Articulations
•
STATIC STABILIZERS
Clinical AnatomyClinical Anatomy– DeltoidDeltoid– Rotator cuffRotator cuff– Teres majorTeres major
– Latissimus dorsiLatissimus dorsi– BicepsBiceps– Pectoralis musclesPectoralis muscles
Clinical AnatomyClinical Anatomy
• Rotator CuffRotator Cuff– SSupraspinatus upraspinatus
ABDABD
– IInfraspinatus nfraspinatus ERER
– TTeres minor eres minor ERER
– SSupscapularis upscapularis IRIR
Depress humeral head against glenoid to allow full abduction
Clinical AnatomyClinical Anatomy
• BursaeBursae– subacromialsubacromial– subdeltoidsubdeltoid– subscapularsubscapular
Physical ExaminationPhysical Examination
• InspectionInspection• Palpation –pressionPalpation –pression• Range of motion examination Range of motion examination • Neurological examination Neurological examination • Special tests for the shoulder Special tests for the shoulder
problems problems • Examination of the related areasExamination of the related areas
Shoulder InspectionShoulder Inspection
• Anterior side Anterior side • Posterior side Posterior side • Lateral side Lateral side • Medial side Medial side
Physical ExamPhysical ExamInspectionInspection
• Front & backFront & back• Height of Height of
shoulder and shoulder and scapulaescapulae
• Muscle atrophy, Muscle atrophy, asymmetryasymmetry
SHOULDER PALPATION SHOULDER PALPATION and PRESSIONand PRESSION
• Bones Bones • Joints Joints • MusclesMuscles• Bursae Bursae • NervesNerves• Lymph nodes Lymph nodes
SHOULDER Range Of SHOULDER Range Of MotionMotion
• Flexion-180 degreeFlexion-180 degree• Extension -45 degreeExtension -45 degree• Abduction -180 degreeAbduction -180 degree• Adduction -30 degreeAdduction -30 degree• Internal rotation -90 degreeInternal rotation -90 degree• External rotation -90 degree External rotation -90 degree
Physical ExamPhysical Exam Range of MotionRange of Motion
• Forward flexion: Forward flexion: – 00oo – 180 – 180oo
Physical ExamPhysical Exam Range of MotionRange of Motion
• ExtensionExtension– 00oo – 40 to 60 – 40 to 60oo
Physical ExamPhysical Exam Range of MotionRange of Motion
• Internal rotationInternal rotation– 80-9080-90oo
• External rotationExternal rotation– 80-9080-90oo
Speed shoulder tests Speed shoulder tests
External rotation External rotation Internal Internal rotationrotation
Neurological Examination Neurological Examination of the Shoulder of the Shoulder
Muscle tests :Muscle tests :• FlexionFlexion• Extension Extension • Abduction Abduction • Adduction Adduction • Internal rotation Internal rotation • External rotation External rotation
Muscle testing scoringMuscle testing scoring
• 0 No contraction• 1 Flicker or trace contraction• 2 Active movement, with gravity
eliminated• 3 Active movement against gravity• 4 Active movement against gravity
and resistance• 5 Normal power
Shoulder Abduction muscle Shoulder Abduction muscle test test
Shoulder flexion and Shoulder flexion and extension muscle testextension muscle test
Shoulder external and Shoulder external and internal rotation muscle internal rotation muscle
testtest
Shoulder abduction and Shoulder abduction and adduction muscle testadduction muscle test
Neurological Examination Neurological Examination of the Shoulderof the Shoulder
sensory tests :sensory tests :• C4C4• C5C5• C6C6• C7C7• C8C8• T1T1• T2T2
Special Tests for the Special Tests for the Shoulder ProblemsShoulder Problems
• Yergason test –biceps tendinitisYergason test –biceps tendinitis• Neer impingement test-acromioclavicular Neer impingement test-acromioclavicular
impingementimpingement• Drop arm test –rotator cuff tear Drop arm test –rotator cuff tear • Resisted flexion (Speed)test –biceps Resisted flexion (Speed)test –biceps
tendinitistendinitis• Resisted abduction(Supraspinatus) test-Resisted abduction(Supraspinatus) test-
supraspinatus lesion supraspinatus lesion • Aprehension test –glenohumeral joint Aprehension test –glenohumeral joint
instability instability
Yergason testYergason test• Yergason test for Yergason test for
biceps tendon biceps tendon instability or instability or tendonitis. tendonitis.
• The patient's elbow The patient's elbow is flexed to 90 is flexed to 90 degrees, and the degrees, and the examiner resists examiner resists the patient's active the patient's active attempts to attempts to supinate the arm supinate the arm and flex the elbow. and flex the elbow.
Drop Arm TestDrop Arm Test
• Passive abduction Passive abduction to 90to 90°°
• Instruct patient to Instruct patient to slowly lower armslowly lower arm
• At 90At 90°° abducted abducted arm will suddenly arm will suddenly drop, may need to drop, may need to add slight pressureadd slight pressure
• (+) drop = (+) test(+) drop = (+) test
SHOULDER PAINSHOULDER PAINSPECIAL TESTSSPECIAL TESTS
• NeerNeer– PASSIVEPASSIVE– Forced forward Forced forward
flexion of arm with flexion of arm with internally rotated internally rotated shouldershoulder
– Test is positive if Test is positive if pain occurs at same pain occurs at same point as with active point as with active forward flexionforward flexion
Speed’s ManeuverSpeed’s Maneuver
• Forward flex the Forward flex the shoulder against shoulder against resistance while resistance while maintaining the elbow maintaining the elbow in extension and the in extension and the forearm in supination. forearm in supination. Pain or tenderness in Pain or tenderness in the bicipital groove in the bicipital groove in dicates bicipital dicates bicipital tendinitis. tendinitis.
Rotator Cuff Strength Rotator Cuff Strength TestingTesting
• Weakness on examWeakness on exam• Grade strength on 0Grade strength on 0→→5 scale5 scale• Compare to other sideCompare to other side
Supraspinatus testing
Apprehension Apprehension Test/Relocation TestTest/Relocation Test
Differantial Diagnosis for Differantial Diagnosis for shoulder painshoulder pain
• Subacromial impingement syndrome Subacromial impingement syndrome • Adhesive capsulitis –frozen shoulderAdhesive capsulitis –frozen shoulder• Biceps tendinopatiBiceps tendinopati• Bursitis Bursitis • Rotator cuff pathology Rotator cuff pathology • Glenohumeral joint pathology Glenohumeral joint pathology • Acromioclavicular joint pathology Acromioclavicular joint pathology • Sternoclavicular joint pathologySternoclavicular joint pathology• Myofascial pain syndromeMyofascial pain syndrome• Radiating or referred pain from cervical Radiating or referred pain from cervical
spine spine
Subacromial Subacromial ImpingementImpingement
• Neer proposed that 95% of rotator cuff tears are due to chronic Neer proposed that 95% of rotator cuff tears are due to chronic impingement between the humeral head and the coracoacrominal impingement between the humeral head and the coracoacrominal
arch.arch.
Subacromial Subacromial ImpingementImpingement• Stage 1 disease consists of edema and Stage 1 disease consists of edema and
hemorrhage of the tendon due to occupational or hemorrhage of the tendon due to occupational or athletic overuse, and is reversible under athletic overuse, and is reversible under conservative treatment.conservative treatment.
Subacromial Subacromial ImpingementImpingement
• Stage 2 disease shows progressive inflammatory changes of Stage 2 disease shows progressive inflammatory changes of the rotator cuff tendons and the subacromial-subdeltoid the rotator cuff tendons and the subacromial-subdeltoid bursa, and can be treated by removing the bursa and bursa, and can be treated by removing the bursa and dividing the coracoacromial ligament after failed dividing the coracoacromial ligament after failed conservative management.conservative management.
ELBOW EXAMINATIONELBOW EXAMINATION
• AnatomyAnatomy• EvaluationEvaluation• Inspection-ObservationInspection-Observation• Palpation-PressionPalpation-Pression• Range of motionRange of motion• Neurological examinationNeurological examination• Special testsSpecial tests• Examination of related areasExamination of related areas
ELBOW ANATOMYELBOW ANATOMY
• BonesBones• JointsJoints• LigamentsLigaments• MusclesMuscles
Elbow Anatomy Elbow Anatomy Medial ElbowMedial Elbow
ElbowElbow Anatomy Anatomy Lateral ElbowLateral Elbow
ELBOW ELBOW Anatomy Anatomy
EVALUATIONEVALUATION
INSPECTIONINSPECTION• Anterior –posterior sideAnterior –posterior side• Medial-lateral sideMedial-lateral side• Carrying angleCarrying angle• Swelling Swelling
PALPATION and PALPATION and PRESSION PRESSION
Bone palpation :Bone palpation :• Lateral epicondyleLateral epicondyle• Radial head Radial head • Medial epicondyleMedial epicondyle• OlecranonOlecranon
SOFT TISSUE SOFT TISSUE PALPATIONPALPATION
Medial aspect Medial aspect • Ulnar nerveUlnar nerve• Wrist flexor –pronator groupWrist flexor –pronator group• Medial collateral ligament Medial collateral ligament Lateral aspectLateral aspect• Wrist extensors (ECRL-ECRB)Wrist extensors (ECRL-ECRB)• Lateral collateral ligament Lateral collateral ligament • Annular ligament Annular ligament
SOFT TISSUE SOFT TISSUE PALPATIONPALPATION
Anterior aspectAnterior aspect• Cubital fossa Cubital fossa • Brachial arteryBrachial artery• Median nerve Median nerve • Musculo-cutaneus nerve Musculo-cutaneus nerve Posterior aspectPosterior aspect• Olecranon bursaOlecranon bursa• Triceps tendon Triceps tendon
ELBOW ROMELBOW ROM
• Flexion -135 degreeFlexion -135 degree• Extension -0 degree Extension -0 degree • Pronation -90 degree Pronation -90 degree • Supination -90 degreeSupination -90 degree
NEUROLOGICAL NEUROLOGICAL EXAMINATION EXAMINATION
Muscle tests:Muscle tests:• Flexion - Extension Flexion - Extension • Pronation - SupinationPronation - Supination Sensation tests Sensation tests • C5-C6-C7-C8-T1C5-C6-C7-C8-T1 Reflex test:Reflex test:• Biceps reflex –C6Biceps reflex –C6• Brachioradial reflex –C6Brachioradial reflex –C6• Triceps reflex-C7Triceps reflex-C7
Elbow Reflex testingElbow Reflex testing
• Biceps reflex –C6Biceps reflex –C6• Brachioradial reflex –C6Brachioradial reflex –C6• Triceps reflex-C7Triceps reflex-C7
SPECIAL TESTSSPECIAL TESTS
• Ligament tests (varus-valgus stres Ligament tests (varus-valgus stres test)test)
• Tennis elbow test Tennis elbow test • Golfers elbow test Golfers elbow test • Tinels sign for ulnar nerve Tinels sign for ulnar nerve
Ligament tests (varus-Ligament tests (varus-valgus stres test)valgus stres test)
Tennis elbow testTennis elbow test
Golfers elbow testGolfers elbow test
Tinels sign for ulnar nerve Tinels sign for ulnar nerve
COMMON ELBOW COMMON ELBOW PROBLEMSPROBLEMS
• Lateral epicondylitis Lateral epicondylitis • Medial epicondylitis Medial epicondylitis • Olecranon bursitis Olecranon bursitis • Fractures Fractures • Triceps tendinitis Triceps tendinitis • Post immbolization capsular Post immbolization capsular
tightnesstightness
(contracture)(contracture)
EXAMINATION of the EXAMINATION of the WRIST and HAND WRIST and HAND
Anatomy Anatomy • Surface anatomy Surface anatomy • Skeletal anatomy Skeletal anatomy • Fibrous anatomy Fibrous anatomy • MusclesMuscles• Nerves Nerves • Blood supply Blood supply
Bony Bony AnatomyAnatomy
• Phalanges: 14Phalanges: 14• Sesamoids: 2Sesamoids: 2• Metacarpals: 5Metacarpals: 5• CarpalsCarpals
– Proximal row: 4Proximal row: 4– Distal row: 4Distal row: 4
• Radius and UlnaRadius and Ulna
Lister’s tubercle
ANATOMY ANATOMY
• Surface anatomy Surface anatomy • Palmar surface Palmar surface • Radial border Radial border • Thenar surface Thenar surface • Thumb –index-middle-ring-small Thumb –index-middle-ring-small
fingers fingers • Hypothenar surface Hypothenar surface • Dorsal surface Dorsal surface • İnterosseus muscle İnterosseus muscle
JOINTSJOINTS
• Radio-carpal Radio-carpal • Ulna-carpal Ulna-carpal • İnter-carpal İnter-carpal • Metacarpo-phalangial (MCP)Metacarpo-phalangial (MCP)• Proximal inter-phalangial (PIP)Proximal inter-phalangial (PIP)• Distal inter-phalangial (DIP)Distal inter-phalangial (DIP)
MusclesMuscles
EVALUATION EVALUATION
• History History • Inspection-Observation (dorsum of the Inspection-Observation (dorsum of the
hand-palm of the hand )hand-palm of the hand )• Palpation-PressionPalpation-Pression• Range of motionRange of motion• Functional assessmentFunctional assessment• Neurological examinationNeurological examination• Special testsSpecial tests• Examination of related areasExamination of related areas
INSPECTIONINSPECTIONPalmar SurfacePalmar Surface
• CreasesCreases• Thenar and Thenar and
Hypothenar Hypothenar EminenceEminence
• Arched FrameworkArched Framework• Hills and ValleysHills and Valleys• Web SpacesWeb Spaces
Palpation-PressionPalpation-Pression
ROM EXAMINATION ROM EXAMINATION
• Forearm pronation-90 degreeForearm pronation-90 degree• Forearm supination -90 degreeForearm supination -90 degree• Wrist flexion (palmar flexion)-90 Wrist flexion (palmar flexion)-90
degree degree • Wrist extension (dorsal flexion )-90 Wrist extension (dorsal flexion )-90
degree degree • Wrist radial deviation -30 degree Wrist radial deviation -30 degree • Wrist ulnar deviation -20 degree Wrist ulnar deviation -20 degree
RANGE OF MOTIONRANGE OF MOTIONWristWrist
• FlexionFlexion• ExtensionExtension• Radial deviationRadial deviation• Ulnar deviationUlnar deviation
– Ulnar deviation is Ulnar deviation is greater than greater than radialradial
FINGERS ROM FINGERS ROM
MCP joint :MCP joint :• Flexion -90 degreeFlexion -90 degree• Extension -20 degree Extension -20 degree PIP joint : PIP joint : • Flexion -90 degreeFlexion -90 degree• Extension -0 degree Extension -0 degree DIP joint :DIP joint :• Flexion -80 degree Flexion -80 degree • Extension -0 degree Extension -0 degree
THUMB ROM THUMB ROM
• Flexion Flexion • Extension Extension • Abduction Abduction • Adduction Adduction • Opposition Opposition
NERVES and BLOOD NERVES and BLOOD SUPPLY SUPPLY
• Radial nerve Radial nerve • Median nerve Median nerve • Ulnar nerve Ulnar nerve
• Radial artery Radial artery • Ulnar artery Ulnar artery
COMMON PROBLEMS COMMON PROBLEMS
• Fractures Fractures • Tenosynovitis :Tenosynovitis :1.1. Thumb extensors –De Querveins diseaseThumb extensors –De Querveins disease2.2. Finger flexors tenosynovitis Finger flexors tenosynovitis 3.3. Finger extensors tenosynovitis Finger extensors tenosynovitis • Arthritis Arthritis 1.1. Rheumatoid arthritis (RA)Rheumatoid arthritis (RA)2.2. Osteoarthritis (OA)Osteoarthritis (OA)––bouchards nodes bouchards nodes -heberdans nodes -heberdans nodes - First MCP OA-Rhizarthrosis- First MCP OA-Rhizarthrosis
DeQuervain’s DeQuervain’s TenosynovitisTenosynovitis
• Inflammation of Inflammation of EXT Pollicis Brevis EXT Pollicis Brevis and ABD Pollicis and ABD Pollicis Longus tendonsLongus tendons
• Tenderness - Tenderness - 1st Dorsal 1st Dorsal CompartmentCompartment
• Finkelstein’s TestFinkelstein’s Test
Rheumatoid ArthritisRheumatoid Arthritis
• MCP swellingMCP swelling• Swan neck Swan neck
deformitiesdeformities• Ulnar deviation Ulnar deviation
at MCP jointsat MCP joints• Nodules along Nodules along
tendon sheathstendon sheaths
OsteoarthritisOsteoarthritis
• Heberden’s nodes: Heberden’s nodes: DIPDIP
• Bouchard’s nodes: Bouchard’s nodes: PIPPIP
COMPRESSION COMPRESSION NEUROPATHIES NEUROPATHIES
• Median nerve compression syndrome Median nerve compression syndrome carpal tunel syndrome (tinel and phalen test )carpal tunel syndrome (tinel and phalen test )• Pronator syndrome Pronator syndrome • Ulnar nerve compression syndromes Ulnar nerve compression syndromes compression at the elbow ulnar tunel syndrome compression at the elbow ulnar tunel syndrome Compresssion at the wrist Guyon canal Compresssion at the wrist Guyon canal
syndromesyndrome• Radial nerve compression syndromes Radial nerve compression syndromes Posterior interosseous nerve syndrome Posterior interosseous nerve syndrome Superficial radial nerve entrapment Superficial radial nerve entrapment
SPECIAL TESTSSPECIAL TESTS
• Finkelsteins test –De Quervein Finkelsteins test –De Quervein tenosynovitis tenosynovitis
• Tinel test –CTS, UTSTinel test –CTS, UTS• Phalens test –CTS Phalens test –CTS
Carpal Tunnel TestsCarpal Tunnel Tests
• Neurologic examNeurologic exam– Median nerve Median nerve
sensation and sensation and motormotor
• Phalen’s Test:Phalen’s Test:both wrists both wrists maximally flexed maximally flexed for 1 minutefor 1 minute
• Tinel’s TestTinel’s Test
EXAMINATION of the EXAMINATION of the RELATED AREAS RELATED AREAS
• Cervical spine Cervical spine • Shoulder Shoulder • Elbow Elbow • Arteries ,veins ,lymphArteries ,veins ,lymph• gallbladder stonegallbladder stone• Heart Heart