Assessment and special tests of upper limb

Question 1

special questions for the upper limb

Answer 1

red flags (non mech pain, cancer, sudden loss of ER, pancrose tumour), trauma (fracture, cuff tear), age (arthritis, capsulitis), PMH (diabetes- capsulitis), steroid use, previous capsulitis, previous dislocation/instability, clicking/ locking with pain- labral

Question 2

pain pattern

Answer 2

night pain= RC pathology, arc of pain 60-100 RC problem, arc of pain>100- AC joint, EOR pain- OA/instabiity, global pain- early frozen shoulder

Question 3

PMH

Answer 3

Screen for systemic disorders e.g. DM/Ca/RA/ ASA

Question 4

special questions

Answer 4

clunking/clicking, giving way, neck pain, altered sensation, functional activities, hand dominance

Question 5

OA capsular pattern shoulder

Answer 5

LR>ABD>MR

Question 6

mechanism of onset

Answer 6

injury (FOOSH), insidious (frozen shoulder) repetitive (degenerative)

Question 7

social history- age of onset shoulder

Answer 7

RC degeneration>35 years, secondary impingement >25 years, calcification 40-60 years, frozen shoulder 45-60 years, atraumatic instability 10-35 years

Question 8

occupation and hobbies related to shoulder pain

Answer 8

occupation- sustained neck-shoulders postures/repetitive arm movements
hobbies- swimming/cross country skiing/racket sports/throwing sports

Question 9

observation what to look for

Answer 9

scapular position, scapular orientation, HOH- affected by tightness of pecs=pulls forward, cervical position, thoracic spine, muscle tone

Question 10

winged scapula

Answer 10

can be due to nerve issue with true wining- long thoracic nerve, protruding shoulder blade= muscle imbalance

Question 11

isometric testing findings

Answer 11

RC tear= weak and painful or just painful/weak- depending on grade of tear, secondary instability= NAD/ painful or/& weak/ apprehension, OA of GHJ- NAD and weak, primary impingement- weakness and pain

Question 12

accessory movements of shoulder

Answer 12

patient in supine, shoulder abducted and LR, holding onto therapist humerus, apply force AP and PA

Question 13

soft tissue lengthening test- pec major

Answer 13

supine lying, stabilize thorax, clavicular fibres- Abd 90° and ER, sternal fibers abd 150° and ER, slowly lower arm to bed

Question 14

soft tissue lengthening test- pec minor

Answer 14

supine lying view from head down, assess the height of the shoulder from the bed, >2cm is normal, then stabilize sternum and push down on coracoid

Question 15

soft tissue lengthening test- lat dorsi

Answer 15

lying supine with knees flexed at 90°, maintain lumbar neural (flex lumbar spine to push down on bed) , full flexion of shoulder, should reach treatment couch if not tight

Question 16

RC pain tests- Hawkins-Kennedy test

Answer 16

passive shoulder flexion to 90°, passively MR humorous, +ve= pain/symptoms,
sensitivity- 58-80%, speceficity- 57%
weak clinical value

Question 17

RC pain tests- Neers test

Answer 17

fix scapula, MR arm, passively flex, +ve= pain reproduction, reduced sub acromial space- greater tubercle leads to compression
59-72 sensivity, 60 speceficity
weak clinical value

Question 18

RC pain tests- full can/empty can

Answer 18

90° in scap plane, full MR, maintain position whilst therapist pushes down, +ve= weakness/pain or both, weakness is more accurate for tears,
empty can test- sensitivity- 74%, speceficity 30%
WEAK CLINICAL VALUE

Question 19

instability test- apprehension test

Answer 19

supine lying, abd arm to 90°, ER arm, +ve= apprehension (fear, muscle spasm, conscious limitation of movement, not pain), repeat test with AP glide to HOH, +ve increased ROM/ reduction in apprehension
sensitivity- 65.6
speceficity- 95.4

Question 20

instability test- load and shift test

Answer 20

test ant and post stability, stabilize scapula, mild compression into glenoid, apply AP force to humeral head, movement 25%= N, up to 50% is G1, over 50% GII, checks for inferior instability

Question 21

instability test- inferior instability (sulcus sign)

Answer 21

sit/st or lying, arm by side, elbow at 90°, caudad mobilisation, assessing for excessive movement, use fingers to palpate between the HOH and acromion

Question 22

instability test- lift off test

Answer 22

standing position, patient lifts arm up back, must maintain this position, problems if lack of movement or pain will reduce contraction
sensitivity- 35, speceficity- 75

Question 23

medial epicondylitis tests

Answer 23

passive test- palpate medial epicondyle, supinate forearm, extend wrist, extend fingers, +ve= pain over medial epicondyle
can also test by resisting strength

Question 24

lateral epicondylitis- Mill’s test

Answer 24

same starting position- passive stretch test, pronate forearm, flex wrist, extend elbow +ve= pain reproduction,
also test by resisting strength

Question 25

lateral epicondylitis- cozens test

Answer 25

active contraction of extensor tendons, elbow 90°, active resisted forearm pronation, wrist extension, wrist radial deviation, +ve=pain, can palpate for pain

Question 26

concave convex rule- concave joint sliding

Answer 26

concave joint surfaces slide in the same direction as the bone movement, if concave joint is moving on stationary convex surface- glide occurs in the same direction as the role

Question 27

concave convex rule- convex surface

Answer 27

convex joint surfaces slide in the opposite direction of the bone movement, if convex surface is moving on stationary concave surface- gliding occurs in opposite direction to roll

Question 28

finkelstein test

Answer 28

for DeQuervains- thickening of tendon sheath around abd pol longus and ext pol brevis, Pt grips own thumb, ulna deviates, +ve test= pain

Question 29

Tinel’s sign

Answer 29

ext wrist and tap over carpal tunnel, +ve test= pain, paresthesia, median nerve test, carpal tunnel syndrome
weak clinical valjue

Question 30

phalens test

Answer 30

flex pt wrist maximally against each other, hold for 1 mins, +ve test= tingling in thumb, index finger and 1/2 ring finger
sensitivity- 85, speceficity- 89

Question 31

treatment- pain

Answer 31

joint mobilisations (grades affected by SIN), education- pain relief (may be MDT), soft tissue mobilisations (pain gate theory and descending inhibition), potentially TENs

Question 32

treatment- stiffness

Answer 32

joint mobilisation, exercises- may start with active assisted/passive physiological movement, stretching, look at scapula for shoulder movement (e.g. 4 point push up- work serratus anterior and scapula muscles and shoulder flexion)

Question 33

treatment- weakness

Answer 33

strength exercises- may start with lower weight and higher reps

Question 34

treatment- instability

Answer 34

strengthening of muscles, closed chain exercises- weight bearing movements, shoulder flexion exercises (can add LR along side flexion)

Question 35

treatment- options

Answer 35

education (pain relief, advice about the condition, timescales, healing, scan, beliefs), activity modification, exercise (strength, load tolerance, endurance, control, stretching), functional demo, mannual therapy, soft tissue treatments

Question 36

exercise ideas- flex, abd, LR, MR, isometric

Answer 36

ROM flex= with bed/table= slide hand across table, ROM abd- use yoga ball, LR- hand on door frame, isometric exercises- using other hand for resistance