Elbow, Wrist + Hand

Question 1

What is the carrying angle of the elbow?

Answer 1

Between 5 - 20 degrees

Question 2

If the elbow has a carrying angle of greater than 20 degrees this is called…

Answer 2

Cubitus Valgus

Question 3

If the carrying angle of an elbow is less than 5 degrees this is called…

Answer 3

Cubitus Varus

Question 4

What are the Rule outs for the elbow?

Answer 4

• shoulder (AF flex & abd w/ OP)
• Wrist (AF flex, ext, radial deviation & ulnar deviation w/ OP)
• C-Spine if presenting w/ paraesthesia (AF, all mvmts w/ OP except ext)
• TOS (if presenting w/ paraesthesia in the limb that does not correspond to PN or Cervical testing) (adson’s, costoclavicular, wright’s)

Question 5

For AR testing of elbow flexion make sure to test in these positions…

Answer 5

Neutral: Brachioradialis

Supination: Biceps Brachii

Pronation: Brachialis

Question 6

Test AR supination with elbow flexed & extended. If pain increases w/ ext you are looking at ____. If Pain has decreased you are looking at _____.

Answer 6

• Supinator
• Biceps Brachii

Question 7

Which movements should you include in AR testing of the elbow?

Answer 7

The wrist ext & flex because forearm flexors and extensors cross the wrist.

Question 8

What are the ligamentous stability tests for the elbow?

Answer 8

• Varus stress test
• Valgus stress test

Question 9

What are the special tests for epicondylitis of the elbow?

Answer 9

• Golfer’s elbow Test
• Tennis elbow Test

Question 10

What are the neurological special tests for the elbow?

Answer 10

• Tinel’s sign at the elbow
• Pinch grip Test
• Pronator Teres syndrome

Question 11

How do you perform the Varus stress test for the elbow? What is this testing? What are the positives?

Answer 11

• px is high seated, shoulder & elbow are both flexed to 20 degrees, forearm is supinated
• therapist positions their lower hand just below the elbow on the lateral side and palpates the lateral collateral ligament
• upper hand is on the medial side just above the elbow
• the upper hand applies pressure away from the body while the lower hand applies pressure towards the body creating a varus stress through the jt

This is testing the stability of the lateral collateral ligament

Positive: pain at the site of the lateral collateral ligament and/or palpation of the JT opening

Question 12

How do you perform the valgus stress test for the elbow? What is this testing? What are the positives?

Answer 12

• px is high seated, shoulder & elbow are both flexed to 20 degrees, forearm is supinated
• therapist positions their lower hand just below the elbow on the medial side and palpates the medial collateral ligament
• the upper hand is positioned on the lateral side just above the elbow and applies pressure towards the body while the lower hand applies pressure away from the body creating a valgus stress through the jt
• repeat this test at 50 degrees of elbow flexion to isolate the ligaments from the joint capsule

This tests the stability of the medial collateral ligament

Positive: pain at the site of the medial collateral ligament and/or palpation of the jt opening

Question 13

How do you perform the Golfer’s elbow test for the elbow? What is this testing? What are the positives?

Answer 13

• px’s forearm is supinated and wrist slightly flexed
• therapist palpates the medial epicondyle
• therapist resists the px’s attempt to flex their wrist

This is testing for medial epicondylitis or common flexor tendonitis

Positive: a sudden severe pain in the area of the common flexor tendon

Question 14

How do you perform the Tennis elbow test? What is this testing? What are the positives?

Answer 14

• px is high seated w/ shoulder flexed to 20 degrees and elbow fully extended
• therapist palpates the lateral epicondyle
• px makes a fist, pronates the forearm and slightly extends the wrist
• therapist resists the px’s attempt to extend their wrist

This tests for lateral epicondylitis or common extensor tendonitis

Positive: a sudden severe pain in the area of the common extensor tendon

Question 15

How do you perform Tinel’s sign at the elbow? What is this testing? What are the positives?

Answer 15

• px is high seated with shoulder and elbow slightly flexed
• therapist taps the area of the ulnar nerve in the groove between the olecronon process and the medial epicondyle

This is testing for irritation of the ulnar nerve

Positive: a tingling sensation in the ulnar nerve distribution of the forearm and hand

Question 16

How do you perform the pinch grip test? What is this testing? What are the positives?

Answer 16

• px is asked to pinch the tips of their index finger and thumb together (can be done with a piece of paper in between)

Positive: the px is unable to perform the task- this may indicate a compression of the anterior interosseous nerve (branch of median nerve) between the two heads of pronator Teres. It can also indicate a nerve pathology.

Question 17

How do you perform the pronator Teres syndrome test for the elbow? What is this testing? What are the positives?

Answer 17

• px is seated w/ elbow flexed to 90 degrees
• therapist resists pronation as the elbow is passively extended

Testing irritation of the median nerve

Positive: tingling or paraesthesia in the medial nerve distribution

Question 18

What muscles strength tests can you do for elbow testing? In what positions?

Answer 18

• biceps brachii (resist flexion w/ forearm supination)
• brachialis ( resist flexion w/ forearm pronated
• brachioradialis (resist flexion w/ forearm in neutral)
• pronator quadratus (flex the elbow with forearm in neutral and resist supination)
• triceps brachii and anconeus (resist elbow extension)

Question 19

What are the deep tendon reflexes for elbow testing?

Answer 19

• C5 biceps reflex
• C6 brachioradialis reflex
• C7 triceps reflex

Question 20

What are some finger and hand deformities? How do they present? Why?

Answer 20

Swan neck deformity: flexion of the MCPs and DIPs w/ ext of the PIPs usually relating to rheumatoid arthritis

Boutonnière deformity: extension of the MCPs and DIPs and flex of the PIPs usually relating to rheumatoid arthritis

Ape hand deformity: wasting of thenar eminence resulting from median nerve palsy w/ the thumb falling back in line w/ the fingers and loss of thumb opposition

Duputytren’s contracture: contracture of the palmar fascia w/ flexion of the MCPs and PIPs usually in 4th or 5th digits

Question 21

What are the rule outs for the wrist & hand?

Answer 21

• Elbow (AF flexion, extension, supination and pronation w/ over pressure)
• Fingers (px makes a half fist and the therapist applies OP, then px makes full fist and therapist applies OP)
• C-spine (if presenting w/ paraesthesia) (AF all movements w/ OP except extension)
• TOS (if presenting w/ paraesthesia in the limb that does not correspond to PN or Cervical testing) (Adson’s, Costoclavicular, Wright’s)

Question 22

Active free is the only function test of the wrist & hand that includes finger movements

Question 23

How do you perform Finkelstein’s Test? What is this test for? What are the positives?

Answer 23

• px is seated w/ arm and wrist in neutral position
• px flexes their thumb and makes a fist around it w/ their fingers
• therapist asks if there’s any pain
• if this position is okay therapist asks the px to ulnar deviate/adduct their wrist

This test for deQuervian’s disease, a tenosynovitis occuring in the first dorsal carpal tunnel. It affects abductor pollicis longus and extensor pollicis brevis.

Positive: a sudden severe pain at the wrist where the tendons pass - pain may shoot down into the thumb and up into the muscle bellies (more severe)

Question 24

How do you perform phalen’s Test? What is this test for? What are the positives?

Answer 24

• have px flex both wrists simultaneously by pushing their dorsal surfaces together
• hold for one minute

Tests for carpal tunnel syndrome

Positive: tingling Or paraesthesia into the thumb and the first two and a half fingers caused by pressure on the median nerve

Question 25

How do you perform reverse phalen’s Test? What is this test for? What are the positives?

Answer 25

- have the px extend both wrists simultaneously by pushing their palmar surfaces together (pray position) - hold for 1 min This is another test for carpal tunnel syndrome Positive: tingling or paraesthesia into the thumb and the first two and a half fingers caused by pressure on the median nerve

Question 26

How do you perform Allen’s Test? What is this test for? What are the positives?

Answer 26

- px raises their hand above their head and open and closes their fist quickly a few times - px then squeezes their fist tightly, therapist places their thumb over the radial artery and their index finger the ulnar artery occluding them - therapist maintains the pressure while the px opens their fist - the palm should be pale, therapist releases pressure on one artery while maintaining the pressure on the other - the palm should flush immediately if circulation is normal, repeat the test for the other artery and then the other hand This tests for circulation in the hand by the ulnar and radial arteries Positive: if it the palm doesn’t react or flushes slowly the released artery is partially or completely occluded

Question 27

How do you perform the bunnel-littler Test? What is it testing? What are the positives.

Answer 27

- therapist holds an MCP slightly extended and tries to flex a PIP Positive: an inability to flex the PIP resulting from tight intrinsic hand mm or jt capsule contractures This test evaluates the tightness of the intrinsic muscle of the hand compared to jt capsule contracture - To differentiate slightly flex the MCP (relaxing the intrinsic hand mm) - attempt to flex the PIP Positive: if the PIP now flexes, restriction of the intrinsic hand mm are the cause of restriction - if the PIP still doesn’t flex, PIP jt capsule contracture is the cause of restriction

Question 28

What muscles can be tested for the hand & wrist?

Answer 28

Palmaris longus Interossei Lumbricals Extensor digitorum

Question 29

How do you perform Tinel’s at the wrist? What is this test for? What are the positives?

Answer 29

- therapist taps several times over the area of the carpal tunnel Test for compression or inflammation of the median nerve as it passes through the carpal tunnel Positive: tingling or paraesthesia into the thumb and the first two and a half fingers caused by pressure on the median nerve