P hysical E xamination of the U pper E xtremiti es

1. Physical Examination of the Upper Extremities Prof.Dr.Hidayet Sarı Physical Medicine and Rehabilitation Department

2. Shoulder Examination ANATOMY • Bones • Joints • Muscles • Bursae • Nerves • Blood supply

3. Bony AnatomyAnterior

4. Bony AnatomyPosterior

5. SHOULDER JOINTS • Glenohumeral • Scapula thoracic • Acromio-clavicular • Sterno-clavicular

7. Bony AnatomyJoints and Articulations STATIC STABILIZERS

8. Clinical Anatomy Deltoid Rotator cuff Teres major Latissimus dorsi Biceps Pectoralis muscles

9. Clinical Anatomy Rotator Cuff Supraspinatus ABD Infraspinatus ER Teres minor ER Supscapularis IR Depress humeral head against glenoid to allow full abduction

10. Clinical Anatomy Bursae subacromial subdeltoid subscapular

11. Physical Examination • Inspection • Palpation –pression • Range of motion examination • Neurological examination • Special tests for the shoulder problems • Examination of the related areas

12. Shoulder Inspection • Anterior side • Posterior side • Lateral side • Medial side

13. Physical ExamInspection Front & back Height of shoulder and scapulae Muscle atrophy, asymmetry

14. SHOULDER PALPATION and PRESSION • Bones • Joints • Muscles • Bursae • Nerves • Lymph nodes

17. SHOULDER Range Of Motion • Flexion-180 degree • Extension -45 degree • Abduction -180 degree • Adduction -30 degree • Internal rotation -90 degree • External rotation -90 degree

18. Physical ExamRange of Motion Forward flexion: 0o – 180o

19. Physical ExamRange of Motion • Extension • 0o – 40 to 60o

20. Physical ExamRange of Motion • Internal rotation • 80-90o • External rotation • 80-90o

21. Speed shoulder tests External rotation Internal rotation

22. Neurological Examination of the Shoulder Muscle tests : • Flexion • Extension • Abduction • Adduction • Internal rotation • External rotation

23. Muscle 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

24. Shoulder Abduction muscle test

25. Shoulder flexion and extension muscle test

26. Shoulder external and internal rotation muscle test

27. Shoulder abduction and adduction muscle test

28. Neurological Examination of the Shoulder sensory tests : • C4 • C5 • C6 • C7 • C8 • T1 • T2

29. Special Tests for the Shoulder Problems • Yergason test –biceps tendinitis • Neer impingement test-acromioclavicular impingement • Drop arm test –rotator cuff tear • Resisted flexion (Speed)test –biceps tendinitis • Resisted abduction(Supraspinatus) test-supraspinatus lesion • Aprehension test –glenohumeral joint instability

30. Yergason test • Yergason test for biceps tendon instability or tendonitis. • The patient's elbow is flexed to 90 degrees, and the examiner resists the patient's active attempts to supinate the arm and flex the elbow.

31. Drop Arm Test Passive abduction to 90° Instruct patient to slowly lower arm At 90° abducted arm will suddenly drop, may need to add slight pressure (+) drop = (+) test

32. SHOULDER PAINSPECIAL TESTS Neer PASSIVE Forced forward flexion of arm with internally rotated shoulder Test is positive if pain occurs at same point as with active forward flexion

33. Speed’s Maneuver • Forward flex the shoulder against resistance while maintaining the elbow in extension and the forearm in supination. Pain or tenderness in the bicipital groove in dicates bicipital tendinitis.

34. Rotator Cuff Strength Testing Weakness on exam Grade strength on 0→5 scale Compare to other side Supraspinatus testing

35. Apprehension Test/Relocation Test

36. Differantial Diagnosis for shoulder pain • Subacromial impingement syndrome • Adhesive capsulitis –frozen shoulder • Biceps tendinopati • Bursitis • Rotator cuff pathology • Glenohumeral joint pathology • Acromioclavicular joint pathology • Sternoclavicular joint pathology • Myofascial pain syndrome • Radiating or referred pain from cervical spine

37. Subacromial Impingement • Neer proposed that 95% of rotator cuff tears are due to chronic impingement between the humeral head and the coracoacrominal arch.

38. Subacromial Impingement • Stage 1 disease consists of edema and hemorrhage of the tendon due to occupational or athletic overuse, and is reversible under conservative treatment.

39. Subacromial Impingement • Stage 2 disease shows progressive inflammatory changes of the rotator cuff tendons and the subacromial-subdeltoid bursa, and can be treated by removing the bursa and dividing the coracoacromial ligament after failed conservative management.

40. ELBOW EXAMINATION • Anatomy • Evaluation • Inspection-Observation • Palpation-Pression • Range of motion • Neurological examination • Special tests • Examination of related areas

41. ELBOW ANATOMY • Bones • Joints • Ligaments • Muscles

42. Elbow Anatomy Medial Elbow

43. ElbowAnatomy Lateral Elbow

44. ELBOW Anatomy

45. EVALUATION INSPECTION • Anterior –posterior side • Medial-lateral side • Carrying angle • Swelling

46. PALPATION and PRESSION Bone palpation : • Lateral epicondyle • Radial head • Medial epicondyle • Olecranon

47. SOFT TISSUE PALPATION Medial aspect • Ulnar nerve • Wrist flexor –pronator group • Medial collateral ligament Lateral aspect • Wrist extensors (ECRL-ECRB) • Lateral collateral ligament • Annular ligament

48. SOFT TISSUE PALPATION Anterior aspect • Cubital fossa • Brachial artery • Median nerve • Musculo-cutaneus nerve Posterior aspect • Olecranon bursa • Triceps tendon

49. ELBOW ROM • Flexion -135 degree • Extension -0 degree • Pronation -90 degree • Supination -90 degree

50. NEUROLOGICAL EXAMINATION Muscle tests: • Flexion - Extension • Pronation - Supination Sensation tests • C5-C6-C7-C8-T1 Reflex test: • Biceps reflex –C6 • Brachioradial reflex –C6 • Triceps reflex-C7