Musculoskeletal
Disorders of the
Upper Limb
Hazel Joy M. Jumawan, MD, DPARM
Rehabilitation Medicine
References
Outline
● Special Tests for Upper Extremities
● Shoulder Conditions
● Elbow Conditions
● Wrist and Hand Conditions
Objectives
● To learn how to perform the special tests to
check for upper extremity musculoskeletal
conditions
● To identify the common musculoskeletal
conditions in the shoulder, elbow, wrist, and
hand
● To know the rehabilitation management of
common upper extremity musculoskeletal
conditions
Special
Tests
Special
Tests:
Shoulder
Anterior Apprehension and Relocation
Tests
● for anterior glenohumeral joint
instability
● Patient: supine position
● Examiner:
○ abducts the patient’s shoulder 90
degrees and flexes the elbow 90
degrees
Anterior Apprehension and Relocation
Tests
● Examiner:
○ uses one hand to slowly
externally rotate the patient’s
humerus, using the patient’s
forearm as the lever
○ other hand is placed posterior
to the patient’s proximal
humerus and exerts an
anteriorly directed force on
the humeral head
Anterior Apprehension and Relocation
Tests
● Positive:
○ patient feels impending
anterior dislocation
Anterior Apprehension and Relocation
Tests
● Examiner:
○ removes the hand from behind the
proximal humerus then
○ places it over the anterior proximal
humerus and then exerts a
posteriorly directed force
● Positive:
○ Patient reports a reduction in
apprehension
Posterior Apprehension Test
● for posterior glenohumeral
joint stability
● Patient: affected shoulder is
forward flexed to 90 degrees
and then maximally internally
rotated
Posterior Apprehension Test
● Examiner:
○ a posteriorly directed force is then
placed on the patient’s elbow
● Positive:
○ 50% or greater posterior translation
of the humeral head or a feeling of
apprehension in the patient
Sulcus Sign
● for inferior glenohumeral joint
instability
● Patient: : seated or standing
with the arm relaxed in
shoulder adduction
Sulcus Sign
● Examiner:
○ grasps patient’s forearm and a
distal traction force is placed
through the patient’s arm
● Positive:
○ sulcus will develop between the
humeral head and the acromion
O’Brien Test
● for acromioclavicular (AC) joint
and labral abnormalities
● Examiner: :
○ The shoulder is flexed to 90 degrees
○ with the elbow fully extended
○ The arm is then adducted 15 degrees,
and the shoulder is internally rotated so
that
○ the patient’s thumb is pointing down.
○ Applies a downward force against that
arm
O’Brien Test
● Patient: : instructed to resist.
O’Brien Test
● Examiner: :
○ The shoulder is then externally
rotated so that the patient’s palm
is facing up, and the examiner
applies a downward force on the
patient’s arm
O’Brien Test
● Positive:
○ pain during the first part (thumb
down) then lessened or
eliminated on the second part
(palm facing up)
● Pain in AC joint: AC pathology
● Pain or painful clicking deep
inside the shoulder: Labral
pathology
Horizontal Adduction Test
● for AC joint pathology or posterior
capsular tightness
● Examiner:
○ The shoulder is passively flexed to 90
degrees and then horizontally adducted
across the chest.
● Positive:
○ Pain in the region of the AC joint: AC joint
pathology
○ Posterior shoulder pain: posterior capsular
tightness
Speed Test
● for biceps tendonitis
● Patient: The patient’s shoulder is forward
flexed to 90 degrees with the elbow fully
extended and the palm facing up
● Examiner:
○ applies a downward force against the
patient’s active resistance
● Positive:
○ Pain in the region of the bicipital groove
Yergason Test
● for bicipital tendinitis and
bicipital tendon instability
● Patient:
○ patient’s arm at the side
○ elbow is flexed to 90 degrees
○ forearm is pronated
Yergason Test
● Examiner:
○ Applies resistance while the patient
tries to simultaneously supinate the
forearm and externally rotate the
shoulder against the resistance.
● Positive:
○ bicipital region pain: bicipital
tendonitis
○ painful “pop”: bicipital tendon
instability
Neer-Walsh Impingement Test
● Examiner:
○ The patient’s shoulder is internally
rotated while at the side passively
forward flexes the patient’s
shoulder to 180 degrees while
maintaining internal rotation.
● Positive:
○ Pain in the subacromial region:
rotator cuff tendonitis
Hawkins-Kennedy Impingement Test
Examiner:
○ The patient’s shoulder and elbow are
each passively flexed to 90 degrees,
respectively.
○ The examiner then grasps the
patient’s forearm, stabilizes the
patient’s scapulothoracic joint, and
uses the forearm as a lever arm to
internally rotate the glenohumeral
joint.
Hawkins-Kennedy Impingement Test
● Positive:
○ pain in the subacromial region
occurring with the internal rotation
Drop Arm Test
● for rotator cuff tear
● Examiner:
○ passively abducts the patient’s
shoulder 90 degrees then
horizontally adduct to 45 degrees
● Patient: slowly lower arm
● Positive:
○ pain and an inability to slowly
lower the arm to the side
Special
Tests:
Elbow
Cozen Test
● for lateral epicondylitis
● Patient: fully extend the elbow,
pronate the forearm, and make a fist
● Examiner:
○ resists the patient’s attempt to
extend and radially deviate the
wrist
● Positive:
○ Pain over the lateral epicondyle
Ligamentous Instability Test
● for RCL and UCL instability
● Examiner:
○ flexes the patient’s elbow 20 to
30 degrees and stabilizes the
patient’s arm by placing a hand at
the elbow and a hand on the
distal forearm.
Ligamentous Instability Test
● for RCL and UCL instability
● Examiner:
○ Varus and valgus forces are
placed across the elbow by the
examiner to test the stability of
the radial and ulnar collateral
ligaments (UCL), respectively
● Positive:
○ Pain and/or joint laxity
Special
Tests:
Wrist and
Hand
Finkelstein Test
● For tenosynovitis of the extensor
pollicis brevis and abductor pollicis
longus tendons (de Quervain
tenosynovitis)
● Patient:
○ makes a fist with the thumb inside the
fingers
Finkelstein Test
● Examiner:
○ passively deviates the wrist in an ulnar
direction
● Positive:
○ pain in the affected tendons
Shoulder
Outline
Rotator Cuff
Acromioclavicular
Tendonitis and
Joint Sprains
Impingement
Glenohumeral Adhesive
Joint Instability Capsulitis
Acromioclavicular Joint Sprains
● AC joint sprains account for only 9% of all
shoulder injuries
● Most frequent in men in their third decade of
life
● Usually partial
● Result of direct trauma from a fall or blow to
the acromion
Rockwood Classification of AC Joint Sprains
Physical Examination
● Point tenderness
● Positive horizontal adduction
test
● Positive O’Brien test
https://www.saintlukeskc.org/health-library/understanding-ac-joint-sprain
Radiographic Evaluation
● Anteroposterior view
● Lateral views
● Zanca view
○ anteroposterior projection
with 15-degree cephalic tilt
● Stress views do not
provide additional
clinically useful
information
Management
● Type 1, 2, and 3
○ Nonoperative
○ Brief period of sling immobilization for pain control
● Type 3
○ Surgical intervention
■ persistent pain
■ unsatisfactory cosmetic results
■ heavy laborers, athletes who participate in sports that
place a high demand on the upper limbs
Management
● Type 4, 5, or 6
○ Surgical treatment
Rotator Cuff Tendonitis and Impingement
https://www.openmed.co.in/2022/02/rotator-cuff-muscles-and-their-actions.html
Rotator Cuff Tendonitis and Impingement
● Causes:
○ Macrotrauma
○ Repetitive
microtrauma
○ Outlet impingement
between the acromion
and greater tuberosity
of the humerus
■ Primary
■ Secondary
Rotator Cuff Tendonitis and Impingement
Primary Outlet Impingement
○ Three types of acromion
The incidence of rotator cuff tears increased
■ Type 1 – relatively flat as the acromion progressed from a type 1 to
■ Type 2 – curved a type 3 shape
■ Type 3 – hooked
Rotator Cuff Tendonitis and Impingement
Secondary Outlet Impingement
○ glenohumeral joint instability
○ weak scapular stabilizers
○ scapulothoracic dyskinesis
○ lack of adequate scapular control or weakness in the
scapular stabilizers can lead to inadequate acromial
retraction during overhead activities, creating secondary
impingement
Symptoms
● Anterior or lateral shoulder pain that occurs
with overhead activity and also at night while
trying to sleep
● Stiffness, weakness, catching
● Underlying glenohumeral joint instability such
as numbness, tingling, feelings of subluxation,
or previous “dead arm” episodes
Physical Examination
● Evaluation of the cervical spine
○ frequently refer symptoms to the shoulder
● Proper scapulothoracic mechanics
● Strength testing of the rotator cuff muscles
○ weakness as a result of a rotator cuff tear or pain
inhibition caused by tendonitis or tendinosis.
Physical Examination
● Neer-Walsh
● Hawkins-Kennedy
● Elimination of the pain
provoked by impingement
testing after injection of 10
mL of 1% lidocaine into the
The lateral aspect of the shoulder is
subacromial space confirms palpated for the point of maximal
tenderness, usually 1 to 2 cm
the diagnosis of impingement inferiorly and 1 to 2 cm anteriorly to
the angle of the acromion
Imaging
● X-ray
○ Anteroposterior
■ Large rotator cuff tears
can be indicated by an
acromiohumeral
distance of less than 7
The acromiohumeral distance was
mm and sclerosis on the measured as the shortest distance
undersurface of the between a radiodense line on the inferior
aspect of the acromion and a line parallel
acromion to it, tangential to the humeral head,
preoperatively (A) and postoperatively
(superior capsule reconstruction) (B)
https://www.researchgate.net/figure/Anteroposterior-radiograph-of-right-shoulder-The-acromiohumeral-distance-was-measured-as_fig1_338604554
Imaging
● X-ray
○ Supraspinatus outlet
■ categorization of the
acromion types
■ reveal AC joint
osteophytes
https://www.slideshare.net/mrinaljoshi3/radiographic-evaluation-of-shoulder
Imaging: X-ray – Supraspinatus Outlet View
Subacromial Impingement
Imaging
● Ultrasound and magnetic resonance imaging (MRI)
have higher levels of sensitivity and specificity for
rotator cuff pathology than radiographs
Management: Non-operative
● Strengthening exercises for the scapular
stabilizing muscles rather than the rotator
cuff should be emphasized in the acute
rehabilitation stage.
○ Specifically, strengthening muscles that retract and
depress the scapula (e.g., serratus anterior and
inferior trapezius)
Management: Non-operative
● Stretching muscles that protract and elevate
the scapula (e.g., pectoralis minor and upper
trapezius) reduce impingement.
Management: Non-operative
● Subacromial corticosteroid
injection
○ although studies of
corticosteroid injections have
shown mixed results.
● Extracorporeal shock-wave
therapy
○ Patients recalcitrant to above
measures
Management: Surgical
● If the patient fails to respond to the above
measures
● Patients who have sustained an acute full-
thickness rotator cuff tear should receive
early surgical intervention to maximize their
postoperative recovery potential
● In the young or active subgroups, surgical
intervention is required.
Glenohumeral Joint Instability
Subluxation Dislocation
humeral head translates to the edge of the humeral head is disassociated
the glenoid, beyond normal physiologic from the glenoid fossa and often
limits, followed by self-reduction requires manual reduction
https://myfamilyphysio.com.au/shoulder-dislocations/
Etiology
● Traumatic
○ Unidirectional type
■ Most common: anterior dislocation
● Atraumatic
○ Congenital capsular laxity
○ Repetitive microtrauma
■ Repetitive overhead activities such as baseball
pitching can cause enough microtrauma to lead to
symptomatic laxity
○ Multidirectional type
Associated injuries
● Bankart Lesion
○ Tear of the anterior inferior
glenoid labrum with or
without some underlying
bone from the glenoid rim
○ Associated with traumatic
anterior glenohumeral
dislocation
Images from
https://litfl.com/bankart-lesion/
https://www.shoulder-pain-explained.com/bankart-lesion.html
Associated injuries
● Hill-Sachs Lesion
○ Compression fracture of the
posterolateral aspect of the
humeral head
○ Associated with traumatic
anterior glenohumeral
dislocation
Image from
https://motionhealth.com.au/common-conditions/shoulder/hill-sachs-lesion/
Symptoms
● Pain, popping, catching, locking, an unstable
sensation, stiffness, and swelling
● Subluxation episodes are commonly
associated with a burning or aching dead
feeling in the arm.
Physical Examination
● Glenohumeral joint ROM
● Analysis of scapulothoracic kinesis
● Upper limb strength, sensation
○ including proprioception
● Reflex evaluations
● Special tests for glenohumeral joint instability
Imaging: X-ray
● Anteroposterior
○ With internal rotation,
the anteroposterior view
can also allow
visualization of a Hill-
Sachs defect
Imaging: X-ray
● Axillary View
○ Anterior or
posterior
subluxation or
dislocation
○ Fractures of the
anterior or
posterior glenoid
rim
Imaging: X-ray – Axillary View
Imaging: X-ray
● Scapular Y view
Imaging: X-ray – Scapular Y View
Anterior dislocation
Imaging: X-ray
● West Point
View
○ Bankart Lesion
Imaging: X-ray – West Point View
Anterior glenoid fracture
Imaging: X-ray
● Stryker Notch
View
○ Hill-Sachs
defect
Imaging: X-ray – Stryker Notch View
Imaging
● Magnetic resonance arthrography provides
optimal visualization of the labrum, cartilage,
and joint capsule
Management: Non-operative
● Strengthening program
○ begin with closed chain exercises that promote
cocontraction of the glenohumeral joint–stabilizing
musculature
https://e3rehab.com/blog/closed-chain-exercises/
Management: Non-operative
● Strengthening program
○ progress to functional open chain exercises as
stability is achieved
https://e3rehab.com/blog/closed-chain-exercises/
Management: Operative
● Considered only in those patients who have failed to
improve after a comprehensive nonoperative
● For older, less active patient
○ nonoperative management frequently is successful
● For younger, more active patient involved in contact
sports
○ very high redislocation rate in those treated nonoperatively
compared with those receiving early operative intervention
Management
● Closed reduction confirmed by radiologic
examination should be performed on all
patients who sustain an acute glenohumeral
joint dislocation that does not spontaneously
reduce
○ Radiologic studies should be performed in two
planes
■ such as anteroposterior and axillary lateral views, to
confirm relocation and exclude an associated fracture
Adhesive Capsulitis
● “Frozen shoulder”
● Painful, restricted shoulder ROM in patients
with normal radiographs
● Usually idiopathic
● Can be associated with
○ diabetes mellitus, inflammatory arthritis, trauma,
prolonged immobilization, thyroid disease,
cerebrovascular accident, myocardial infarction,
autoimmune disease.
Adhesive Capsulitis
● 2 to 4 times more common in women
● Most frequently seen between 40 and 60
years
Adhesive Capsulitis
● Pathologic evaluation can reveal
○ fibroblastic proliferation with increased collagen
and nodular band formation
○ perivascular inflammation
Freezing Stage
Frozen Stage
Thawing Stage
Management
● Physical modalities, analgesics, and activity
modification to reduce pain and inflammation
● Up to three intraarticular corticosteroid
injections can be used
Management
● Postural retraining to reduce
kyphotic posture and forward
humeral positioning
● Passive joint glides
● Passive and active assisted ROM
exercises should be initiated
Management
● Early scapular stability exercises and closed
chain rotator cuff exercises
● Active ROM activities, open chain and
proprioceptive exercises once symptoms
improve
● Restoration of normal function over 12 to 14
months
Management
● If no improvement after 6 months of
nonoperative treatment,
Capsular hydrodilatation Arthroscopic lysis of adhesions
Elbow
Outline
Lateral Medial
Epicondylopathy Epicondylopathy
A more appropriate term for this condition is epicondylosis rather than epicondylitis.
Epicondylitis is a misnomer for this condition because the pathologic changes are
not inflammatory but rather degenerative.
However, since histopathologic studies are not performed on a routine basis for this
condition, it is commonly referred toas epicondylopathy.
Lateral Epicondylitis
● Tendinopathy of the lateral
elbow
● “Tennis elbow”
○ occurs in up to 50% of tennis
players
● Caused by any activity that
places excessive repetitive
stress on the lateral
forearm musculature
Lateral Epicondylitis
● More common in older than 35 years of age
○ Peaks between 40 and 50 years old
● Male > Females in tennis players
Lateral Epicondylitis
● Degenerative changes occur
most commonly in the origin
of the extensor carpi radialis
brevis
○ May also involve the extensor
digitorum communis origin in
30%
○ Origins of the extensor carpi
radialis longus or extensor carpi
ulnaris are only rarely involved
Symptoms
● Gradual onset of symptoms, which usually occur
after specific activities like
○ Gripping
○ Repetitive wrist extension
○ Forearm pronation and supination
○ Backhand swing in tennis
● Traumatic or sudden onset of symptoms can
also occur
Physical Examination
● Point tenderness over the lateral epicondyle
● Positive Cozen test
Imaging
● Standard anteroposterior and lateral
radiographs
● usually normal
● Oblique view of the lateral epicondyle
● punctate calcifications in the extensor tendon origin
Management
○ Discontinuation of provocative activities
○ Oral analgesics
○ Physical modalities
○ Bracing
■ (e.g., lateral counter-force strap or neutral wrist splint)
Management
○ Exercise
■ Eccentric strengthening of the wrist
extensors
○ Correct inappropriate tennis racquet
grip size and string tension
○ Peritendinous corticosteroid
injections occasionally used, but
longterm efficacy is questionable
Management
○ New treatments
■ ultrasound-guided percutaneous needle
tenotomy
■ autologous blood injections
■ platelet-rich plasma injections
○ Recalcitrant cases
■ Extracorporeal shock-wave
● 48-73% success
■ Surgical débridement of the degenerative
tissue
● 85% good to excellent results
Medial Epicondylitis
● “Golfer’s elbow”
● 3 to 7 times less frequent than
lateral epicondylitis
● Degenerative changes are most
frequently found in the
pronator teres and flexor carpi
radialis origins
Risk Factors
○ Training errors
○ Faulty equipment
○ Repetitive activities requiring wrist
flexion and forearm pronation
○ Biomechanical abnormalities
■ Poor strength,
■ Flexibility imbalances
■ Joint instability
Symptoms
● Gradual onset of pain over the medial epicondyle
exacerbated by activities that require
○ repetitive gripping
○ wrist flexion
○ forearm pronation and supination
● Feeling of grip strength weakness
● Symptoms of a concomitant ulnar neuropathy can also be
present
Physical Examination
○ Tenderness over the medial epicondyle
○ Weakness in grip strength
○ Pain when a tight fist is made
○ Pain with resisted wrist flexion and forearm pronation
Imaging
● Oblique radiographs of the medial epicondyle
○ punctate calcifications in the region of the flexor
tendon origins
Management: Non-operative
● Discontinuation of aggravating
activities
● Analgesics
● Physical modalities
● Bracing
○ (e.g., medial counter-force strap
and neutral wrist splint) for pain
control and correcting kinetic
chain deficits and training errors.
Management: Non-operative
● Eccentric exercises
● Extracorporeal shock-wave
therapy
● Corticosteroid injections
Management: Operative
● For those who fail to improve with conservative measures.
● Incision and drainage if no improvement with the above
measures
Wrist and
Hand
Outline
First
De Quervain Metacarpophalangeal
Syndrome Joint Ulnar Collateral
Ligament Sprain
De Quervain Syndrome
● Stenosing tenosynovitis
● Most common tendonitis of the wrist
● Frequently seen in patients who perform activities
requiring forceful gripping with ulnar deviation of the
wrist or repetitive use of the thumb
De Quervain Syndrome
● The first dorsal compartment of the
wrist contains
○ abductor pollicis longus tendon
○ extensor pollicis brevis tendon
● Tendons run beneath a sheath over
the dorsal aspect of the radial styloid
process, along the inferior portion of
the anatomic snuff box
● Shear and repetitive microtrauma
occur in this area
Symptoms
● Insidious onset of pain over the dorsal radial
aspect of the wrist aggravated by activities
○ such as racquet sports, golf, or fly fishing
● Sensation of wrist crepitus
Physical Examination
● Mild edema localized to the dorsal radial wrist
● Tenderness to palpation over the first dorsal
compartment
● Finkelstein test is pathognomonic for the
diagnosis
Management
● Rest
● Modalities
● Analgesics
● Thumb spica splint
● First dorsal compartment
peritendinous corticosteroid
injection
○ reduces symptoms in 62% to
100% of cases
First Metacarpophalangeal Joint Ulnar
Collateral Ligament Sprain
● Radially directed forces
across the first
metacarpophalangeal (MCP)
joint can result in a UCL injury
● “Gamekeeper’s thumb”
○ seen in skiers and athletes who
participate in sports such as
basketball and football
First Metacarpophalangeal Joint Ulnar
Collateral Ligament Sprain
● UCL injuries to the first MCP joint can be categorized
into a three-grade severity scale of ligament sprains
Stener Lesion
○ Grade 3 UCL sprain of the first MCP joint
○ Avulsion of the distal end of the ligament from the base
of the first proximal phalanx
Stener Lesion
○ Possibility of interposition of the adductor pollicis
aponeurosis between the base of the first proximal
phalanx and the ruptured end of the UCL
○ Prevent adequate healing leading to chronic joint pain
and instability
Symptoms
● “pop” and a feeling of instability in the joint
Physical Examination
● Tenderness to palpation over the UCL
● Stener lesion: palpable mass on the ulnar
side of the first MCP joint might be present,
representing the avulsed UCL
● UCL stress examination should be
performed after local anesthesia via
a wrist block
○ performed with the joint in both full
extension and 30 degrees of flexion
○ complete tear indicated by an angular
difference between the injured and
uninjured first MCP joint during stress
examination
■ greater than 15 to 30 degrees.
○ lack of an endpoint suggests complete
UCL disruption
Imaging
● Anteroposterior, Lateral, and Oblique radiographs
○ presence of fractures or joint subluxation
● MRI allows better visualization of soft tissue
injuries
○ Sensitivity and specificity for this condition is still being
examined
Management: Non-operative
● Partial tears
○ modalities, analgesics,
○ immobilization in a thumb spica cast for 10 to 14 days,
○ followed by a wrist-hand-thumb spica orthosis for 2 weeks and a
○ hand-based thumb spica orthosis for 2 to 4 more weeks
Management: Non-operative
● Patients in contact sports
○ continue to wear a thumb spica splint during competition
for the remainder of the season
● Local taping for stability during activity can be used
after the period of splinting is completed
● Gentle progressive ROM exercises should begin after
cast immobilization by removing the splint twice
daily, and activity should be progressed as tolerated
Management: Operative
● Complete ruptures
● Stener lesion
● Avulsion fracture of the base of the proximal
phalanx with angulation and displacement greater
than 3 mm, or with chronic recurrent instability
Thank you!
CREDITS: This presentation template was created by
Slidesgo, and includes icons by Flaticon and
infographics & images by Freepik
