1. Introduction to Upper Extremity Orthopedic Tests

2. Shoulder Orthopedic Tests

3. Tendinitis (Supraspinatus)
Supraspinatus tendinitis is a common inflammatory condition of the shoulder that causes anterior shoulder pain.
Pain is present especially in abduction.
The painful arc is between 60° and 90° of abduction.

4. Tendinitis (Supraspinatus)
Clinical Signs and Symptoms
Anterolateral shoulder pain
Pain sleeping on the affected side
Stiffness
Catching of the shoulder during use
Pain on active and passive range of motion
Local tenderness

5. Supraspinatous Tendinitis Test
Procedure: Patient seated. Abduct the arm to 90° with the arm between abduction and forward flexion. Abduct against resistance.
Positive Test: Pain or weakness over the insertion of the supraspinatous tendon may indicate tendinitis or tear. Pain over the deltoid may indicate a strained deltoid muscle.

6. Supraspinatous Tendinitis Test

7. Apley Scratch Test
Procedure: Patient seated. Place hand of affected shoulder behind head to touch superior angle of opposite scapula. Place hand behind back to touch inferior angle of opposite scapula.
Positive Test: Pain indicates tendinitis of the tendons of the rotator cuff, usually the supraspinatous tendon.

8. Apley Scratch Test

9. Tendinitis (Bicipital)
The biceps brachii has two heads, the long and the short.
The long head travels over the superior aspect of the humeral head.
The long head is the tendon affected by bicipital tendinitis.

10. Tendinitis (Bicipital)
Clinical Signs and Symptoms
Anterior shoulder pain
Pain on palpation of the bicipital groove.
Pain on active and passive elbow flexion and extension.

11. Biceps Tendon

12. Speed’s Test
Procedure: Patient seated with elbow extended, supinated, and the shoulder flexed forward to 45°. Place your fingers in the bicipital groove and your opposite hand on the patient’s wrist. Instruct the patient to elevate the arm forward against resistance.
Positive Test: Pain or tenderness in the bicipital groove.

13. Speed’s Test

14. Bursitis The subacromial bursa overlies the rotator cuff tendons.
Usually bursitis is associated with tendinitis of the adjacent supraspinatus tendon.
Common causes of bursitis are trauma, overuse, repeated multiple traumas, and improper executed activity.

15. Bursitis Clinical Signs and Symptoms Anterolateral shoulder pain
Pain sleeping on the affected side
Stiffness
“Catching” of the shoulder during use
Pain on active and passive range of motion
Local tenderness

16. Subacromial Bursa

17. Subacromial Push-Button Sign
Procedure: Patient seated. Apply pressure to the subacromial bursa.
Positive Test: Local pain suggests inflammation of the subacromial bursa (bursitis).

18. Subacromial Push-Button Sign

19. Rotator Cuff Instability
Rotator cuff instability involves partial or complete tearing of one of the tendons of the rotator cuff.
Usually the supraspinatous tendon is involved.
Rotator Cuff Muscles
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis

20. Rotator Cuff Instability
Clinical Signs and Symptoms
Severe anterior lateral shoulder pain
Pain when sleeping on the affected side
Stiffness
“Catching” of the shoulder during use
Pain on active and passive range of motion
Localized tenderness
Unable to abduct shoulder

21. Drop Arm Test
Procedure: Patient seated. Abduct the arm past 90°. Instruct the patient to lower the arm slowly.
Positive Test: If the patient cannot lower the arm slowly or if it drops suddenly, this indicates a rotator cuff tear, usually of the supraspinatus.

22. Drop Arm Test

23. Supraspinatous Test
Procedure: Instruct the patient to abduct the arm to 90°. Grasp the patient’s arm and press down against resistance by the patient. Next, rotate the shoulder internally so the thumb points down. Press down against resistance.
Positive Test: Weakness or pain may indicate a tear of the supraspinatus muscle or tendon. It may also indicate suprascapular neuropathy.

24. Supraspinatous Test

25. Biceps Tendon Instability
The biceps brachii has two heads: long and short.
The long head traverses the bicipital groove.
A shallow bicipital groove or a lax or ruptured transverse humeral ligament may snap the biceps tendon into and out of the bicipital groove.
This will cause anterior shoulder pain with point tenderness at the bicipital groove.

26. Biceps Tendon Instability
The painful snap may also indicate a tear of the biceps tendon.
A bicipital tendon tear will cause swelling and ecchymosis near the bicipital groove and a characteristic bulging of the belly of the bicpes muscle near the antecubital fossa (Popeye sign).

27. Bicipital Tendon

28. Biceps Tendon Instability
Clinical Signs and Symptoms
Anterior shoulder pain
Stiffness
Pain on active and passive range of motion
Localized tenderness
Bulging of biceps muscle (complete tear)

29. Yergason’s Test
Procedure: Patient seated with elbow flexed to Stabilize the patient’s elbow with one hand. Grasp the patient’s wrist and have him externally rotate the shoulder and supinate the forearm against resistance.
Positive Test: Local pain or tenderness in the bicipital tendon indicates an inflammation of the biceps tendon or tendinitis. If the tendon pops out of the bicipital groove, suspect a lax or ruptured transverse humeral ligament or a congenital shallow bicipital groove.

30. Yergason’s Test

31. Elbow Orthopaedic Tests

32. Medial Aspect (Ulnar Nerve)

33. Medial Epicondyle

34. Ulnar Collateral Ligament

35. Lateral Epicondyle

36. Radial Collateral Ligament Annular Ligament

37. Olecranon Process and Bursa

38. Triceps

39. Lateral Epicondylitis (Tennis Elbow)
Lateral epicondylitis is a repetitive strain injury of the common extensor tendon at thelateral epicondyle of the humerus.
Symptoms persist because of constant traction movement of the wrist and hand.

40. Lateral Epicondylitis (Tennis Elbow)

41. Lateral Epicondylitis (Tennis Elbow)
Clinical Signs and Symptoms
Local lateral elbow pain
Weakness of the forearm

42. Cozen’s Test
Procedure: Patient seated. Stabilize forearm. Patient should make a fist and extend it against resistance.
Rationale: The tendons that extend the wrist attach to the lateral epicondyle. Forcing the extended wrist into flexion will exacerbate the pain if the tendons are inflamed.

43. Cozen’s Test

44. Mill’s Test
Procedure: Patient seated. Instruct the patient to pronate the arm and flex the wrist. Then, instruct them to supinate against resistance.
Rationale: The supinator tendon is attached to the lateral epicondyle. If pain is elicited, suspect inflammation of the lateral epicondyle.

45. Mill’s Test

46. Medial Epicondylitis (Golfer’s Elbow)
Medial epicondylitis is a repetitive injury of the common flexor tendon at the medial epiconsyle of the humerus.
Symptoms persist due to constant traction and movement of the wrist and hand.

47. Medial Epicondylitis (Golfer’s Elbow)
Clinical Signs and Symptoms
Local medial elbow pain
Weakness of the forearm

48. Medial Epicondylitis (Golfer’s Elbow)

49. Golfer’s Elbow test
Procedure: Patient seated. Instruct the patient to extend the elbow and supinate the hand. Then, instruct the patient to flex the wrist against resistance.
Rationale: The tendons that flex the wrist are attached to the medial epicondyle. If pain is elicited, suspect inflammation of the medial epicondyle.

50. Golfer’s Elbow test

51. Neuropathy / Compression Syndromes
Neuropathy and compression syndromes of the elbow are peripheral neurological disorders.
They are caused by trauma, overuse, arthritis, and postural considerations.

52. Neuropathy / Compression Syndromes
Paresthesia and weakness of the forearm and/or hand.
The ulnar nerve is most often affected.
Compression occurs in the groove between the olecranon process and the medial epicondyle or the cubital tunnel.

53. Neuropathy / Compression Syndromes
Clinical Signs and Symptoms
Forearm and/or hand paresthesia
Forearm and/or hand weakness

54. Tinel’s Sign
Procedure: Patient seated. Tap the ulnar nerve in the groove between the olecranon process and the medial epicondyle with a neurological reflex hammer.
Rationale: If pain is elicited, it suggests a neuritis or neuroma of the ulnar nerve.

55. Tinel’s Sign

56. Causes of Ulnar Nerve Damage
Excessive use or repetitive motion injuries.
Arthritis of the elbow joint.
Cubital tunnel compression, between the heads of the flexor carpi ulnaris muscle.
Postural habits that compress the nerve, such as sleeping with elbows flexed and hands under head.
Recurrent nerve subluxations or dislocations.

57. Wrist Orthopaedic Tests

58. Anterior Aspect Flexor Tendons Flexor carpi ulnaris Palmaris longus
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor pollicis longus
Flexor carpi radialis

59. Flexor Tendons

60. Carpal Tunnel
The median nerve and the finger flexion tendons lie within the carpal tunnel.
This is a common site of compression neuropathy.

61. Carpal Tunnel

62. Guyon’s Canal (Ulnar Tunnel)
The ulnar nerve and artery lie within Guyon’s tunnel.
This is also a common site of compression neuropathy.

63. Guyon’s Canal (Ulnar Tunnel)

64. Posterior Aspect
The ulnar styloid process is at the posterior aspect of the wrist proximal to the fifth digit.
The radial tubercle is at the posterior aspect of the wrist proximal to the thumb.
Pain the the tubercle may indicate Colle’s fracture.
Pain at the ulnar styloid process may indicate a distal ulnar fracture.

65. Ulnar Styloid Process and Radial Tubercle

66. Posterior Aspect
There are six fibro-osseous tunnels at the posterior aspect of the wrist.
The extensor tendons to the hand pass through these tunnels.
They are bound by an extensor retinaculum superficially.

67. Extensor Tendons Tunnels and associated tendons
Tunnel 1 Adductor pollicis longus, extensor pollicis brevis
Tunnel 2 Extensor carpi radialis longus and brevis
Tunnel 3 Extensor pollicis longus
Tunnel 4 Extensor digitorum and extensor indexes
Tunnel 5 Extensor digiti minimi
Tunnel 6 Extensor carpi ulnaris

68. Extensor Tendons

69. Carpal Tunnel Syndrome
Carpal tunnel syndrome is a compression neuropathy of the median nerve.
Compression occurs under the flexor retinaculum at the wrist.

70. Carpal Tunnel Syndrome

71. Carpal Tunnel Syndrome
Clinical Signs and Symptoms
Loss of sensation of the tips of the first three fingers
Hand and wrist pain
Weakness of grip

72. Tinel’s Wrist Sign
Procedure: Patient’s hand supinated. Stabilize the wrist with one hand. With your opposite hand, tap the palmar surface of the wrist with a neurological reflex hammer.
Rationale: Tingling along the distribution of the medial nerve indicates carpal tunnel syndrome. The cause could be any of the following: inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.

73. Tinel’s Wrist Sign

74. Phalen’s Test
Procedure: Flex both wrist and approximate them towards each other. Hold for 60 seconds.
Rationale: When both wrists are flexed, the flexor retinaculum provides increased compression of the medial nerve in the carpal tunnel. Tingling in the distribution of the median nerve (thumb, index finger, middle finger, and medial half of ring finger) indicates carpal tunnel syndrome.

75. Phalen’s Test

76. Ulnar Tunnel Syndrome
The ulnar nerve travels through the tunnel of Guyon and innervates the muscles of the little and ring fingers.
Ulnar nerve syndrome is a compression neuropathy of the ulnar nerve.

77. Guyon’s Canal (Ulnar Tunnel)

78. Ulnar Tunnel Syndrome Clinical Signs and Symptoms
Pain over the little and ring finger
Weakness of grip
Difficulty with finger spreading
Claw hand

79. Ulnar Tunnel Triad
Procedure: Inspect and palpate the patient’s wrist, looking for tenderness over the ulnar tunnel, clawing of the ring finger, and hypothenar wasting.
Rationale: All of these signs are indicative of ulnar nerve compression possibly in the tunnel of Guyon.

80. Ulnar Tunnel Triad