“Brace Yourself”

Physical Exam, Functional Testing

and Bracing of Common Upper
Extremity Orthopedic Complaints
 Objectives
• Surface anatomy, muscle testing,
special tests, & bracing
– Cervical spine
– Shoulder
– Elbow, wrist, hand

• Apply these skills to your clinical

practice
 Cervical Spine Exam
• Surface Anatomy
– C 3 thru 7
 Cervical Spine Exam
• Manual Muscle Tests
• Special Tests
– Spurlings Compression
Shoulder Anatomy
Skeletal
Shoulder Anatomy
Muscular
 Shoulder Exam
• Surface Anatomy
– Sternoclavicular joint
– Clavicle
– Acromoclavicular joint
– Coracoid process
– Tip of Acromion
– Proximal Humerus
– Spine of the Scapula
 Shoulder Exam
• Manual Muscle Tests
• Special Tests
– AC Spring Test
– Sulcus Sign
– Apprehension Test
– Hawkins-Kennedy Impingement Test
– Drop Arm Test
 Shoulder Exam
Location of Pain & Other Sym ptom s

Fell Down--Pain on Fell Down--Pain in Neck Twisted--Burning Arm Goes Lim p Pain on Raising
Top of Shoulder Front of Shoulder Pain Down Arm Shoulder

A-C Separation Dislocation Stinger Subluxation Rotator Cuff

1. Piano Key Sign 1. Apprehension 1. Rule out other 1. Apprehension 1. Em pty Can
2. A-C Shear Test Test causes of pain Test 2. Full Can
2. Axilla Region 2. Test strength 2. Relocation 3. Drop Arm Test
Palpation around shoulder Test
 Shoulder Braces
• Shoulder
Stabilizer
• “SAWA”
Elbow, Wrist, and Hand Anatomy
Medial Elbow
Elbow, Wrist, and Hand Anatomy
Lateral Elbow
Elbow, Wrist, and Hand Anatomy
Wrist and Hand
 Elbow Exam
• Surface Anatomy
– Medial Epicondyle
– Lateral Epicondyle
– Olecranon
– Ulnar groove
 Wrist and Hand Exam
• Surface Anatomy
– Scaphoid
– Pisiform
– Radial Head
– Ulnar Styloid
Elbow, Wrist, and Hand Exam
• Manual Muscle Tests
• Special Tests
– Valgus Stress Test
– Tennis Elbow Test (Lateral
Epicondylitis)
– Finkelstein Test
 Elbow Exam
Sym ptom s

Fell on A rm or O utstretched Hand M edial Elbow Pain in G radual O nset of P ain

Young Pitcher After Heavy Use

Dislocaton Hyperextension
Little League Elbow Lateral E picondylitis

1. Deform ity 1. Passive ext

2. Check wrist 2. Valgus test 1. Medial 1. Tennis E lbow Test
pulse 3. Varus test Epicondylitis 2. Cozen's Test
3. S ensation Test
 Wrist Exam
H o w Inju re d?

F e ll o n O u tstre tc h ed C lu b o r R acq u et P a in A fte r E x e rc ise

H a nd H its G ro u nd

B ro k e n N a v ic u lar B ro k en H am a te T e n do n itis

1 . P a in in A na to m ic al 1 . Te nd e r a t ba se of 1 . P ain w ith res is ted

s nu ffb ox h ypo the n ar e m in en ce m otio n u sin g in v olv ed
2 . P a in w ith s up ina tion 2 . P a in fle xing 4th a nd ten don
a nd p ron ation 5 th fing e rs
 Hand Exam
Type of Injury

Finger bent back Fist hits hard Thumb pulled back Finger bent forward
object

Jersey Volar Mallet Buttonhole

finger plate Fractured G am ekeeper's Finger Finger
m etacarpal Thumb

Inability to Pain on volar Inability to Inability to

flex the surface of 1. Tender at site 1. UCL Valgus extend DIP extend PIP
DIP Joint finger of fracture stress test
2. Malrotation of 2. Pain on UCL
fingers in fist
 Upper Extremity Function
• Mirroring

• Double/single arm balancing

• Sport specific skill testing

– Identify tasks
– Progress intensity to game-like situation
 Elbow Braces
• Hinged Elbow Brace
– Control ROM
– Prevent hyperextension
 Wrist/Hand Bracing
• Cock-Up
– Immobilize
 Wrist/Hand Bracing
• Wrist/Thumb Spica Brace
 Orthopedic Exam References

Amato, H., Venable-Hawkins, C.,

Cole, S. 2002. Practical Exam
Preparation Guide of Clinical
Skills for Athletic Training.
Thorofare, NJ: SLACK
Incorporated.
 Orthopedic Exam References
• Magee, D. 2002. Orthopedic Physical
Assessment, 4th Ed. Philadelphia, PA:
Saunders.
• Kendall, F., McCreary, E., Provance, P.
1993. Muscles, Testing and Function.
Baltimore, MD: Williams & Wilkins.
 Injury Scenario # 1
• A football player reaches out with his arm
to tackle the ball carrier. After the play he
walks to the sideline supporting the arm and
is in a great deal of pain.

– Discuss how to evaluate this problem and

immediate care procedures.
 Answer: Injury Scenario # 1
• Injury
– Anterior shoulder dislocation
• Plan
– Attempt to reduce
– Sling the arm (above heart)
– Assess vascular integrity of the arm
– Assess neurological integrity of the arm
– Transport to doctor for immediate reduction
 Answer: Injury Scenario # 1
• Bracing
– Shoulder stabilizer for
stability
 Injury Scenario # 2
• A soccer player running downfield was
tripped and fell on her shoulder with the
arm extended. She complains of pain over
the distal end of the clavicle. On
examination she has a lump on the top of
the shoulder (not found on bilateral
examination) which is tender.
– Demonstrate what you would do.
 Answer: Injury Scenario # 2
• Injury
– Acromioclavicular sprain
• Evaluation
– Palpable pain at acromion process and AC ligament
– Piano key sign
– Positive AC sprain special tests
– Holds arm in loose packed position
– Limited shoulder ROM
 Injury Scenario # 3
• During a football game the quarterback makes a
throw & just as he releases the ball is struck from
his blindside. His head appears to be forced
sideways with the shoulder already lowered from
his follow-through. The athlete comes to you on
the sideline complaining of pain, numbness &
tingling in his neck & down his right arm.

– Evaluate this injury and discuss what return to

play criterion should be used.
 Answer: Injury Scenario # 3
• Injury
– Brachial plexus strain (Burner/Stinger)
• Plan
– Light stretch of injured area
– Perform upper extremity neurological
assessment
– Light cervical traction
– Brachial plexus tension tests
 Answer: Injury Scenario # 3
• Plan (cont)
– Assess grip strength
– Ice over brachial plexus
• Return to Play
– Full sensation and full strength demonstrated
 Injury Scenario # 4
• A tennis player reports with a chief
complaint of elbow pain. Considering the
injury has an insidious onset, the sport the
athlete participates in and the joint injured.

– Demonstrate the key components to the

evaluation and list the plan of action for care of
the athlete.
 Findings: Injury Scenario # 4
• Evaluation
– Pain with active and resistive extension of the
wrist and forearm
– Pain and weakness with manual muscle test for
the extensor muscle group
– Palpable pain over lateral epicondyle
– Positive tennis elbow test
– Positive Cozens test
 Answer: Injury Scenario # 4
• Injury
– Lateral Epicondylitis
• Plan
– Evaluate biomechanics with coaches assistance
– Discuss racket tension
– Discuss grip size
– Ultrasound (phono if no improvement) for
inflammation
 Answer: Injury Scenario # 4
• Plan (cont.)
– Ice cup after activity
– Strap to reduce tension
on extensor tendons
 Injury Scenario #5
• The quarterback was injured during the first quarter
of the contest while carrying the ball. The physician
diagnosed the injury as trauma to the abdominal
area also known as “getting the wind knocked out”
and ruled that he could resume activity. During the
fourth quarter, he started to talk about abdominal
pain that was radiating up into the left shoulder.

– Describe your evaluation process and recommended

treatment for the athlete.
 Answer: Injury Scenario # 5
• Plan
– Assess respiratory integrity of athlete for
pathology
– Assess for other signs and symptoms of heart
complications
– Listen to heart sounds with stethoscope
– Palpate abdomen for areas of rebound
tenderness (especially around spleen)
– Have athlete urinate and look for blood in urine
 Injury Scenario #6
• During an ice hockey game a player catches
a slap-shot directly in his chest. The athlete
tries to get up but collapses back to the ice
and cannot catch his breath.

– Demonstrate what you would do.

 Answer: Injury Scenario # 6
• Injury
– Possible heart arrhythmia
• Treatment
– Monitor ABC’s
– Activate emergency action plan
– X-Ray ribs