Prof.Dr.Hidayet Sarı
Physical Medicine and Rehabilitation
Department

ANATOMY
• Bones
• Joints
• Muscles
• Bursae
• Nerves
• Blood supply

Bony Anatomy
Anterior

Bony Anatomy
Posterior

1.
Glenohumeral
2.
Scapula thoracic
3.
Acromio-clavicular
4.
Sterno-clavicular

•
Bony Anatomy
Joints and Articulations
STATIC STABILIZERS

– Deltoid
– Rotator cuff
– Teres major
– Latissimus dorsi
– Biceps
– Pectoralis muscles

• Rotator Cuff
– S upraspinatus ABD
– I nfraspinatus ER
– T eres minor ER
– S upscapularis IR
Depress humeral head against glenoid to allow full abduction

• Bursae
– subacromial
– subdeltoid
– subscapular

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

• Anterior side
• Posterior side
• Lateral side
• Medial side

Physical Exam
Inspection
• Front & back
• Height of shoulder and scapulae
• Muscle atrophy, asymmetry

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

• Flexion-180 degree
• Extension -45 degree
• Abduction -180 degree
• Adduction -30 degree
• Internal rotation -90 degree
• External rotation -90 degree

Physical Exam
Range of Motion
• Forward flexion:
– 0 o – 180 o

• Extension
– 0 o – 40 to 60 o
Physical Exam
Range of Motion

• Internal rotation
– 80-90 o
Physical Exam
Range of Motion
• External rotation
– 80-90 o

External rotation Internal rotation

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

• 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

Shoulder Abduction muscle test

Shoulder flexion and extension muscle test

Shoulder external and internal rotation muscle test

Shoulder abduction and adduction muscle test

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

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) testsupraspinatus lesion
• Aprehension test –glenohumeral joint instability

• 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.

• 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

SHOULDER PAIN
SPECIAL 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

• 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.

• Weakness on exam
• Grade strength on 0→5 scale
• Compare to other side
Supraspinatus testing

Apprehension Test/Relocation Test

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

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

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

• 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.

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

• Bones
• Joints
• Ligaments
• Muscles

Medial Elbow

Lateral Elbow

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

Bone palpation :
• Lateral epicondyle
• Radial head
• Medial epicondyle
• Olecranon

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

Anterior aspect
• Cubital fossa
• Brachial artery
• Median nerve
• Musculo-cutaneus nerve
Posterior aspect
• Olecranon bursa
• Triceps tendon

• Flexion -135 degree
• Extension -0 degree
• Pronation -90 degree
• Supination -90 degree

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

• Biceps reflex –C6
• Brachioradial reflex –C6
• Triceps reflex-C7

• Ligament tests (varus-valgus stres test)
• Tennis elbow test
• Golfers elbow test
• Tinels sign for ulnar nerve

Ligament tests (varus-valgus stres test)

Tinels sign for ulnar nerve

COMMON ELBOW PROBLEMS
• Lateral epicondylitis
• Medial epicondylitis
• Olecranon bursitis
• Fractures
• Triceps tendinitis
• Post immbolization capsular tightness
(contracture)

EXAMINATION of the WRIST and HAND
Anatomy
• Surface anatomy
• Skeletal anatomy
• Fibrous anatomy
• Muscles
• Nerves
• Blood supply

• Phalanges: 14
• Sesamoids: 2
• Metacarpals: 5
• Carpals
– Proximal row: 4
– Distal row: 4
• Radius and Ulna
Lister’s tubercle

• Surface anatomy
• Palmar surface
• Radial border
• Thenar surface
• Thumb –index-middle-ring-small fingers
• Hypothenar surface
• Dorsal surface
• İnterosseus muscle

• Radio-carpal
• Ulna-carpal
• İnter-carpal
• Metacarpo-phalangial (MCP)
• Proximal inter-phalangial (PIP)
• Distal inter-phalangial (DIP)

• History
• Inspection-Observation (dorsum of the hand-palm of the hand )
• Palpation-Pression
• Range of motion
• Functional assessment
• Neurological examination
• Special tests
• Examination of related areas

• Creases
• Thenar and Hypothenar
Eminence
• Arched Framework
• Hills and Valleys
• Web Spaces

Palpation-Pression

• Forearm pronation-90 degree
• Forearm supination -90 degree
• Wrist flexion (palmar flexion)-90 degree
• Wrist extension (dorsal flexion )-90 degree
• Wrist radial deviation -30 degree
• Wrist ulnar deviation -20 degree

• Flexion
• Extension
• Radial deviation
• Ulnar deviation
– Ulnar deviation is greater than radial

MCP joint :
• Flexion -90 degree
• Extension -20 degree
PIP joint :
• Flexion -90 degree
• Extension -0 degree
DIP joint :
• Flexion -80 degree
• Extension -0 degree

• Flexion
• Extension
• Abduction
• Adduction
• Opposition

• Radial nerve
• Median nerve
• Ulnar nerve
• Radial artery
• Ulnar artery

• Fractures
• Tenosynovitis :
1.
Thumb extensors –De Querveins disease
2.
Finger flexors tenosynovitis
3.
Finger extensors tenosynovitis
• Arthritis
1.
Rheumatoid arthritis (RA)
2.
Osteoarthritis (OA)
–bouchards nodes
-heberdans nodes
- First MCP OA-Rhizarthrosis

• Inflammation of EXT
Pollicis Brevis and ABD
Pollicis Longus tendons
• Tenderness 1st
Dorsal Compartment
• Finkelstein’s Test

• MCP swelling
• Swan neck deformities
• Ulnar deviation at
MCP joints
• Nodules along tendon sheaths

• Heberden’s nodes:
DIP
• Bouchard’s nodes:
PIP

COMPRESSION
NEUROPATHIES
• Median nerve compression syndrome carpal tunel syndrome (tinel and phalen test )
• Pronator syndrome
• Ulnar nerve compression syndromes compression at the elbow ulnar tunel syndrome
Compresssion at the wrist Guyon canal syndrome
• Radial nerve compression syndromes
Posterior interosseous nerve syndrome
Superficial radial nerve entrapment

• Finkelsteins test –De Quervein tenosynovitis
• Tinel test –CTS, UTS
• Phalens test –CTS

• Neurologic exam
– Median nerve sensation and motor
• Phalen’s Test: both wrists maximally flexed for 1 minute
• Tinel’s Test

EXAMINATION of the RELATED
AREAS
• Cervical spine
• Shoulder
• Elbow
• Arteries ,veins ,lymph
• gallbladder stone
• Heart