Upper extremity osteopathy

The flexibility of the upper extremity results in a wide range of movements across the shoulder, elbow, and wrist joints, which often leads to excessive and directionally awkward stress. The upper extremity is attached to the torso through multiple muscular attachments and one bony attachment (the sternoclavicular joint). Therefore, osteopathic examination and treatment are often first directed at the cervical and thoracic spine. Dysfunction can be present in any of the cardinal directions of each joint, as well as the radial head of the humerus. Osteopathic treatment in this region mostly consists of articulatory techniques, muscle energy, and high-velocity low-amplitude.

Upper extremity

Shoulder

Bones

• See article on shoulder, axilla, and brachial plexus.

Osteopathic landmarks of the shoulder

• Sternoclavicular joint
• Acromioclavicular joint
• Coracoid process
• Bicipital groove
• Spine of scapula (T3)
• Inferior angles of scapula (T7)

Range of motion

• Flexion: 180°
• Extension: 45°
• Abduction: 180°
• Adduction: 55°
• Internal rotation: 55°
• External rotation: 45°

Elbow

Bones

• See article on arm and elbow.

Osteopathic landmarks of the elbow

• Medial epicondyle
• Lateral epicondyle
• Coronoid process
• Radial head
• Olecranon process
• Epicondylar (ulnar) groove

Range of motion

• Flexion: ∼ 135°
• Extension: 0–5°
• Pronation: 75°
• Supination: 85°
• Abduction: 1–2°
• Adduction: 1–2°

Wrist

Bones

• See article forearm, wrist, and hand.

Osteopathic landmarks of the wrist

• Styloid process of the ulna
• Styloid process of the radius
• Radial fossa (“anatomical snuff box”)
• Hook of hamate

Range of motion

• Flexion: 80°
• Extension: 70°
• Ulnar deviation: 30°
• Radial deviation: 20°

Shoulder

Apley scratch test

• See “Apley scratch test” in the learning on orthopedic shoulder examination.

Shoulder apprehension tests

• See “anterior apprehension test” and “posterior apprehension test” in the article on orthopedic shoulder examination.

Neer sign

• See “Neer test” in the article on orthopedic shoulder examination.

Hawkins-Kennedy test

• See “Hawkins-Kennedy test” in the article on orthopedic shoulder examination.

Adson test

• See “Adson test” in the article on thoracic outlet syndrome.

Wright test

• See “Wright test” in the article on thoracic outlet syndrome.

Drop arm test

• Function: assesses supraspinatus tendon integrity
• Position: seated
• Procedure: starting from ∼ 90 degrees, ask patient to slowly adduct arms
• Positive test: inability to lower arms slowly or smoothly

Yergason test

• See “Yergason test” in the article on orthopedic shoulder examination.

Costoclavicular syndrome test (military posture test)

• Function: assesses for thoracic outlet syndrome
• Position: seated or standing
• Procedure
  1. Ask patient to bring back and depress the shoulders (assuming a military posture).
  2. Stabilize the patient's scapula.
  3. While monitoring the radial pulse, slightly abduct and extend the shoulder.
  4. Add lateral traction.
• Positive test: reproduction of symptoms or a diminished radial pulse

Elbow

Tinel test

• See “Tinel test” in the article on ulnar nerve entrapment.

Wrist

Watson test

• Function: assesses for instability between the scaphoid and lunate
  Position: seated
• Procedure
  1. Place thumb on the scaphoid tubercle with patient's wrist in ulnar deviation.
  2. Apply dorsal pressure while the patient deviates hand radially.
• Positive test: pain or laxity

Shuck test

• Function: assesses for perilunate instability
• Position: seated
• Procedure
  1. Hold patient's wrist in flexion.
  2. Ask patient to extend fingers against equal resistance.
• Positive test: pain over the dorsum of the wrist

Allen test

• See “modified Allen test” in the article on arterial access.

Finkelstein test

• See “Finkelstein test” in the article on tenosynovitis.

Phalen test

• See “Phalen test” in the article on carpal tunnel syndrome.

Tinel sign

• See “Tinel sign” in the article on carpal tunnel syndrome.

Spencer technique (seven steps of Spencer)

• Position: lateral recumbent with affected shoulder pointing upward
• Procedure
  • Step 1 (extension): with the elbow flexed, gently extend the shoulder into its anatomical barrier seven times.
  • Step 2 (flexion): with the elbow extended, gently flex the shoulder into its anatomical barrier seven times.
  • Step 3 (circumduction with compression): with the elbow flexed and shoulder abducted to 90°, circumduct the arm with a gentle compression in clockwise and counterclockwise concentric circles while gradually increasing the range.
  • Step 4 (circumduction with traction): with the elbow extended and shoulder abducted to 90°, circumduct the arm with gentle upward traction in clockwise and counterclockwise concentric circles while gradually increasing the range.
  • Step 5a (adduction and external rotation): with the elbow flexed, gently adduct the shoulder into its anatomical barrier seven times.
  • Step 5b (abduction): with the elbow flexed, gently abduct the shoulder into its anatomical barrier seven times.
  • Step 6 (internal rotation): with the patient's wrist behind the rib cage, gently bring the elbow forward seven times.
  • Step 7 (distraction): with the elbow extended and shoulder flexed, grasp the patient's humerus and apply gentle traction in various directions on the glenohumeral joint.

Shoulder flexion dysfunction

Diagnosis

• Shoulder extension restriction (flexion freedom of motion)

Treatment

Muscle energy

• Position: lateral recumbent with dysfunctional side up
• Procedure
  1. Place shoulder into extension barrier.
  2. Ask patient to flex shoulder against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Shoulder extension dysfunction

Diagnosis

• Shoulder flexion restriction (extension freedom of motion)

Treatment

Muscle energy

• Position: lateral recumbent with dysfunctional side up
• Procedure
  1. Place shoulder into flexion barrier.
  2. Ask patient to extend shoulder against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Shoulder abduction dysfunction

Diagnosis

• Shoulder adduction restriction (abduction freedom of motion)

Treatment

Muscle energy

• Position: lateral recumbent with dysfunctional side up
• Procedure
  1. Place shoulder into adduction barrier.
  2. Ask patient to abduct shoulder against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Shoulder adduction dysfunction

Diagnosis

• Shoulder abduction restriction (adduction freedom of motion)

Treatment

Muscle energy

• Position: lateral recumbent with dysfunctional side up
• Procedure
  1. Place shoulder into abduction barrier.
  2. Ask patient to adduct shoulder against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Shoulder internal rotation dysfunction

Diagnosis

• Shoulder external rotation restriction (internal rotation freedom of motion)

Treatment

Muscle energy

• Position: seated
• Procedure
  1. Flex elbow to ∼ 90 degrees.
  2. Place shoulder into external rotation barrier.
  3. Ask patient to internally rotate shoulder (push wrist and forearm toward the midline) against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage barrier and repeat.
  6. Reassess.

Shoulder external rotation dysfunction

Diagnosis

• Shoulder internal rotation restriction (external rotation freedom of motion)

Treatment

Muscle energy

• Position: seated
• Procedure
  1. Flex elbow to ∼90 degrees.
  2. Place shoulder into internal rotation barrier.
  3. Ask patient to externally rotate shoulder (push wrist and forearm laterally) against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage barrier and repeat.
  6. Reassess.

Anterior radial head dysfunction

Diagnosis

• Pronation restriction (supination freedom of motion)

Treatment

Muscle energy

• Procedure
  1. Place elbow in pronation barrier.
  2. Ask patient to supinate against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

High-velocity low-amplitude

• Procedure
  1. Perform myofascial technique.
  2. Monitor radial head on the anterior aspect of the forearm with the thumb.
  3. Bring wrist into pronation barrier (brings radial head posterior).
  4. Apply a dorsal thrust while hyperflexing the elbow.
  5. Reassess.

Posterior radial head dysfunction

Diagnosis

• Supination restriction (pronation freedom of motion)

Treatment

Muscle energy

• Procedure
  1. Place elbow in supination barrier.
  2. Ask patient to pronate against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

High-velocity low-amplitude

• Procedure
  1. Perform myofascial technique.
  2. Place thumb over the anterior aspect of the radial head with index and middle fingers on the posterior aspect.
  3. Place elbow into supination barrier (brings radial head anterior).
  4. Gently hyperextend the elbow.
  5. Apply an anterior thrust on the radial head.
  6. Reassess.

Radial deviation dysfunction

Diagnosis

• Ulnar deviation restriction (radial deviation freedom of motion)

Treatment

Muscle energy

• Procedure
  1. Place wrist into ulnar deviation restriction.
  2. Ask patient to radially deviate against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Ulnar deviation dysfunction

Diagnosis

• Radial deviation restriction (ulnar deviation freedom of motion)

Treatment

Muscle energy

• Procedure
  1. Place wrist into radial deviation restriction,
  2. Ask patient to ulnar deviate against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.