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.

Shoulder

Bones

• Clavicle
• Scapula
• Humerus
• For more information, see “Shoulder and axilla” and “Brachial plexus.”

Muscles

• Rotator cuff muscles
  • Supraspinatus: primary function is abduction
  • Infraspinatus: primary function is external rotation
  • Teres minor: primary function is external rotation
  • Subscapularis: primary function is internal rotation
• Other muscles
  • Deltoid
    • Anterior portion: primary function is flexion of the arms
    • Middle portion: primary function is abduction of the arms
    • Posterior portion: primary function is extension of the arms
  • Coracobrachialis: primary function is flexion of the arms
  • Lattissimus dorsi: primary function is extension, adduction, and internal rotation of the arms
  • Teres major
    • Primary function is extension of the shoulder
    • Internal rotation of the arms
  • Pectoralis major
    • Primary function is adduction of the shoulder
    • Internal rotation, adduction, and flexion of the arms
  • Serratus anterior
    • Lateral rotation and protraction of the scapula
    • Abduction of the arms
  • Trapezius
    • Adduction, rotation, elevation, and depression of the scapula
    • Abduction of the arms
  • Levator scapulae: elevation of the scapula
  • Rhomboid (major and minor): adduction and medial rotation of the scapula
• For more information, see “Shoulder and axilla.”

Joints

• Glenohumeral joint
• Acromioclavicular joint
• Sternoclavicular joint
• Physiologic joint: scapulothoracic joint
• For more information, see “Shoulder and axilla.”

The acromioclavicular and sternoclavicular joints move in opposite directions.

Innervation

• For more information, see “Brachial plexus” in “Neurovasculature of the upper limbs.”

Vasculature

• Brachiocephalic artery
• Subclavian artery
• Axillary artery
• Brachial artery
• Radial artery
• Ulnar artery
• For more information, see “Neurovasculature of the upper limbs.”

Thoracic outlet

• Ribs 1–4
• Clavicle
• Pectoralis minor
• Anterior scalene and middle scalene muscles

Anatomical landmarks of the shoulder

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

Elbow and forearm

Bones

• Humerus
• Radius
• Ulna
• For more information, see “Upper arm and elbow,” and “Forearm, wrist, and hand.”

Muscles

• Upper arm
  • Brachialis muscle: flexion of the elbow
  • Triceps muscle: extension of the elbow and arm
• Supinators of the forearm
  • Biceps muscle
  • Supinator muscle
• Pronators of the forearm
  • Pronator teres
  • Pronator quadratus
• Forearm extensors and flexors
  • Posterior compartment: extension
    • Extension of the wrist
    • Extension of the digits
  • Anterior compartment: flexion
    • Flexion of the wrist
    • Flexion of the digits
• For more information, see “Upper arm and elbow,” and “Forearm, wrist, and hand.”

Joints

• Elbow: ulna and humerus
• Radioulnar joint: distal and proximal
• Interosseous membrane of the forearm
• For more information, see “Upper arm and elbow,” and “Forearm, wrist, and hand.”

Innervation

• Musculocutaneous nerve
• Radial nerve
• Median nerve
• For more information, see “Neurovasculature of the upper limbs.”

Anatomical landmarks of the elbow

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

Wrist

Bones

• Carpal bones (eight)
• Metacarpals (five)
• Phalanges (fourteen)
• For more information, see “Forearm, wrist, and hand.”

Muscles

• Flexors of the wrist and hands
• Extensors of the wrist and hands
• Muscles of the thenar eminence: thumb motion
• Muscles of the hypothenar eminence: pinky motion
• Lumbricals: flexion of the MCPs, extension of the DIPs and PIPs
• Interossei: dorsal abduction and proximal adduction
• For more information, see “Forearm, wrist, and hand.”

Joints

• Intercarpal joints
• Carpometacarpal joints
• Metacarpophalangeal (MCP) joints
• Proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints
• For more information, see “Forearm, wrist, and hand.”

Innervation

• Median nerve
• Ulnar nerve
• Radial nerve
• For more information, see “Neurovasculature of the upper limbs.”

Anatomical landmarks of the wrist

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

Shoulder

• Type: ball and socket joint
• Motion
  • Glenohumeral joint
    • Flexion and extension
    • Abduction and adduction
    • External and internal rotation
  • Scapulothoracic joint
    • Lateral and medial glide
    • Superior and inferior glide
• Range of motion
  • Flexion: 180°
  • Extension: 45°
  • Abduction: 180°
  • Adduction: 55°
  • Internal rotation: 55°
  • External rotation: 45°

Clavicle

• Motion
  • Anterior and posterior glide
  • Superior and inferior glide

Elbow

• Motion
  • Flexion and extension
  • Supination and pronation
  • Abduction and adduction
• Range of motion
  • Flexion: ∼ 135°
  • Extension: 0–5°
  • Pronation: 75°
  • Supination: 85°
  • Abduction: 1–2°
  • Adduction: 1–2°
• Carrying angle
  • The angle between the axis of the humerus and the axis of the forearm is in full extension and supination.
  • Normal angle: approx. 10–15° away from the body.
    • 5° in men
    • 10–12° in women
  • Ulnar abduction → increased carrying angle → the wrist adducts
  • Ulnar adduction → decreased carrying angle → the wrist abducts

Radial head and wrist

• Motion
  • Movement of the radial head and wrist are linked.
  • In pronation of the hand (wrist flexion), the radial head glides posteriorly.
  • In supination of the hand (wrist extension), the radial head glides anteriorly.
• Wrist range of motion
  • Flexion: 80°
  • Extension: 70°
  • Ulnar deviation: 30°
  • Radial deviation: 20°

The radial head moves in relation to the hand.

• Nerve injuries
  • Axillary nerve injury
  • Radial nerve injury
  • Median nerve injury
  • Ulnar nerve injury
  • Erb-Duchenne palsy
  • Klumpke palsy
  • Saturday night palsy (radial nerve injury)
  • Pronator teres syndrome
• Shoulder
  • Thoracic outlet syndrome
  • Tendinitis
  • Biceps tendinopathy
  • Frozen shoulder (adhesive capsulitis)
  • Rotator cuff tear
  • Shoulder dislocation
• Scapula: winged scapula (injury to the serratus anterior muscle or long thoracic nerve)
• Forearm and wrist
  • Lateral epicondylitis (tennis elbow)
  • Medial epicondylitis (golf elbow)
  • Carpal tunnel syndrome
  • Cubital tunnel syndrome
  • De Quervain tenosynovitis
  • Scaphoid fracture
  • Avascular necrosis

• Shoulder flexion dysfunction
  • Shoulder extension restriction
  • Flexion freedom of motion
• Shoulder extension dysfunction
  • Shoulder flexion restriction
  • Extension freedom of motion
• Shoulder abduction dysfunction
  • Shoulder adduction restriction
  • Abduction freedom of motion
• Shoulder adduction dysfunction
  • Shoulder abduction restriction
  • Adduction freedom of motion
• Shoulder internal rotation dysfunction
  • Shoulder external rotation restriction
  • Internal rotation freedom of motion
• Shoulder external rotation dysfunction
  • Shoulder internal rotation restriction
  • External rotation freedom of motion

Radial somatic dysfunctions

• Anterior radial head dysfunction
  • Caused by falling backward on a supinated forearm
  • Pronation restriction (supination freedom of motion)
  • Impaired posterior glide of the radial head.
• Posterior radial head dysfunction
  • Caused by falling forward on a pronated forearm
  • Supination restriction (pronation freedom of motion)
  • Impaired anterior glide of the radial head.
• Radial deviation dysfunction
  • Ulnar deviation restriction
  • Radial deviation freedom of motion

Ulnar somatic dysfunctions

• Ulnar abduction dysfunction
  • Lateral deviation of the forearm at the elbow: medial deviation of the olecranon, lateral deviation of the distal ulna
  • Adduction of the wrist
• Ulnar adduction dysfunction
  • Cubitus varus: decreased carrying angle < 3°
  • Medial deviation of the forearm at the elbow: lateral deviation of the olecranon, medial deviation of the distal ulna
  • Abduction of the wrist
• Ulnar deviation dysfunction
  • Radial deviation restriction
  • Ulnar deviation freedom of motion

The ulna and the wrist move in opposite directions.

Cubitus valgus (carrying angle > 15°) → ulnar abduction → wrist adduction

Cubitus varus (carrying angle < 3°) → ulnar adduction → wrist abduction

• Wrist flexion somatic dysfunction
  • Wrist extension restriction (wrist flexion freedom of motion)
  • Impaired ventral glide of the proximal carpal bones (dorsal glide freedom of motion)
• Wrist extension somatic dysfunction
  • Wrist restricted in flexion (freedom of motion in extension)
  • Proximal carpal bones are restricted in dorsal glide (freedom of motion in ventral glide)

Shoulder

• Apley scratch test
• Drop arm test
• Jobe test (empty can test)
• Shoulder apprehension tests
• Neer test
• Hawkins-Kennedy test
• Speed test
• Adson test
• Wright test
• Roos stress test

Drop arm test

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

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, forearm, and wrist

• Modified Allen test
• Finkelstein test
• Phalen test
• Tinel test

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

Shoulder flexion dysfunction

Muscle energy

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

Shoulder extension dysfunction

Muscle energy

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

Shoulder abduction dysfunction

Muscle energy

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

Shoulder adduction dysfunction

Muscle energy

• Position: lateral recumbent with dysfunctional side up
• Procedure
  1. Place shoulder into abduction barrier.
  2. Ask the patient to adduct the 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

Muscle energy

• Position: seated
• Procedure
  1. Flex elbow to ∼ 90 degrees.
  2. Place shoulder into external rotation barrier.
  3. Ask the patient to internally rotate the 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

Muscle energy

• Position: seated
• Procedure
  1. Flex elbow to ∼90 degrees.
  2. Place shoulder into internal rotation barrier.
  3. Ask the patient to externally rotate the 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.

Spencer technique of the shoulder (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 (abduction): with the elbow flexed, gently abduct the shoulder into its anatomical barrier seven times.
  • Step 5b (adduction and external rotation): with the elbow flexed, gently adduct 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.

Anterior radial head dysfunction

Muscle energy

• Procedure
  1. Place elbow in pronation barrier.
  2. Ask the 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 the radial head on the anterior aspect of the forearm with the thumb.
  3. Bring wrist into pronation barrier (brings radial head posteriorly).
  4. Apply a dorsal thrust while hyperflexing the elbow.
  5. Reassess.

Posterior radial head dysfunction

Muscle energy

• Procedure
  1. Place elbow in supination barrier.
  2. Ask the 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 the thumb over the posterior aspect of the radial head with the 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

Muscle energy

• Procedure
  1. Place wrist into ulnar deviation restriction.
  2. Ask the 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

Muscle energy

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