Summary
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.
Anatomy
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°
Special tests
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
- 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
- Place thumb on the scaphoid tubercle with patient's wrist in ulnar deviation.
- Apply dorsal pressure while the patient deviates hand radially.
- Positive test: pain or laxity
Shuck test
- Function: assesses for perilunate instability
- Position: seated
-
Procedure
- Hold patient's wrist in flexion.
- 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.
Articulatory techniques
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 diagnosis and treatment
Shoulder flexion dysfunction
Diagnosis
- Shoulder extension restriction (flexion freedom of motion)
Treatment
Muscle energy
- Position: lateral recumbent with dysfunctional side up
-
Procedure
- Place shoulder into extension barrier.
- Ask patient to flex shoulder against equal resistance for 3–5 seconds.
- Relax for 5 seconds.
- Re-engage barrier and repeat.
- Reassess.
Shoulder extension dysfunction
Diagnosis
- Shoulder flexion restriction (extension freedom of motion)
Treatment
Muscle energy
- Position: lateral recumbent with dysfunctional side up
-
Procedure
- Place shoulder into flexion barrier.
- Ask patient to extend shoulder against equal resistance for 3–5 seconds.
- Relax for 5 seconds.
- Re-engage barrier and repeat.
- Reassess.
Shoulder abduction dysfunction
Diagnosis
Treatment
Muscle energy
Shoulder adduction dysfunction
Diagnosis
Treatment
Muscle energy
Shoulder internal rotation dysfunction
Diagnosis
- Shoulder external rotation restriction (internal rotation freedom of motion)
Treatment
Muscle energy
- Position: seated
-
Procedure
- Flex elbow to ∼ 90 degrees.
- Place shoulder into external rotation barrier.
- Ask patient to internally rotate shoulder (push wrist and forearm toward the midline) against equal resistance for 3–5 seconds.
- Relax for 5 seconds.
- Re-engage barrier and repeat.
- Reassess.
Shoulder external rotation dysfunction
Diagnosis
- Shoulder internal rotation restriction (external rotation freedom of motion)
Treatment
Muscle energy
- Position: seated
-
Procedure
- Flex elbow to ∼90 degrees.
- Place shoulder into internal rotation barrier.
- Ask patient to externally rotate shoulder (push wrist and forearm laterally) against equal resistance for 3–5 seconds.
- Relax for 5 seconds.
- Re-engage barrier and repeat.
- Reassess.
Radial head diagnosis and treatment
Anterior radial head dysfunction
Diagnosis
- Pronation restriction (supination freedom of motion)
Treatment
Muscle energy
- Procedure
High-velocity low-amplitude
-
Procedure
- Perform myofascial technique.
- Monitor radial head on the anterior aspect of the forearm with the thumb.
- Bring wrist into pronation barrier (brings radial head posterior).
- Apply a dorsal thrust while hyperflexing the elbow.
- Reassess.
Posterior radial head dysfunction
Diagnosis
- Supination restriction (pronation freedom of motion)
Treatment
Muscle energy
-
Procedure
- Place elbow in supination barrier.
- Ask patient to pronate against equal resistance for 3–5 seconds.
- Relax for 5 seconds.
- Re-engage barrier and repeat.
- Reassess.
High-velocity low-amplitude
-
Procedure
- Perform myofascial technique.
- Place thumb over the anterior aspect of the radial head with index and middle fingers on the posterior aspect.
- Place elbow into supination barrier (brings radial head anterior).
- Gently hyperextend the elbow.
- Apply an anterior thrust on the radial head.
- Reassess.
Wrist diagnosis and treatment
Radial deviation dysfunction
Diagnosis
- Ulnar deviation restriction (radial deviation freedom of motion)
Treatment
Muscle energy
-
Procedure
- Place wrist into ulnar deviation restriction.
- Ask patient to radially deviate against equal resistance for 3–5 seconds.
- Relax for 5 seconds.
- Re-engage barrier and repeat.
- Reassess.
Ulnar deviation dysfunction
Diagnosis
- Radial deviation restriction (ulnar deviation freedom of motion)
Treatment
Muscle energy
-
Procedure
- Place wrist into radial deviation restriction,
- Ask patient to ulnar deviate against equal resistance for 3–5 seconds.
- Relax for 5 seconds.
- Re-engage barrier and repeat.
- Reassess.