An Evidence-Based Approach to the Orthopedic Physical Exam – Part 2: The Upper Extremity

An Evidence-Based Approach to the Orthopedic Physical Exam –

Part 2: The Upper Extremity

Christopher B. Roecker, DC, MS, DACO¹, DACBSP, Milad Asefi, DC²

¹Assistant Professor, Palmer College of Chiropractic Life Science & Foundations Department

²Part-Time Faculty, Palmer College of Chiropractic Technique Department

Published: March 2017

Journal of the Academy of Chiropractic Orthopedists

March 2017, Volume 14, Issue 1

This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: https://ianmmedicine.org. © 2017 Roecker/Asefi and the Academy of Chiropractic Orthopedists.

ABSTRACT

Upper extremity conditions are a common musculoskeletal complaint. Establishing an accurate diagnosis for upper extremity conditions is intended to guide clinical management and improve patient care. The purpose of this article is to provide an overview of the evidence-based orthopedic physical exams for many upper extremity conditions. We have attempted to emphasize orthopedic physical exams that have demonstrated the highest diagnostic utility, or to point out when no such test exists. We encourage clinicians to utilize an evidence-based approach to clinical care, which deliberately combines the clinician’s expertise with the best available research evidence and the patient’s preferences, in an attempt to provide optimal patient care.

KEY WORDS (MeSH terms)

Evidence Based Practice; Chiropractic; Differential Diagnosis; Injuries, Arm; Injuries, Shoulder; Injuries, Forearm; Injuries, Wrist

Introduction

Diagnosing patients with orthopedic conditions is a complex process consisting of the patient interview and physical examination. A well-performed history serves to narrow the list of potential diagnoses, while the likelihood of various differential diagnosis is further refined during the physical examination (1,2). All of health care, including the chiropractic profession, is transitioning towards an evidence-informed approach to clinical care, known as evidence-based practice (3). This evidence-based approach to clinical care integrates three primary components, which are 1.) the best available research evidence, 2.) the practitioner’s clinical expertise, and 3.) the individual patient’s values and preferences (see Figure 1) (4). It is important to note that the relative proportion of each of these three components is rarely equal in the setting of real-world patient care. Therefore, far from being a “cookbook” approach to care, we view evidence-based practice as a dynamic approach to clinical decision-making where the emphasis of each of the three components varies among individual patients.

Figure 1 – Three Components of Evidence-Based Practice

Unfortunately, many orthopedic physical exam textbooks provide little guidance on the usefulness (utility) of the exams that they describe. Traditionally, these texts provide a detailed description of how to perform various orthopedic exams and which pathology the test purport to identify, while omitting information related to diagnostic utility (i.e. likelihood ratios, sensitivity, or specificity). The objective of this article is to provide clinicians with an overview of the diagnostic utility for many orthopedic physical exams used to evaluate for upper extremity conditions.

Methods

This is a narrative review of the evidence-based orthopedic physical examinations used to evaluate many upper extremity conditions. Information used to write this article was collected from various sources, listed in Table 1. This article focuses on background information; therefore, authoritative textbooks on the topic of evidence-based orthopedic exams were emphasized, and the source articles informing these reference textbooks were obtained when additional information was needed. Source articles were assessed for quality using the QUADAS grading system. When multiple sources existed for a given test, information was used from the studies with the highest QUADAS scores, in lieu of lower-quality studies. We also utilized the iOS iPad application, known as CORE Orthopedics (Clinical ORthopedic Exam) by Clinically Relevant Technologies to assist in our review of the literature; this application links orthopedic exams with their source articles on PubMed.gov and provides a synopsis of the exam statistics.

Table 1 – Sources Used for this Narrative Review

DISCUSSION

Categories of Upper Extremity Disorders

The focus of this article is on evidence-based orthopedic exams for upper extremity conditions. The organization of this article begins by presenting material related to the proximal upper extremity, with the shoulder, and proceeds distally.

Shoulder

Shoulder pain is a common condition that affects approximately 50% of the adult population (5). The shoulder is a complex joint that provides a diagnostic challenge to many clinicians. The shallow nature of the glenohumeral joint allows for a high degree of mobility, which comes at the cost of joint stability.

Shoulder dislocations or fractures frequently present with a sudden onset of pain following an acute injury and necessitate referral for radiological consultation. Shoulder dislocations and fractures are deemphasized in this article because these conditions are unlikely to present for initial evaluation to clinicians outside of the emergency department.

Obtaining a thorough history is important for narrowing down which structures may be involved with a patient’s shoulder complaint and establishing a list of differential diagnoses. Table 2 contains characteristic patient presentations related to several shoulder conditions.

Table 2: Initial Shoulder Hypotheses Based Upon Patient Presentation

Adapted from Netter’s Evidence-Based Orthopedic Exam, 2nd Ed. (6)

Rotator Cuff Tears

A rotator cuff tear (RCT) can affect any of the four rotator cuff muscles. Our review of the literature revealed that most orthopedic exams related to RCTs focus on evaluating for supraspinatus and subscapularis tears. A test that shows utility for isolating both infraspinatus and teres minor tears is the external rotation lag sign (ERLS). ERLS for an infraspinatus tear has a sensitivity of 70% and a specificity of 100% (7). ERLS for a teres minor tear has both a sensitivity and specificity of 100% (7,8). Decreased rotator cuff muscle strength has been shown to be useful for identifying specific RCTs, whereas the location of pain has not been shown to have diagnostic utility. Patients are most likely to report pain in the lateral and anterior shoulder, regardless of the location of the tear (9). Table 3 and Table 4 provide a review of the test statistics related to diagnosing supraspinatus and subscapularis RCTs, respectively.

Table 3: Orthopedic Tests for Supraspinatus Tear

*When pain and weakness are considered positive for a full thickness tear
+LR = positive likelihood ratio; -LR = negative likelihood ratio; ERLS = External Rotation Lag Sign

Table 4: Orthopedic Tests for Subscapularis Tear

*Small sample size additional studies required
+LR = positive likelihood ratio; -LR = negative likelihood ratio

Glenohumeral Instability

Glenohumeral instability (GHI) exists when the humeral head will not remain centered in the glenoid fossa due to congenital joint abnormalities or laxity of the glenohumeral capsule. We would like to emphasize that clinicians should use caution when evaluating patients with possible GHI, since these tests may induce dislocation. Glenohumeral instability is most likely to occur in the anterior direction and is most likely to coincide with a labrum tear of the shoulder; therefore, patients with GHI should also be suspected of having labral tear. We have focused this review on the orthopedic tests involved with detecting anterior GHI, which are summarized in Table 5. It should be noted that most tests listed within this table are effective at ruling in GHI, due to the relatively high positive likelihood ratios (+LRs).

Table 5: Orthopedic Tests for Instability

+LR = positive likelihood ratio; -LR = negative likelihood ratio

Bony Apprehension Test included because of its merit in screening for instability due to Bankart or Hill-Sachs lesion (19).

Glenoid Labrum Tear

A labral tear should be considered if a patient reports any of the following: their shoulder becomes “stuck” in a certain position, they experience sharp pain in specific positions, or shoulder movements reproduces a prominent clunk (5,20,21). Clinicians should be mindful that patient characteristics, such as advanced age and repetitive overhead work or sport activities, may be important factors for diagnosing labral tears (22).

It is important to note that a specific labral tear, the superior labral tear from anterior to posterior (SLAP lesion), is the type of labral tear that most orthopedic tests are designed to evaluate. Table 6 provides an overview of the orthopedic tests that have demonstrated the greatest diagnostic utility for evaluating patients with a suspected labral tear.

Table 6: Orthopedic Tests for Labral Tears

+LR = positive likelihood ratio; -LR = negative likelihood ratio

*Results are variable and further research is needed to establish test statistics related to this test (19,23)

Subacromial Impingement

Subacromial impingement, also known as impingement syndrome or swimmer’s shoulder, develops following mechanical compression of the subacromial structures including; rotator cuff tendons and the subacromial bursa. This condition develops when the humerus undergoes excessive superior translation when abducting the arm, which results in decreased space between the humerus and the acromion process (5,19,23). Table 7 provides a review of the orthopedic tests that have been shown to have the greatest diagnostic utility when evaluating patients suspected of having subacromial impingement.

Table 7: Orthopedic Tests for Subacromial Impingement

+LR = positive likelihood ratio; -LR = negative likelihood ratio
*Further studies are needed regarding Internal Rotation Resisted Strength Test as the one study conducted as the quality of the study is in question

Many of the previous shoulder conditions presented in this article (RCTs, labral tears, and instability) may alter the biomechanics of the shoulder joint complex, which predisposes patients to the development of subacromial impingement. For this reason, Cook notes that impingement tests are not strong diagnostic tools (22).

Acromioclavicular Joint

Most acromioclavicular (AC) joint problems become evident during the patient history, observation, and palpation of the shoulder (5,6). Traumatic injuries involving a fall on top of the shoulder, which depresses the acromion, are the most likely cause of an AC joint injury (shoulder separation)(6). Table 8 contains a review of the best available orthopedic tests for screening patients suspected of having an AC joint injury.

Table 8: Orthopedic Tests for Acromioclavicular Joint Injury

+LR = positive likelihood ratio; -LR = negative likelihood ratio
AC = acromioclavicular

Adhesive Capsulitis

Patients with adhesive capsulitis (frozen shoulder) commonly present with gradually worsening shoulder pain in the absence of preceding trauma. They may also report poorly-demarcated shoulder pain, shoulder stiffness, or shoulder pain that is aggravated by movement and relieved by rest along with a marked reduction in active and passive abduction of the arm. Adhesive capsulitis is a disease of adulthood and is most likely to affect females over age 45 (6)(28). Patients with type II diabetes mellitus can be up to five times more likely to experience adhesive capsulitis than the general population (29).

Our review discovered only one orthopedic test that has demonstrated utility in confirming a diagnosis of adhesive capsulitis. This test is the Coracoid Pain Test, which yields a +LR of 8.73 and a -LR of 0.04. We would like to emphasize that the quality of this study was relatively low and clinicians are encouraged to combine the findings of this test with their own clinical experience.

Additional Shoulder Conditions

Table 9 provides a brief overview of Shrug Sign and the Upper Cut Test, but we would like to emphasize that the relatively poor test statistics for these tests limits their diagnostic utility.

Table 9: Orthopedic Tests for Various Conditions

+LR = positive likelihood ratio; -LR = negative likelihood ratio

Elbow & Forearm

Many orthopedic conditions of the elbow involve acute trauma or repetitive movements (5). A structured approach to evaluating elbow and forearm conditions begins by discerning whether the onset was gradual, related to repetitive use, or sudden, following a bony or ligamentous injury in the area of complaint. Determining the mechanism of injury and quality of the patient’s pain is likely to assist in establishing a short list of differential diagnoses. Table 10 provides a summary of several initial diagnostic hypotheses, along with the associated patient history and clinical presentation, for many elbow and forearm conditions.

Unfortunately, there is a scarcity of well-designed studies evaluating the usefulness of orthopedic exams for elbow and forearm conditions. This review will emphasize the studies that have demonstrated the greatest utility, and will also highlight tests that lack validation.

Table 10: Initial Elbow & Forearm Hypotheses Based Upon Patient Presentation

Adapted from Netter’s Evidence-Based Orthopedic Exam, 2nd Ed.(6).

Elbow Fractures

Patients who present with a history of acute elbow trauma should first be assessed for fracture or dislocation (31). Tests that are used to evaluate for a fracture involve performing active ranges of motion and a positive test result consists of an inability to fully perform the specified range. Table 11 demonstrates the test statistics associated with screening for elbow fractures.

Table 11: Orthopedic Tests for an Acute Elbow Fracture

∞ = infinity; this results from an inability to calculate likelihood ratios when the sensitivity or specificity of a test is 100%; +LR = positive likelihood ratio; -LR = negative likelihood ratio

Our review of the literature failed to discover any orthopedic tests that have demonstrated utility for elbow dislocations. This apparent absence of research indicates that a clinician’s most useful tool is a focus on the patient presentation and mechanism of injury. Traditionally, elbow dislocations occur following hyperextension injuries, and may cause frank deformity or a “generalized looseness” of the elbow(5). Elbow dislocations should be treated as medical emergencies due to the high risk for neurovascular or cartilaginous complications (39).

Lateral Epicondylitis

Lateral epicondylitis (tennis elbow) is the most common form of epicondylitis and affects approximately 1 in 400 individuals (5,40,41). While this condition is reported to be evaluated with Cozen’s Test, Resisted Tennis Elbow Test, and Maudsley’s Test (22), we were unable to identify any studies that have evaluated the diagnostic utility of these tests (22, 40).

While there are no orthopedic tests that have been shown to assist in the diagnosis of lateral epicondylitis, there have been studies evaluating various manual therapies for the management of this condition; Table 12 provides a summary of these management studies.

Table 12: Review of Manual Therapies for the Management of Lateral Epicondylitis

Medial Epicondylitis

Medial epicondylitis (Golfer’s elbow) is classically described as developing in the dominant arm of a golfer and represents about 20% of all cases of epicondylitis (46). This condition is reported to be evaluated via the Golfer’s Elbow Test (46,47); however, we were unable to identify any studies that have evaluated the Golfer’s Elbow Test for diagnostic utility.

Elbow Instability

Injury to the collateral ligaments of the elbow is most likely to occur following repetitive trauma to the elbow in overarm-throwing sports, and up to half of all ligamentous injuries occur in children or adolescents (47,48,49).

Ulnar Collateral Ligament Injury (Little League Elbow)

The ulnar collateral ligament is on the medial side of the elbow and provides valgus stability. This ligament may be injured by an acute valgus stress to the arm or repetitive trauma from throwing activities. While the Valgus Stress Test is commonly reported to evaluate the integrity of the ulnar collateral ligament, it has yet to be evaluated for utility. Fortunately, a newer test, known as the Moving Valgus Stress Test, has been shown to be useful for ruling out the presence of ulnar collateral ligament injury in the event of a negative test result (50). See Table 13 for the test statistics related to evaluating for elbow instability.

Table 13: Orthopedic Tests for Elbow Instability (ligamentous injury)

+LR = positive likelihood ratio; -LR = negative likelihood ratio

Radial Collateral Ligament

The radial collateral ligament is a component of the lateral collateral ligament complex and protects the elbow against varus stress. Injury to this structure is commonly reported to follow acute varus stress to the arm and is relatively rare. The Varus Stress Test is commonly reported to evaluate the integrity of the radial collateral ligament, but just like the Valgus Stress Test, has yet to be evaluated for diagnostic utility.

Nursemaid’s Elbow

Nursemaid’s elbow is an example of an orthopedic subluxation involving the malpositioning of the radial head relative to the ulna. Children (ages 2-4) are most likely to develop this condition following axial traction of the upper extremity (5). Diagnosis is typically made upon patient presentation and reduction is commonly achieved via passive elbow flexion and supination and/or pronation (5).

Cubital Tunnel Syndrome (Ulnar Nerve Entrapment)

The most common site of ulnar nerve entrapment is the epicondylar (ulnar) groove along the medial elbow; this is the second most common site of upper extremity nerve entrapment, superseded only by carpal tunnel syndrome (51). Fortunately, orthopedic tests for this condition have been thoroughly studied and have yielded favorable results; please see Table 14 for a review of the cubital tunnel syndrome tests.

Table 14: Orthopedic Tests for Cubital Tunnel Syndrome

+LR = positive likelihood ratio; -LR = negative likelihood ratio

Pronator Teres Syndrome

Pronator teres syndrome (median nerve pronator syndrome) is a form of median nerve entrapment in the forearm, where the median nerve is compressed between the two heads of the pronator teres muscle. This condition presents with sensory alterations, such as an “aching” pain in the anterior forearm, tenderness over the median nerve distribution, and numbness in the thumb and index finger (51, 52). Pronator teres syndrome is exacerbated via the following: deep palpation of the pronator teres muscle, resisted pronation combined with wrist flexion, and passive extension of the elbow and wrist (5,55). Unfortunately, these provocative maneuvers have yet to be evaluated and their utility is unknown.

Olecranon Bursitis

Olecranon bursitis is an elbow condition where the subcutaneous olecranon bursa becomes inflamed following acute or repetitive trauma (5). Diagnosis of this condition appears to be based upon connecting the physical appearance of inflammation with a history of elbow trauma. We were unable to locate any orthopedic tests that purport to assist in the diagnosis of this condition.

Wrist & Hand

As with any region of the body, an accurate diagnosis of wrist or hand conditions begins with a thorough history. The patient’s mechanism of injury and chief complaint are informative when establishing an initial diagnostic hypothesis and many wrist and hand conditions have well-established patient presentations (6). Table 15 provides a summary of several initial diagnostic hypotheses, along with the associated patient history and clinical presentation, for many wrist or hand conditions.

Table 15: Initial Wrist & Elbow Hypotheses Based Upon Patient Presentation

Adapted from Netter’s Evidence-Based Orthopedic Exam (6)
OA = osteoarthritis; RA = rheumatoid arthritis

Fracture of the Wrist (and Distal Forearm)

When evaluating the hand and wrist it is important to begin by considering more serious pathologies, such as fracture, which necessitates immediate neurovascular and radiographic evaluation. Wrist fractures frequently develop following a direct blow or fall on an outstretched hand. Common fractures of the distal forearm and wrist involve the distal radius, distal ulna, and scaphoid. We were unable to identify any orthopedic tests to evaluate for fractures of the distal radius and ulna; therefore, clinicians are left to rely on the patient’s history and their clinical judgement to determine whether radiographs are needed to confirm a fracture diagnosis.

Multiple orthopedic tests have been established to evaluate for a possible scaphoid fracture. Unfortunately, the theme that emerges from these studies is that these tests have little, if any, diagnostic utility. Please see Table 16 for a review the tests used to evaluate for scaphoid fractures.

Table 16: Tests Used to Evaluate for a Scaphoid Fracture

+LR = positive likelihood ratio; -LR = negative likelihood ratio; AROM = active range of motion

Wrist Instability

Carpal instability involves any structural malalignment of the carpal bones. Carpal instability may also reflect a dynamic abnormality in the amount or quality of carpal bone movement, which may become evident when forces are applied to the wrist. While a complete review of the structure and function of the carpal ligaments is beyond the scope of this review, we have reported many useful or commonly-reported orthopedic tests related to carpal instability in Table 17.

Table 17: Tests Used to Evaluate for Instability of the Wrist

+LR = positive likelihood ratio; -LR = negative likelihood ratio

Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common form of median nerve entrapments and involves compression of this nerve within the carpal tunnel of the wrist (62). The primary feature of CTS is intermittent paresthesia of the median nerve distribution of the hand along digits 1 – 3, which may be exacerbated during specific activities (e.g., driving, typing). Other features reported to be associated with CTS involve weakness or clumsiness, reduced grip strength, pain in the median nerve distribution, nocturnal pain, atrophy of the thenar musculature, and relief when physically shaking the hands (5,6). Table 18 provides an overview of how useful many historical and neurological findings are for evaluating patients suspected of having CTS.

Table 18: Historical and Neurological Findings Associated with Carpal Tunnel Syndrome

+LR = positive likelihood ratio; -LR = negative likelihood ratio

The orthopedic tests that have been reported assist in the diagnosis of CTS and have been extensively evaluated. Table 19 provides an overview of the tests that have been shown to have the greatest diagnostic utility. We have also included tests that are well known or commonly reported, but have little clinical value.

Table 19: Tests Used to Evaluate for Carpal Tunnel Syndrome

+LR = positive likelihood ratio; -LR = negative likelihood ratio; CTS = carpal tunnel syndrome

More recently, a clinical prediction rule has been developed to help diagnose CTS and this study determined that a small set of variables were predictive for diagnosing CTS (see Table 20)(63). A patient who tests positive for 4 (out of 5) of these variables yields a +LR = 4.6 and a -LR = 0.28, while testing positive for all 5 variables yields a +LR = 18.3 and a -LR = 0.83.

Table 20: Five Variables used for the Carpal Tunnel Syndrome Clinical Prediction Rule

CTS = carpal tunnel syndrome
* Wrist-Ratio Index is calculated by dividing the anterior-to-posterior wrist width by the medial-to-lateral wrist width (in centimeters), using a pair of sliding calipers to measure at the distal wrist crease (74,75)
** A higher Symptom Severity Scale score indicates worse CTS symptoms and is derived from an 11-item questionnaire (76)

It may be of interest to the readers of this article that manipulation has been studied as a management strategy for CTS (74). This study was a randomized controlled trial comparing non-surgical medical care and chiropractic care. In this study, medical care consisted of ibuprofen and nocturnal wrist splints, while chiropractic care consisted of soft tissue mobilization, upper extremity and spinal manipulation, ultrasound over the carpal tunnel, and nocturnal wrist splints. This study showed that both groups demonstrated significant reductions in pain and dysfunction along with improved nerve conduction and median nerve sensation. Importantly, this study demonstrates that chiropractic care can be as effective for managing CTS as non-surgical medical care.

De Quervain’s Tenosynovitis

De Quervain’s tenosynovitis is an entrapment tendonitis involving the tendons of the abductor pollicis longus and extensor pollicis brevis. This condition produces lateral wrist and thumb pain that is exacerbated upon repetitive thumb movements (i.e. texting) or with resisted thumb extension (5, 77). The Finkelstein’s Test has long been associated with de Quervain’s tenosynovitis, but this test has minimal research supporting its use. We were only able to locate a single study that showed Finkelstein’s Test to have a +LR = 1.62 and a -LR = 0.38 (78). Therefore, a positive Finkelstein’s Test has little-to-no impact on ruling in de Quervain’s, while a negative Finkelstein’s Test may have some impact on ruling out the condition.

Limitations

This report is a narrative review; therefore, the selection of relevant reference articles is subject to selection bias and the search results are less reproducible than in a systematic review of the literature. While we attempted to select reference materials with the highest methodological rigor, we did not formally grade all the articles used in this report.

Conclusion

The purpose of this article is to provide clinicians with evidence-based information regarding orthopedic tests for upper extremity conditions. Unfortunately, relatively few of orthopedic tests reported to be useful for the upper extremity have demonstrated meaningful clinical utility. This is not to say that orthopedic tests without established validity are completely without value, but rather they should not be used in isolation. We encourage clinicians to emphasize orthopedic tests that have been shown to have the greatest utility in the interest of improving efficiency as well as diagnostic accuracy.

List of Abbreviations

∞ = infinity

+LR = positive likelihood ratio

-LR = negative likelihood ratio

AROM = active range of motion

CTS = carpal tunnel syndrome

ERLS = external rotation lag sign

GHI = glenohumeral instability

OA = osteoarthritis

RCT = rotator cuff tear

ROM = range of motion

RA = rheumatoid arthritis

SJC = shoulder joint comple

Competing Interests: The authors declare that they have no competing interests related to this work.

Author’s Contributions

CBR conceived this project, contributed to the literature review, and participated in the drafting and revisions of this work. MA contributed to the literature review, drafting, and revisions of this work. Both CBR and MA met criteria to substantiate their authorship of this manuscript.

Acknowledgements

None.

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