Practical Teaching Session – 2 hour session on Soft Tissue Lesion Upper Limb.

Shoulder

The Painful Arc Sign: To test for the presence of sub-acromial impingement.

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator.

2. Positions simulator in standing position.

3. Performing the Test: The patient is instructed to actively elevate the arm in the
scapular plane, and then slowly reverse the motion.

3. The test is considered positive if the patient has pain between 60- 120 degrees
of
scaption during elevation.

Neer Test

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator
2. Purpose of Test: To test for the presence of sub-acromial impingement.
3. Positions the simulator in sitting or standing.
4. Stabilizes the scapula and with the thumb pointing down and passively flex the arm.
5. Pain indicates positive test.

Drop Arm Test (Rotator Cuff)

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator.
2. Passively abduct the shoulder to 90 degrees, flex to 30 degrees and point
thumbs down.
3. The test is positive if the patient is unable to keep arms elevated after the
examiner releases.
4. If the rotator cuff (especially the supraspinatus) is torn, the patient will be unable
to lower the arm slowly and smoothly but drop the arm.

Impingement Sign (Rotator Cuff)

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator.
2. Starts with the patient's arm relaxed and the shoulder in neutral rotation.
 3. Abducts the arm to 90 degrees.
4. Significant shoulder pain as the arm is raised suggests an impingement of the
rotator cuff against the acromion.

Empty Can Test

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator
2. Passively abduct the shoulder to 90 degrees, flex to 30 degrees and point thumbs down. 
3. In this position, provides resistance as the patient lifts upward.
4. Pain or weakness suggests possible tendinonopathyT or tear.

Hawkins Test

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator
2. Hawkins Test assesses for possible rotator cuff impingement. 
3. Stabilizes the scapula, passively abduct the shoulder to 90 degrees, flex the
shoulder to 30 degrees, flex the elbow to 90 degrees, and internally rotate the
shoulder.
4. Pain is a positive test.

Speed's Test

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator.
2. Purpose of Test:  To assess the integrity of biceps tendon or labrum.
3. Positions the simulator in sitting or standing.
4. Starts with the patient’s arm in 90 degrees of shoulder flexion.
5. Have the patient resist a movement into extension, a first time supinated and a
second time with the arm pronated. 
6. A positive test is considered if there is significantly greater pain in the bicipital groove
with the arm supinated.

Yergason's Test
1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator
2. A provocative test that assesses for long head of the biceps tendon pathology.
3. Positions simulator in Sitting or standing.
4. The examiner stands next to the patient on the testing side.
5. The patient’s elbow is flexed to 90 degrees and resting in a pronated position.
6. The patient is instructed to supinate the forearm and flex the elbow while the
examiner applies a pronation force, resisting the supination ad flexion .
7. While performing the test, the examiner is palpating the biceps tendon at the
bicipital groove.
8. The test is considered positive if you have localized pain at the bicipital groove or
a snapping of the biceps tendon out of the bicipital groove. 

Anterior Apprehension Test

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator
2. To assess for anterior instability of the glenohumeral joint capsule.
3. Positions the simulator in supine
4. The examiner flexes the patient’s elbow to 90 degrees and abducts their
shoulder to 90 degrees.
5. The examiner then slowly externally rotates the patient’s shoulder.
6. The test is considered positive if the patient demonstrates apprehension during
shoulder external rotation.

Posterior Apprehension
1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator
2. Purpose: To test for posterior glenohumeral capsular laxity and/ or posterior
labrum.
 3. Positions simulator in supine.
4. The examiner places the tested arm in 90 degrees shoulder flexion, neutral
rotation, and 100-105 degrees of horizontal adduction.
5. Next, the examiner places their other hand underneath the patient's scapula for
support & applies a force through the long axis of the humerus. Assess the
patient's response.
6. A positive test is indicated if the long axis force reproduces a sense of
apprehension and increased muscle guarding to prevent posterior shoulder
dislocation. 

Elbow

Lateral Epicondylitis: Resisted wrist extension

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator
2. Positions the simulator in seated position.
3. Asks simulator to make fist & extends the wrist
4. Pushes down on wrist against resistance.
5. Positive sin if the extensor origin region is painful.

Medial Epicondylitis: Resisted wrist flexion

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator.

2. Positions the simulator in seated position

3. Asks simulator to make fist & flexes wrist in supination

4. Examiner tries to extend wrist

5. At same time you may apply pressure to flexor tendon origin

6. Resisted forearm pronation

7. More reliable than resisted wrist flexion

8. Due to pronator teres eccentric contraction

Valgus Stress Test (MCL most important stabilizer/Common in throwing athletes
because throwing causes valgus stress at elbow).

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator
1. To determine the presence of medial collateral ligament tear of the elbow.
2 Positions simulator in seated position
3. The affected elbow is placed in 20 degrees of flexion with the humerus in full
lateral
rotation and a neutral forearm while palpating the medial joint line. 
5. Applies a valgus force to the elbow. 
6. If the patient experiences pain or excessive gapping compared to the contralateral
side the test is considered positive.   

Varus Stress Test

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator
2. Purpose: To determine the presence of lateral collateral ligament tear of the
elbow.
3. Positions simulator in seated position.
4. Performing the Test: The affected elbow is placed in approximately 20 degrees of
flexion with the humerus in full medial rotation while palpating the lateral joint
line. 
5. Applies a varus force to the elbow. 
6. If the patient experiences pain or excessive gapping compared to the
contralateral side the test is considered positive.  

Wrist & Hand

Finkelstein’s test
1. Introduces oneself and explains the purpose of procedure and obtains inform
 consent from simulator.
2. Positions simulator in seated position.
3. Instructs simulator to flex thumb down across the palm of the hand, and then
cover the thumb with 4 fingers.

4. Instructs to ulnar deviate wrist and if this causes pain, it is likely positive sign of
De
Quervain's tenosynovitis
Phalen’s test (Median Nerve)
1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator.
2. Positions simulator in seated position.

3. Asks the simulator to press the back of the hands together with the wrists fully
flexed
4. Asks to hold this position for 60 seconds and then comment on how the hands
feel.
5. Pain, tingling, or other abnormal sensations in the thumb, index, or middle fingers
strongly suggest carpal tunnel syndrome.

Tinel’s sign (Median Nerve/Ulnar nerve)

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator.
2. Positions simulator in seated position.

3. Uses the middle finger or a reflex hammer to tap over the carpal tunnel.
4. Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome.
5. Tap over medial aspect of elbow between medial epicondyle and olecranon for
ulnar nerve

Murphy's Sign- Dislocation of the lunate.

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator.
2. Positions simulator in seated position.
3. Asks the patient to make a fist
4. As the examiner, visually inspect the dorsal aspect of the hand.
5. Normally the knuckle formed by the head of the third metacarpal is more
prominent and protrudes further distally as compared to the knuckles of the second
and fourth metacarpal heads.
6. If the knuckle of the third metacarpal head is level with the knuckles of the
second and fourth metacarpal heads, the sign is positive and indicative of a lunate
dislocation

Anatomical Snuffbox Compression Test

1. Introduces oneself and explains the purpose of procedure and obtains inform
consent from simulator.
2. Positions simulator in seated position
3. Asks simulator to rest the involved forearm on the table.
4. Asks the simulator to extend the thumb so that these tendons become prominent.
5. The anatomical snuff box is formed by space between the abductor pollicis
longus and extensor pollicis brevis tendons on the radial border and the extensor
pollicis longus tendon on the ulna side.
6. Press in the anatomical snuffbox, applying compression to the scaphoid bone.
7. Pain with palpation of the snuffbox is indicative of a scaphoid fracture, particularly
if the patient also has pain in the same area with passive wrist hyperextension.

Boutonniere Deformity Test

1. Positions the patient with the forearm in pronation and the hand relaxed on the
table surface.
2. Assesses central slip integrity of the extensor tendon at the PIP joint
3. Grasp the proximal phalanx and stabilize the metacarpophalangeal joint in
extension.
 4. Instruct the patient to actively extend the P.I.P. joint. If the patient is unable to
actively extend the P.I.P. joint, an avulsion of the extensor tendon central slip is
indicated.
5. This represents a boutonniere deformity, which is characterized by
hyperextension of the D.I.P. joint with the P.I.P. joint assuming a position of
flexion.

Mallet Finger Test

1. Positions the patient with the forearm in pronation and the hand relaxed on the
table surface.
2. Assesses extensor tendon integrity at the DIP joint.
3. Isolate the tendon by holding the involved finger at the middle phalanx. Begin
with the D.I.P. joint relaxed in flexion.
4. Instruct the patient to extend the D.I.P. joint. Inability to extend the D.I.P. joint is
indicative of extensor tendon avulsion at its attachment on the base of the distal
phalanx.

Allen Test

1. Instructs the simulator to make a tight fist and open it fully three or four times.
2. This test determines whether or not the radial and ulnar arteries are supplying
the hand to their full capacities.
3. While the simulator is holding the last fist, the evaluator places compression on
either the radial or ulnar artery. If upon release, blood fails to return to the palm
and fingers, an obstruction to the artery's blood flow is possible.

Flexor Digitorum Superficialis Test

1. Positions the patient with the forearm in supination and the hand relaxed on the
table surface.
2. Assesses flexor digitorum superficialis tendon function.
 3. To isolate the involved tendon, holds the simulator’s fingers in extension, except
for the one being tested.
4. Then have the patient flex the involved finger at the P.I.P. joint. If the patient can
actively flex the P.I.P. joint, the tendon is intact. If not, the tendon may be cut or
ruptured

Flexor Digitorum Profundus Test

1. Positions the patient with the forearm in supination and the hand relaxed on the
table surface.
2. Position the patient with the forearm in supination and the hand relaxed on the
table surface
3. Assesses flexor digitorum profundus tendon function.
4. Isolate the tendon by holding the patient's fingers in extension, except for the
involved finger.
5. You should further isolate the D.I.P. joint by maintaining the M.C.P. and P.I.P.
joints of the affected finger in full extension.
6. Then have the patient flex the finger in question at the D.I.P. joint. If the patient
can actively flex the D.I.P. joint, the tendon is intact. If not, the tendon may be cut
or ruptured.