Upper extremity

During evaluation consider cervical nerve issues
Joints of the shoulder
- Acromioclavicular (AC) joint – Acromion to the clavicle
- Glenohumeral joint – Glenoid is the end of the scapula
Muscles of the rotator cuff – SITS muscles
- Supraspinatus – abducts the arm (This is the most commonly injured muscle)
- Infraspinatus – externally rotates the arm
- Teres minor – externally rotates the arm
- Subscapularis – internally rotates the arm

Osteoarthritis of the AC Joint

Rotator cuff impingement is when the rotator cuff becomes pinched underneath the acromion
A Rotator cuff tear is an actual tear in one of the four muscles of the rotator cuff
Causes
- Overuse
- Degeneration
- Trauma

Older patients may have asymptomatic rotator cuff tears
Resisted external rotation checks infraspinatus and teres minor
Resisted internal rotation checks subscapularis
Can emptying test– patients arm is adducted in and raised to shoulder height. Patient then performs internal rotation (point thumb down) Push down on the patient’s hands. Pain is a bad sign, weakness implies a rotator cuff tear. This movement isolates the supraspinatus
Drop arm test. If a patient is unable to hold arm in abduction or actively move arm in abduction consider rotator cuff tear.
Neer test – Move arm in forward flexion. Pain is indicative of impingement
Hawkins test – Move arm in abduction and then internally rotate the arm. Pain is indicative of impingement
X-ray is typically normal
MRI can diagnose a full thickness tear

This occurs when the median nerve becomes compressed as it passes through the carpal tunnel.
The carpal tunnel is made up of the carpal bones which form an arch and the flexor retinaculum which bridges the arch creating a tunnel.
The flexor retinaculum is also known as the transverse carpal ligament
Carpal tunnel may have risk factors
- Idiopathic/genetic predisposition
- Arthritis
- Obesity
- Diabetes
- Tumor
- Hypothyroidism

I’m having trouble with my first two fingers and my thumb. They feel numb and weak from time to time. They also tingle and kind of burn.
When I wake up in the middle of the night and half my hand feels like it’s burning.

Anaesthesia, paresthesia and possibly weakness in the media nerve distribution.
- Thumb
- Index finger
- Middle finger
- Radial half of the ring finger
There should be no paresthesia over the thenar eminence
Severe case may have an atrophied thenar eminence
Positive Tinel’s’ sign – Pain and tingling along the median nerve distribution with percussion of the flexor retinaculum.
Phalen’s Test – Flex the wrist as far as possible and have the patient hold that position. If there is pain and tingling along the median nerve distribution within 60 seconds this is considered a positive test. This is more accurate than Tinel’s
Electromyography

Avoid repetitive movements (typing)
Night splint
NSAIDS
Steroid injection
Once symptoms are constant surgical release of the flexor retinaculum is recommended