Hello and welcome to episode 110 of the Physician Assistant Exam Review Podcast. This week we’re going to be covering the upper extremity. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. And a long time ago, I decided to put this podcast out there to help students get through PA school and ultimately pass the PANCE and find their dream job. That was really my goal. Some of you may not know this.

In the beginning of some of these episodes, I say season two because this is episode 110, but that’s really not true. This is season two. It’s my second time going through the blueprint. I’ve learned things. I’ve created new ways of studying and thinking about test taking, thinking about, what do you call it? Thinking about studying, thinking about test taking, thinking about how to be a better PA, be a better PA student. So I decided to go through the entire blueprint a second time.

And that’s where we are right now. We’re actually more than halfway through it the second time, and I may very well start it again. But anyway, that’s why sometimes you’ll hear me say season two. I sort of stopped doing that at episode 110. It started to seem irrelevant. So I just wanted to let you know that. But this week, we are going to be covering the upper extremity.

We’re going to continue through musculoskeletal. If you’d like to get, I grabbed 25 questions from The Final Step, my short question book, and I’m going to make those available to you at physicianassistantexamreview.com/msk. If you head over to that webpage, you’ll be able to get your hands on those 25 questions. They’re similar to the priming questions, which we’re about to get into, and they will help you to see, to pull out the most relevant information and to store it easily in your mind so that you can grab onto it when you need it.

All right, so without further ado, let’s jump right into the priming questions for today. Name the four rotator cuff muscles, the four muscles of the rotator cuff. Name the four muscles of the rotator cuff. Tennis elbow refers to lateral or medial epicondylitis. Tennis elbow refers to lateral or medial epicondylitis? What is the most commonly injured rotator cuff muscle? What is the most commonly injured rotator cuff muscle?

We have five today. Describe Phalen’s sign. Describe Phalen’s sign. And lastly, what does a fat pad sign indicate? What does a fat pad sign indicate? The point of those questions is to get your brain thinking, to get you involved here, right? I always talk about active studying.

I always talk about putting your brain into what you’re doing, not just sitting passively and listening, right? So I want you to be thinking as we go through this, what are the four muscles of the rotator cuff? Which one is lateral epicondylitis? Which one is medial epicondylitis? Which one, what is the most injured rotator cuff muscle? What are the signs and tests we have throughout this section. There’s a lot of those.

This is an easy section to ask questions about what tests, what physical exam tests you should be doing. You should be keeping a track of those as we go through this. And then lastly, you should be thinking when you hear the term fat pad sign, that should jump out at you today as we go through this. This is not a passive idea. This is supposed to be you participating here with me. I know you’re not here with me sitting across from me, but I need your brain engaged. I need you thinking as we go through this today.

All right, upper extremity. So a couple of things to know about upper extremity. During evaluation, consider cervical nerve issues. Consider cervical nerve issues. You may not get them on your test. In fact, you probably won’t get them on your test, but in the clinic, you will absolutely see nerve issues, cervical nerve issues which are presenting themselves through the upper extremities, right? So keep that in mind as you’re doing this.

Let’s talk about the shoulder to begin with, joints of the shoulder, the acromioclavicular joint, the AC joint. This is between the acromion and the clavicular, or the clavicle, clavicular. This is going to be a tough show. I hope you’re ready. The glenohumeral joint, which is where the glenoid at the end of the scapula, and then the humerus sits right up against it. The glenohumeral joint. That’s what we’re replacing when we do a total shoulder replacement.

We’re placing the glenohumeral joint, and we’re replacing the head of the humerus. Muscles of the rotator cuff. These are the SITS muscles, right? Because that’s the acronym for them, because it’s supraspinatus, infraspinatus, teres minor. And subscapularis. So, the first letter of each of those spells out SITS. It’s any I’m not a huge fan of acronyms and mnemonics, but in this case, I think that’s a pretty short one.

It’s not hard to remember, so you’re not taking extra work to remember. I find that if I use mnemonics, I tend to spend more energy remembering the mnemonic than I do just trying to remember the thing itself, and I’ll get to that later on today, how that affects what you learn. The supraspinatus. This abducts the arm, and this is the most commonly injured muscle of the rotator cuff. So, you caught one already, right? The infraspinatus externally rotates the arm, the teres minor externally rotates the arm, and the subscapularis internally rotates the arm. If I were getting ready for my PANCE or I was getting ready for a medicine test on the upper extremity, I would absolutely know the functions of those.

Osteoarthritis of the AC joint is where we’re going to begin today’s discussion. This is a clinical presentation here is pain in the anterior of the shoulder right at the AC joint. A good test for this is the crossover test that squeezes the AC joint and causes pain there. Pain relief with an injection of lidocaine into the AC joint is one way to diagnose this, right? So if they have pain in that joint and you inject it with lidocaine and the pain goes away, you’re pretty confident that that’s what’s going on here. And an x-ray of the shoulder can show signs of arthritis there. Treatments.

So you can do a steroid injection, NSAIDs, ice, physical therapy, and then finally surgical repair. That’s going to consist of excision of the distal clavicle. So that’s going to be a scope, right? It’s going to be usually arthroscopically. I guess it doesn’t have to be, but generally today we do them arthroscopically. We stick a scope into the joint. You stick a bone burr, essentially.

It’s kind of like a little, essentially like a Dremel tool on a long handle that you put into the shoulder. And as you visualize it with the scope, and you burr off the end of the clavicle there, and it opens up that joint.

Next, we have rotator cuff impingement and rotator cuff tears. A rotator cuff impingement is when the rotator cuff becomes pinched underneath the acromion. And a rotator cuff tear is an actual tear in one of the four muscles of the rotator cuff, right? Not that complicated. Causes here are overuse, degeneration over time. Lots and lots of older Americans will have rotator cuff tears, even if they’re asymptomatic. And then trauma.

You can get a rotator cuff tear from trauma. Clinical presentation, increasing shoulder pain and weakness. Patients will come in complaining of not being able to lift their arm above their shoulder. The indicators for this are places where they’ll notice it as a problem. Because again, if this is something that builds up over time and is sort of aggravating, and then there’s not a complete tear, there’s a small tear, and then it grows, you’ll be surprised that people will put off treatment for these kinds of things. But I’m sure you have things that you should probably get looked at that you haven’t. And over time, they get a little worse and a little worse and a little worse.

And then all of a sudden you go in and the doc’s like, holy cow, how come you didn’t come see me? But it was that slow progression, right? So a lot of times what people will present with rotator cuff tears are things like not being able to brush their hair or not being able to clasp, reach back behind their back to undo the clasp of a bra. That sort of maneuver are, you know, or not being able to lift their arm up over their shoulder. Those sort of things are indications of rotator cuff tears. Lab studies and physical exam findings. Like I said, older patients may have asymptomatic rotator cuff tears where they don’t really have pain.

They just sort of lose some motion, but they kind of think that’s part of aging.

Okay, and then as far as your physical exam goes, if you know what the muscles do, the physical exam stuff is pretty easy to hold in your head. This is one of those areas that I’m not going to memorize both. What the muscles do and then how I test them, right? You can learn what the muscles do and then understand how to test them. I hope that makes sense. So if you’re going to check the infraspinatus and the teres minor, how would you do it? Well, you would have the person externally rotate their arm, right?

Because you know that those two muscles are in charge of external rotation. You can do resisted external rotation because if they have a tear, they may be able to do the maneuver, but it may be more difficult with resistance, right? To be pushing against and asking them to do it is different than just asking them to do it without resistance. Resisted internal rotation was going to check what? What is resisted internal rotation going to check? Well, it’s going to check the subscapularis, right? Because the subscapularis is in charge of internal rotation.

A couple other tests you can do. One would be the can emptying test. You have the patient’s arm is abducted and raised to shoulder height. So out in front of them, raised up to shoulder height. The patient then performs internal rotation, so they point the thumb down, so like they’re emptying out a can. Then you push down on the patient’s hands, and if they have pain or weakness, this is going to imply a rotator cuff tear. This movement isolates the supraspinatus.

The drop arm test is if the patient is unable to hold an arm in abduction or actively move the arm into abduction, consider a rotator cuff tear. Since we were talking about impingement as well, a Neer test is where you move the arm in forward flexion and pain is indicative of impingement. And then the Hawkins is the other one here, which is you move the arm into abduction and internally rotate the arm and then again, pain is indicative of impingement. Your x-ray is typically going to be normal, and an MRI is what you’re going to use to diagnose this. Although, again, MRIs are good. They’re not fantastic. They will show a full thickness tear.

They’ll show a large tear, but they can miss things for sure. Treatments for either impingement syndrome or a rotator cuff tear are going to be NSAIDs, ice, rest, something like a COX-2 inhibitor like Celebrex, physical therapy, steroid injections, avoiding repetitive motions that may be attributing or causing pain here. And then finally, surgical correction. The surgery is kind of a bigger deal for a rotator cuff repair. Patients tend to be down for a while. It is not a particularly fun recovery. It is done arthroscopically.

So it’s usually through several small incisions. We rarely, I haven’t done an open rotator cuff repair in probably, I don’t know, five, 10 years. They’re pretty much all done arthroscopically at this point, but it does take some time to recover from this procedure.

Next, we have lateral epicondylitis, which is colloquially referred to as tennis elbow, and this is caused by resisted supination, right? Do you remember the difference here, pronation and supination? So supination is when you take the hand and you rotate the thumb out laterally, and your palm comes up. That’s supination. Pronation is when you put the palm down.

Okay, so tennis elbow comes from resisted supination. Think of the backhand shot that a tennis player makes. They have their arm across their body, and they’re rotating their hand, they’re supinating their hand against the force of the ball. That’s where tennis elbow comes in. Treatment is going to be rest, ice, injection, stop repetitive activity, a counterforce brace will be helpful here, and physical therapy.

Now, the opposite here, we have medial epicondylitis. So what do you think? How do you think you get medial epicondylitis? Well, it’s caused by resisted pronation of the wrist. We call this golfer’s elbow because golfers, well, with the way that they swing the club, get this resisted pronation of the wrist causing a medial epicondylitis. And these people are hurt directly over these epicondyles. This is not a difficult diagnosis.

You can also easily recreate either one. You know, people will come to me with elbow pain and one of the first things you can do is almost like you’re shaking their hand and hold them steady and ask them to supinate and pronate. And they will, if they have one of these conditions, they will have pain at that site, right? Either with supination or pronation. Treatment is going to be rest, ice, injection, stop repetitive activity, counterforce brace, and physical therapy. The biggest thing with these, excuse me, is to shut people down for a while. You know, one problem I’ve seen is with lateral epicondylitis in particular, you can get people who are manual laborers.

So someone who is running, like an electrician comes to mind, someone who’s using a screwdriver a lot and is turning that screw can get a lateral epicondylitis from that resisted supination. If you can picture it, just hold your hand out in front of you and actually do the motion and it’ll help you to retain it. That physical action, think about turning a screw to the right clockwise, that’s going to, over time, is going to cause or may cause lateral epicondylitis.

Next, we have carpal tunnel syndrome. 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. Pretty sure you are aware of that, most of you at this point. The flexor retinaculum is also known as a transverse carpal ligament.

Now, so as the nerves pass through the carpal tunnel, the carpal tunnel inflames, gets compressed, and generally speaking, it’s the median nerve that gets angry, and pinched off. Some risk factors here. Arthritis, right? If we get some arthritis into that space. Obesity, so we’re just jamming it up with stuff. Diabetes, again, same idea. Tumors or hypothyroidism.

All reasons to increase risk for carpal tunnel. Clinical presentation, the patients come in having trouble with the first two to three fingers and their thumb. They get numb and weak, and they can also get a nervy, tingly pain. It’s important to be able to discern the difference between nerve pain with your patients and things like muscle or bone pain, right? You get that burning sensation or that numbness that goes along with the nerve pain. Or the other common complaint is they wake up in the middle of the night and their hand is asleep and it feels like it’s burning. A lot of people will compress that carpal tunnel when they sleep and wake up with much more severe symptoms.

Lab studies and physical exam findings. You can get anesthesia, paresthesia, and possible weakness in the median nerve distribution. So the thumb, index finger, middle finger, and radial half of the ring finger. There should be no paresthesias over the thenar eminence. Although severe cases will have an atrophied thenar eminence. That’s one way you can remember which side of the hand the median nerve innervates is that thenar wasting. If you consider that as the severe case of carpal tunnel, that may help you to remember which side of the hand, which fingers in the hand the carpal tunnel affects and the median nerve affects.

Two signs you should know here for physical exam. Positive Tinel sign is pain and tingling along the median nerve distribution with percussion of the flexor retinaculum. So, if you tap over that carpal tunnel, you may be able to elicit some pain and tingling along that nerve distribution. Phalen’s test is where if you flex the wrists as far as possible and have the patient hold that position. If there’s pain and tingling along the median nerve distribution within 60 seconds, that is considered a positive test. This is more accurate than Tinel. So again, we’re just creating pressure or compression over that carpal tunnel.

And then you can prove this with electromyography. Treatment, number one is going to be to avoid risk factors like repetitive movements, like typing. I’m starting to get a little of this in my right hand from the typing and clicking from sitting behind at this desk. And also from the OR, I found when I was doing a lot, one particular case, if I was doing, it’s an ACDF, it’s an anterior cervical discectomy and fusion. What I’m doing during that case is retracting the esophagus out of the way so the surgeon can operate on the spine from the anterior direction, right? So, but what I’m doing, the retraction I have to do in order to do that, I found was causing me a carpal tunnel for the next two or three days after I would do one of those cases. I haven’t done one in a little bit, so it’s been less of an issue, but that in particular has been a problem for me.

Treatments. So avoid those things that cause the problem. I said earlier that people will wake up with this because they crank on that carpal tunnel when they sleep. I know it sounds kind of weird, but people absolutely do. So a night splint will help this. Just keeps that wrist out of flexion. It keeps that wrist extended overnight.

People won’t like to wear it, but it does help. NSAIDs will help, steroid injections, and then once symptoms are constant, surgical release of the flexor retinaculum is recommended.

All right, let’s start talking about trauma. Actually, on second thought, I think what we’re going to do is split this up again into like we did with lower extremity into two separate shows because there’s still a little bit here to cover more than I want you to hold in your head at one time. So we’re going to quit there for our upper extremity. We’ll get to upper extremity trauma and probably include the ribs into next week because that was another thing. I was debating what I was going to do this week because that was just too long. But I think I’ll stop there and we’ll split it up.

All right. So before we get into our answers, because we got to most of the questions that I wanted to ask, most of the priming question answers already, though.

Let’s get into our study tip for today. Our study tip for today has a lot to do with the priming questions. You hear me talk a lot about active learning, getting involved, getting your brain working, getting you functioning out there, not just sitting and letting the material wash over you, but actually using the material. One way to do that, and I talked about this in the May issue of the Physician Assistant Exam Scholars newsletter, went into great detail, but one great way to do this is to write your own questions. And I went into a ton of detail as to why this works so well, what the capacities are, how it helps you to take tests better, how it helps you to remember better. I went through some of the steps I used to do it, the important points there. But in our limited time here, if you just focus on writing short questions, like what I do for the priming questions, that was a huge method I used throughout PA school.

I probably wrote, I don’t know, 10,000 questions throughout PA school. I started out writing them by hand, realized that that took way too long, started typing them, and then once I typed them, I started distributing them out to my classmates. Some of them didn’t think they were of any value, but a lot of people really liked it and found it helpful. I thought the action of writing the questions was incredibly helpful. Then it gave me a fast way to study. And I was able to retain far more because of something called the testing effect, which has to do with your brain, basically just has to do with your brain working, putting in the work. And what you might find is that by answering questions, you retain things far longer.

That’s what I found. So I started writing these questions, but I found writing the questions was its own value. So again, I’m not going to go into a whole lot of detail here, but certainly there’s enough for you to get started. Look at the priming questions. And that’s essentially what The Final Step is. I wrote that book for myself as I was getting ready for my PANRE. And then I talked about it on the show a long time ago when I initially released it, like 2014, 2015, something like that.

And I just mentioned it here and there. And people started clamoring for it and asking me to release it. So I did. I wound up publishing that book and it’s very much what the priming questions here are because I found that that testing effect was so positive that I got so much out of it. But there’s two parts to it, right? One is answering all those questions. Two is writing all those questions.

Obviously writing them takes longer but there’s value in both pieces. So, anyway, our study tip for today is to write your own questions. I know people think it’s time consuming but people also complain they forget things too quickly, or they have trouble telling what information is important, or what to focus on. And my argument is, writing your own questions will help you retain more information, and it will teach you what to focus on.

All right. Let’s get to answering our priming questions for today. Lateral epicondylitis. Now that we’ve gone through it and we’ve talked about it, do you remember which one is lateral epicondylitis? Was just a few minutes ago. Don’t memorize it. Think about it.

Lateral epicondylitis was caused by resisted supination, right? That’s tennis elbow from the backhand. What’s the most commonly injured rotator cuff muscle? What’s the most commonly injured rotator cuff muscle? The supraspinatus. Describe Phalen’s sign. Describe Phalen’s sign.

Do you remember which one that was? Phalen’s sign was with wrist flexion for 60 seconds to cut off that carpal tunnel. And we’ll answer the fat pad question in the next episode because that has to do with specific fractures. So we’re not going to talk about that today.

All right, fantastic. Well, thank you so much for being part of the show today. Thank you so much for participating. Thank you so much for sharing the show with people who you think it’ll help. Again, if you want access, ooh, sorry, if you want access to the 25 musculoskeletal questions from The Final Step, just go to physicianassistantexamreview.com/msk. We’ll get you to the… we’ll get you there.

All right, take care, good luck, and I’ll talk to you next time.