Examination of Upper Quarter Neurogenic Pain Jane Fedorczyk, PT, PhD, CHT Thomas Jefferson University, Philadelphia, PA Center of Excellence for Hand and Upper Limb Rehabilitation

I. History

Mechanism of Injury: Trauma? Co-morbidities: metabolic disorders, obesity, respiratory conditions, Occupational risk factors: prolonged periods of time in non-neutral postures, especially arms overhead Rule out: cervical pathology, shoulder pathology, myofascial pain, injury to long thoracic nerve, dorsal scapular nerve, suprascapular nerves

Pain Assessment – Patient Interview (location/nature of symptoms), Body Diagram

II. Observation and Examination: Tests and Measures

Posture Assessment – Forward Head, Protracted Shoulders – Scapula Position and/or Dyskinesias – Presence of anti-tension postures

Breathing Pattern: use of accessory muscles

UQ Screen – Cervical spine examination necessary? – Shoulder examination necessary? – For now, what does cervical motion, especially lateral flexion or rotation tell you?

TOS Provocative Tests – see last page Adson’s Wright’s Costoclavicular Roos or EAST

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Regional Special Tests for Nerve Compression

Elbow Flexion Test (Cubital Tunnel) Phalen’s or Reverse Phalen’s (Carpal Tunnel/ Ulnar Tunnel)

Sensibility Testing: dermatomes with UQ Screen; screen for radial, ulnar, and median nerves in the hand

Strength: review MMT

– Test key muscles (one high/one low) for radial, ulnar, and median nerves in the hand and forearm – Grip & Pinch Strength – Abdominals/Core Strength – Scapula Stabilizers: trapezius, serratus anterior

Muscle Length

– Latissimus Dorsi – Pectoralis Minor and Major – Scalenes (anterior, middle)

Assessment of Adverse Neural Tension

Active Dysfunction – Patients willingness to move when asked to bring arm up over your head (Active abduction / forward flexion) – Observe - cervical spine and extremity joint positioning

Passive Dysfunction: Upper Extremity Neurodynamic Testing

Median: Abduction/External Rotation Supination Wrist/Finger Extension Elbow Extension Shoulder Depression and/or Cervical CLF 2 Ulnar: Abduction/External Rotation Pronation or Supination Wrist/Small Finger Extension Elbow Flexion Shoulder Depression and/or Cervical CLF

Radial: Abduction/Internal Rotation Pronation Wrist/Thumb-Index Flexion Elbow Extension Shoulder Depression and/or Cervical CLF

Palpation: Neural Hyperalgesia

Brachial Plexus: Posterior Triangle – Trunks Axilla – Cords

Median Nerve: Medial Humerus Medial to Biceps Pronator Carpal Tunnel

Ulnar Nerve: Medial Humerus Cubital Tunnel FCU Origin Ulnar Tunnel: Pisiform Hook of Hamate Dorsal Ulnar Cutaneous Nerve

Radial Nerve: Spiral Groove Lateral Epicondyle Radial Tunnel Radial Sensory – BR insertion

Tender Spots/Points Tender points in tissues innervated by the peripheral nerve or cervical segment involved

Local Cervical Segment Dysfunction Segmental stiffness in the cervical spine for the segmental levels composing the brachial plexus and/or the peripheral nerves involved.

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Carpal Tunnel Syndrome Phalen’s and Reverse Phalen’s Durkan’s Carpal Compression Test Berger’s Lumbrical Provocation Test

Pronator Syndrome or Proximal Median Nerve Entrapment Resisted Elbow Flexion Resisted Pronation Resisted Finger Flexion

Comparison of Clinical Signs and Symptoms:

Carpal Tunnel Pronator Syndrome/Proximal Median Nerve

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Cubital Tunnel Ulnar/Guyon’s Tunnel Elbow Flexion Test Phalen’s Reverse Phalen’s Wartenburg’s Sign Froment’s Sign Claw Deformity

What are the differences in sensory changes between Cubital Tunnel Syndrome and Ulnar Tunnel Syndrome?

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Radial Tunnel Syndrome Resisted Middle Finger Extension Resisted Supination Mill’s Maneuver Tennis Elbow Test (Cozen’s)

Wartenburg’s Syndrome – irritation of the DSRN Finklestein’s Test

How do you differentiate between Radial Tunnel Syndrome and Tennis Elbow?

How do you differentiate between DSRN irritation and DeQuervain’s?

6 Patient Name: Date: Upper Quarter Screening Examination Form

Inspection: Myotome Scan

 Forward Head Posture Weakness Pain  Asymmetry Shdr Shrug (C2,3,4)    Muscle Atrophy Shdr Abduct (C5)    Deformity Elbow Flex (C5-6)   Elbow Ext (C7)   Wrist Ext (C6)   Cervical Spine (AROM + Passive overpressure) Wrist Flex (C7)   Thumb Abd (C8)   Pain ROM Finger Abd/Add (T1)   Flex    R Rot    L Rot   Sensory Scan (light touch) R SideBend   L SideBend   Diminished Ext   Supraclavicular (C4)   Anterolat Arm (C5)   Lat forearm/thumb (C6)  Distraction  Middle finger (C7)  Compression  Ulnar hand (C8)  L Spurling’s  Medial forearm (T1)  R Spurling’s  Apex of axilla (T2) 

 Neural Tension Symptoms Joint Scan (AROM + Passive overpressure) Shoulder abduct/ext rot  + elbow ext Pain ROM + wrist/finger ext Shoulder Elev   Elb Flex (pron/sup)   Elb Ext (pron/sup)   Palpation / Neural Compression  Deep Tendon Reflexes Symptoms Brachial Plexus  Left Right Radial tunnel  Biceps + 1 2 3 4 + 1 2 3 4 Cubital tunnel  Brachioradialis + 1 2 3 4 + 1 2 3 4 Carpal tunnel  Triceps + 1 2 3 4 + 1 2 3 4

             Adson’s Wright’s Maneuver Test     The extremity remains supported in the patient’s lap and the patient performs rotation and extension of the cervical spine to the tested side. The patient takes a deep breath, which is held between 10 – 30 seconds. The examiner palpates the radial pulse for obliteration, decreased rate or intensity of beat. Sensory complaints may also be reproduced.                   Roos = EAST Costoclavicular Maneuver   

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