Upper Extremity

Differentials

Diagnosing pain experienced in the distal extremities often includes not only local pathology but also that arising from the trunk. The functionally open-chain upper extremity is no exception:

• Systemic: Arthritides (e.g. Rheumatoid), Gout, RSD

• Neurogenic: Radicular pain, radiculopathy with/without discopathy, peripheral entrapments (Radial, Median, Ulnar nerves),

• Vascular: chemical, artery disease, DVT

• Muscles: Intrinsic hand muscles, wrist extensors, wrist flexors, extensors/flexors of the elbow

• Osseous: Fractures, joint mobility issues

Anatomy

Assessments

Certainly first consider pathoanatomical axial structures and shoulders, including vascular exams. Then, for elbows recall Cozen’s, Mill’s, Golfer’s, AB/ADduction Stress Tests. For wrists consider Phalen’s, Prayer, Finkelstein’s, English, and Froment’s. While these look to rule-in certain conditions, it’s often unnecessary if performing O’Donahues correctly. Quick reminder on Froment’s… the adduction is caused by adductor pollicus which is innervated by the ULNAR nerve!

In assessing peripheral nerves, initial investigation should include Nerve Tension Testing. Following this up with tinel taps or entrapment release strategies (my preference) . I’ll save entrapment release strategies for another blog, but here is a list of nerve entrapment sites to consider:

Median Nerve: Carpal Tunnel, Flexor digitorum, Ligament of Struthers, Pronator Teres, Thenar muscles

Ulnar Nerve: Flexor Carpi Ulnaris (and at Pronator Quadrates), Hypothenar mm., Subscap, Medial Intermusc. Septum/Triceps, Tunnel of Guyon

Radial Nerve: Spiral Groove, Arcade of Frohse, Brachioradialis/Brachialis, Extensor mm, Lateral Intermusc. Septum, Supinator, Superior Radial Tunnel