non-traumatic joint pain: upper extremity

Repetitive strain → muscle imbalance, fascial restriction, impaired lymphatic/venous return.

how do overuse disorders contribute to somatic dysfunctions?

gentle techniques (indirect MFR, BLT, lymphatics), avoid high-force manipulation.

OMT focus of arthritic conditions (RA, OA)

facilitated segments model

Repeated irritation (somatic or visceral) at a spinal segment lowers the threshold for activation → persistent hyperexcitability → pain, altered reflexes, tissue texture changes.

T2-8

sympathetics of the upper extremities

chronic cuff tear

supraspinatus/infraspinatus muscle wasting may indicate

rotator cuff injury

DDx of shoulder ROM where active is more limtied than passive

adhesive capsulitis or arthritis

DDX if both active and passive shoulder ROM are limited

neer, hawkins-kennedy

special tests for subacromial impingement

neer test

impingment test of subscalpular n/supraspinatus

hawkins-kennedy test

compression of the supraspinatus tendon against the coracoacromial ligament to assess the possibility of impingement of the subacromial bursa

drop arm test, empty can (Jobe's) test, external rotation lag

tests for rotator cuff tear

drop arm test

identifies tear and/or full rupture of rotator cuff

Empty Can Test/ Supraspinatus Test

Purpose: Assess supraspinatus involvement with shoulder injury.

Method: Pt. raises arms in scaption to shoulder height with thumps up. Pt rotates thumbs down ( "empty can" ). PT applies resistance.

Positive Test: Pain or weakness

apprehension test, relocation test, O'Brien's

tests for labral injury/instability

apprehension test

movement of a joint while observing the patient for signs of pain and increased joint laxity, to assess joint stability

Relocation Test

tests for anterior glenohumeral instability

O'Brien Test

tests for SLAP lesion

speed's, yergason's

test for biceps tendon

speed's test

stretching or lengthening of the biceps tendon to assess the possibility of tenosynovitis

Yergason's Test

pt in sitting with shoulder in neutral/stabilized against trunk, elbow flexed 90 deg and forearm pronated. PT places one hand on patient's forearm and other over bicipital groove. pt instructed to actively supinate and laterally rotate against resistance. (+) tendon of biceps long head will "pop out" of groove, (+) pain or tenderness in bicipital groove. Identifies bicipital tendonitis and integrity of transverse ligament.

cross arm adduction

test for AC joint

anterior dislocation

most common type of shoulder dislocation

anterior shoulder dislocation

Arm held abducted and externally rotated.

Loss of normal rounded deltoid contour ("squared-off" appearance).

Humeral head palpable anteriorly.

Apprehension test positive (patient resists abduction/external rotation).

anterior: abducted and externally rotated

posterior: adducted and internally rotated

how is the arm held in anterior vs posterior dislocation

light bulb sign on AP view

XRay sign of posterior dislocation

inferior dislocation

what type of dislocation?

Arm locked in abduction, humeral head inferiorly displaced.

rotator cuff tendonitis

Pain with overhead activity, often gradual onset; worse at night lying on shoulder

rotator cuff tendonitis

Painful arc of abduction (70-120°), pain with resisted cuff testing (empty can, external rotation), strength usually intact

Compression of supraspinatus tendon & bursa under acromion; insidious pain with overhead motion

what causes impingement syndrome?

impingement syndrome

Positive Neer and Hawkins-Kennedy tests; painful arc; no true weakness unless tear develops

subacromial area

name area of palpation

subacromial bursitis

-Acute or subacute pain after overuse or trauma; diffuse lateral shoulder pain

-Pain with passive ROM and palpation of subacromial area; often pain throughout motion, not just arc; weakness due to pain inhibition, not tendon tear

subacromial bursitis

diffuse tenderness, pain with passive + active ROM, weakness from pain not structural tear.

spencer technique

A 7-step articulatory technique for glenohumeral joint dysfunction; can be applied in arthritis, adhesive capsulitis, or restricted ROM.

lateral recumbent, physician behind

position of patient for spencer technique

1. Extension - move humerus posteriorly.

2. Flexion - move humerus anteriorly.

3. Circumduction with compression - small circles while pressing humerus into joint.

4. Circumduction with traction - small circles while distracting humerus.

5. Abduction & adduction - move arm away from and toward body.

6. Internal rotation - elbow flexed, hand behind back, move further posterior.

7. Pump (lymphatic technique) - apply gentle springing pressure to humeral head.

what are the steps of spencer technique?

Every Fancy Cat Takes An Indoor Dump

Extension: Move the arm into extension while stabilizing the shoulder girdle.

Flexion: Move the arm into flexion while stabilizing the shoulder girdle.

Circumduction with Compression: Apply gentle compression through the elbow while moving the arm in small, rhythmic circumduction circles.

Circumduction with Traction: Apply traction to the arm and perform small circumduction circles.

Adduction with External Rotation: Guide the patient's hand to their opposite shoulder, inducing adduction and external rotation.

Abduction: Move the arm into abduction while stabilizing the shoulder girdle.

Internal Rotation: Have the patient place their hand behind their back and bring the arm into internal rotation.

what is the mnemonic for the steps of spencer's technique?

spencer technique

this technique helps improve range of motion, especially in pts with adhesive capsulitis

adhesive capsulitis

extreme stiffness of the shoulder joint (a.k.a. frozen shoulder)

Lateral Epidondylitis (tennis elbow)

elbow pain with resisted wrist extension indicates

medial epicondylitis

elbow pain with resisted wrist flexion indicates

radial tunnel syndrome

elbow pain with resisted supination indicates

UCL injury MOI

elbow valgus stress test (medial elbow instability) indicates

Lateral Epidondylitis

elbow pain caused by overuse of wrist extensors

medial epicondylitis

elbow pain due to overuse of wrist flexors/pronators

radial head fracture

post-trauma, pain with pronation/supination.

cubital tunnel syndrome

numbness/tingling 4th-5th digits, worsens with elbow flexion.

extensor carpi radialis brevis

most likely muscle involved with lateral epidondylitis

radial head often restricted in posterior motion

-prefers supination, anterior radial head

osteopathic findings (radial head) typical of lateral epicondylitis

common flexor tendon, pronator teres, flexor carpi radialis

tendons/muscles associated with medial epidondylitis

radial head often restricted in anterior motion (prefers pronation, posterior radial head)

radial head findings associated with medial epicondylitis

posterior radial head

from FOOSH (fall on outstretched hand) → difficulty with supination.

anterior radial head

from fall backward on extended arm → difficulty with pronation.

Physician pronates and flexes wrist to barrier.

Patient gently tries to extend/supinate against resistance (isometric).

Hold 3-5 seconds, relax, repeat → new barrier.

muscle energy for lateral epicondylitis

Patient supine/seated.

Physician supinates and extends wrist to barrier.

Patient gently tries to flex/pronate against resistance.

Hold 3-5 seconds, relax, repeat → new barrier.

muscle energy for medial epicondylitis

Phalen's, Tinel's, carpal compression test.

special tests for carpal tunnel

Phalen's test

test for carpal tunnel syndrome

Froment's sign

test for cubital tunnel syndrome

radial nerve entrapment

wrist drop, sensory loss dorsum hand indicates this nerve injury

Finkelstein's test

special test for de Quervain's tenosynovitis

carpal tunnel syndrome

numbness/tingling in thumb, index, middle fingers; worse at night; thenar weakness/atrophy.

cervical radiculopathy (C6-8)

neck pain with radiation, dermatomal distribution.

Wrist splint in neutral, especially at night.

NSAIDs, corticosteroid injection if severe.

Ergonomic adjustments.

medical management of carpal tunnel syndrome

-MFR of transverse carpal ligament

-thenar/hypothenar release

-cervical/thoracic/somatic dysfunction

OMM techniques for carpal tunnel syndrome

Thumb spica splint, NSAIDs, corticosteroid injections if refractory.

Avoid repetitive thumb abduction/ulnar deviation.

medical management of de Quervain's tenosynovitis

abductor pollicis longus + extensor pollicis brevis tendons

de Quervain's tenosynovitis is inflammation of what tendons?

MFR of wrist

counterstrain tenderpoint near radial styloid

muscle energy

forearm prontation/supination

osteopathic treatment for dQT

near radial styloid → position thumb into flexion/adduction with slight ulnar deviation.

tenderpoint associated with dQ tenosynovitis

Place wrist into extension barrier.

Patient gently flexes wrist against resistance.

Hold 3-5 sec, relax, move to new barrier. Repeat.

muscle energy technique for carpal tunnel

Stabilize wrist in mild adduction.

Patient gently abducts thumb against resistance.

Repeat cycles of isometric contraction and relaxation.

muscle energy technique for de Quervain's

Rest: prevents further injury, allows initial healing.

Ice: vasoconstriction → reduces blood flow, inflammation, and pain. Apply 15-20 min every 2-3 hrs for first 48 hrs.

Compression: decreases swelling/edema; use elastic bandage or sleeve (ensure circulation intact).

Elevation: above heart level → promotes venous/lymphatic drainage, decreases edema.

role of RICE therapy

Diclofenac gel (Voltaren)

topical NSAID for localized pain

Pendulum swings (Codman's exercises).

Wall crawls (finger walk up wall).

Resistance band external/internal rotation.

shoulder home exercises for rotator cuff tendonitis, impingement

Codman's exercises

Finger tip wall walking exercises to restore shoulder movements