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 Supraspinatus tendinitis is a common inflammatory
condition of the shoulder that causes anterior shoulder
pain.
 Pain is present especially in abduction.
 The painful arc is between 60° and 90° of
abduction.
 Clinical Signs and Symptoms
 Anterolateral shoulder pain
 Pain sleeping on the affected side
 Stiffness
 Catching of the shoulder during use
 Pain on active and passive range of motion
 Local tenderness
 Procedure: Patient seated. Abduct the arm to 90°
with the arm between abduction and forward flexion.
Abduct against resistance.
 Positive Test: Pain or weakness over the insertion of
the supraspinatous tendon may indicate tendinitis or
tear. Pain over the deltoid may indicate a strained
deltoid muscle.
 Procedure: Patient seated. Place hand of affected
shoulder behind head to touch superior angle of
opposite scapula. Place hand behind back to touch
inferior angle of opposite scapula.
 Positive Test: Pain indicates tendinitis of the tendons
of the rotator cuff, usually the supraspinatous tendon.
 The biceps brachii has two heads, the long and the
short.
 The long head travels over the superior aspect of the
humeral head.
 The long head is the tendon affected by bicipital
tendinitis.
 Clinical Signs and Symptoms
 Anterior shoulder pain
 Pain on palpation of the bicipital groove.
 Pain on active and passive elbow flexion and extension.
 Procedure: Patient seated with elbow extended,
supinated, and the shoulder flexed forward to 45°.
Place your fingers in the bicipital groove and your
opposite hand on the patient’s wrist. Instruct the
patient to elevate the arm forward against resistance.
 Positive Test: Pain or tenderness in the bicipital
groove.
 The subacromial bursa overlies the rotator cuff
tendons.
 Usually bursitis is associated with tendinitis of the
adjacent supraspinatus tendon.
 Common causes of bursitis are trauma, overuse,
repeated multiple traumas, and improper executed
activity.
 Clinical Signs and Symptoms
 Anterolateral shoulder pain
 Pain sleeping on the affected side
 Stiffness
 “Catching” of the shoulder during use
 Pain on active and passive range of motion
 Local tenderness
 Procedure: Patient seated. Apply pressure to the
subacromial bursa.
 Positive Test: Local pain suggests inflammation of the
subacromial bursa (bursitis).
 Rotator cuff instability involves partial or complete
tearing of one of the tendons of the rotator cuff.
 Usually the supraspinatous tendon is involved.
 Rotator Cuff Muscles
 Supraspinatus
 Infraspinatus
 Teres Minor
 Subscapularis
 Clinical Signs and Symptoms
 Severe anterior lateral shoulder pain
 Pain when sleeping on the affected side
 Stiffness
 “Catching” of the shoulder during use
 Pain on active and passive range of motion
 Localized tenderness
 Unable to abduct shoulder
 Procedure: Patient seated. Abduct the arm past 90°.
Instruct the patient to lower the arm slowly.
 Positive Test: If the patient cannot lower the arm
slowly or if it drops suddenly, this indicates a rotator
cuff tear, usually of the supraspinatus.
 Procedure: Instruct the patient to abduct the arm to
90°. Grasp the patient’s arm and press down against
resistance by the patient. Next, rotate the shoulder
internally so the thumb points down. Press down
against resistance.
 Positive Test: Weakness or pain may indicate a tear of
the supraspinatus muscle or tendon. It may also
indicate suprascapular neuropathy.
 The biceps brachii has two heads: long and short.
 The long head traverses the bicipital groove.
 A shallow bicipital groove or a lax or ruptured
transverse humeral ligament may snap the biceps
tendon into and out of the bicipital groove.
 This will cause anterior shoulder pain with point
tenderness at the bicipital groove.
 The painful snap may also indicate a tear of the biceps
tendon.
 A bicipital tendon tear will cause swelling and
ecchymosis near the bicipital groove and a
characteristic bulging of the belly of the bicpes muscle
near the antecubital fossa (Popeye sign).
 Clinical Signs and Symptoms
 Anterior shoulder pain
 Stiffness
 Pain on active and passive range of motion
 Localized tenderness
 Bulging of biceps muscle (complete tear)
 Procedure: Patient seated with elbow flexed to 90.
Stabilize the patient’s elbow with one hand. Grasp the
patient’s wrist and have him externally rotate the
shoulder and supinate the forearm against resistance.
 Positive Test: Local pain or tenderness in the bicipital
tendon indicates an inflammation of the biceps
tendon or tendinitis. If the tendon pops out of the
bicipital groove, suspect a lax or ruptured transverse
humeral ligament or a congenital shallow bicipital
groove.
 Lateral epicondylitis is a repetitive strain injury of the
common extensor tendon at thelateral epicondyle of
the humerus.
 Symptoms persist because of constant traction
movement of the wrist and hand.
 Clinical Signs and Symptoms
 Local lateral elbow pain
 Weakness of the forearm
 Procedure: Patient seated. Stabilize forearm. Patient
should make a fist and extend it against resistance.
 Rationale: The tendons that extend the wrist attach to
the lateral epicondyle. Forcing the extended wrist into
flexion will exacerbate the pain if the tendons are
inflamed.
 Procedure: Patient seated. Instruct the patient to
pronate the arm and flex the wrist. Then, instruct
them to supinate against resistance.
 Rationale: The supinator tendon is attached to the
lateral epicondyle. If pain is elicited, suspect
inflammation of the lateral epicondyle.
 Medial epicondylitis is a repetitive injury of the
common flexor tendon at the medial epiconsyle of the
humerus.
 Symptoms persist due to constant traction and
movement of the wrist and hand.
 Clinical Signs and Symptoms
 Local medial elbow pain
 Weakness of the forearm
 Procedure: Patient seated. Instruct the patient to
extend the elbow and supinate the hand. Then,
instruct the patient to flex the wrist against resistance.
 Rationale: The tendons that flex the wrist are attached
to the medial epicondyle. If pain is elicited, suspect
inflammation of the medial epicondyle.
 Neuropathy and compression syndromes of the elbow
are peripheral neurological disorders.
 They are caused by trauma, overuse, arthritis, and
postural considerations.
 Paresthesia and weakness of the forearm and/or hand.
 The ulnar nerve is most often affected.
 Compression occurs in the groove between the
olecranon process and the medial epicondyle or the
cubital tunnel.
 Clinical Signs and Symptoms
 Forearm and/or hand paresthesia
 Forearm and/or hand weakness
 Procedure: Patient seated. Tap the ulnar nerve in the
groove between the olecranon process and the medial
epicondyle with a neurological reflex hammer.
 Rationale: If pain is elicited, it suggests a neuritis or
neuroma of the ulnar nerve.
 Excessive use or repetitive motion injuries.
 Arthritis of the elbow joint.
 Cubital tunnel compression, between the heads of the
flexor carpi ulnaris muscle.
 Postural habits that compress the nerve, such as
sleeping with elbows flexed and hands under head.
 Recurrent nerve subluxations or dislocations.
 Flexor Tendons
 Flexor carpi ulnaris
 Palmaris longus
 Flexor digitorum profundus
 Flexor digitorum superficialis
 Flexor pollicis longus
 Flexor carpi radialis
 The median nerve and the finger flexion tendons lie
within the carpal tunnel.
 This is a common site of compression neuropathy.
 The ulnar nerve and artery lie within Guyon’s tunnel.
 This is also a common site of compression neuropathy.
 The ulnar styloid process is at the posterior aspect of
the wrist proximal to the fifth digit.
 The radial tubercle is at the posterior aspect of the
wrist proximal to the thumb.
 Pain the the tubercle may indicate Colle’s fracture.
 Pain at the ulnar styloid process may indicate a distal
ulnar fracture.
 There are six fibro-osseous tunnels at the posterior
aspect of the wrist.
 The extensor tendons to the hand pass through these
tunnels.
 They are bound by an extensor retinaculum
superficially.
 Tunnels and associated tendons
 Tunnel 1 Adductor pollicis longus, extensor pollicis





brevis
Tunnel 2 Extensor carpi radialis longus and brevis
Tunnel 3 Extensor pollicis longus
Tunnel 4 Extensor digitorum and extensor indexes
Tunnel 5 Extensor digiti minimi
Tunnel 6 Extensor carpi ulnaris
 Carpal tunnel syndrome is a compression neuropathy
of the median nerve.
 Compression occurs under the flexor retinaculum at
the wrist.
 Clinical Signs and Symptoms
 Loss of sensation of the tips of the first three fingers
 Hand and wrist pain
 Weakness of grip
 Procedure: Patient’s hand supinated. Stabilize the
wrist with one hand. With your opposite hand, tap the
palmar surface of the wrist with a neurological reflex
hammer.
 Rationale: Tingling along the distribution of the
medial nerve indicates carpal tunnel syndrome. The
cause could be any of the following: inflammation of
the flexor retinaculum, anterior dislocation of the
lunate bone, arthritic changes, or tenosynovitis of the
flexor digitorum tendons.
 Procedure: Flex both wrist and approximate them
towards each other. Hold for 60 seconds.
 Rationale: When both wrists are flexed, the flexor
retinaculum provides increased compression of the
medial nerve in the carpal tunnel. Tingling in the
distribution of the median nerve (thumb, index finger,
middle finger, and medial half of ring finger) indicates
carpal tunnel syndrome.
 The ulnar nerve travels through the tunnel of Guyon
and innervates the muscles of the little and ring
fingers.
 Ulnar nerve syndrome is a compression neuropathy of
the ulnar nerve.
 Clinical Signs and Symptoms
 Pain over the little and ring finger
 Weakness of grip
 Difficulty with finger spreading
 Claw hand
 Procedure: Inspect and palpate the patient’s wrist,
looking for tenderness over the ulnar tunnel, clawing
of the ring finger, and hypothenar wasting.
 Rationale: All of these signs are indicative of ulnar
nerve compression possibly in the tunnel of Guyon.