MSK Upper Limbs (acknowledgements to Arthritis Research UK Student Manual)

Expected Examination Steps

Notes

SHOULDERS (BOTH)
1. LOOK and describe from front, side & back..
FEEL:
2. Temperature over the front (deltoid, joint
line,pectoralis)
3. Sternoclavicular joint
4. Clavicle
5. Acromioclavicular joint

Looking for loss of symmetry, muscle wasting

or scars
Compare joint line with deltoid area and
pectoralis
For tenderness
For tenderness
For tenderness. This can be tender with AC
joint pathology

6. Acromion process
7. Joint line: anteriorly and posteriorly
8. Scapula
9. Muscle bulk: supra- and infraspinatus, deltoid

MOVE:.

10. Place both hands behind neck

11. Place both hands behind back.

12. Ext rotation shoulder with elbows at the side

and flexed at 90 (active & passive)

13. Flexion of shoulder (active & passive)

At the posterior border of the acromium. The

biceps tendon is also palpable.
For tenderness
Comparing left and right
Compare active and passive range of motion
(ROM). In an articular process, a decrease in
active ROM is also seen in passive ROM
testing. In a peri-articular process, a decrease
in active ROM should not persist with passive
ROM testing
Assessing Abduction and External Rotation
Assessing Adduction and Internal Rotation.
Comparing how high up the back the patient
can reach
For passive, feel for crepitations at the
shoulder joint. This is a good screening test for
glenohumoral arthritis and frozen shoulder. To
distinguish these two, look for additional joints
involved (suggesting glenohumoral arthritis) or
perform an x-ray to clarify.
For the assessment of passive motion in items
13, 14, it is helpful to use one hand to press
down on the top of the shoulder to feel for
crepitus.

14. Extension shoulder (active & passive)

15. Abduction shoulder (active & passive)

Use one hand to press down on top of

shoulder. This is essential to isolate
glenohumeral joint movement from scapular
rotation.
Painful arc (between 10
and 120) can be assessed in active abduction.

16. Observe from behind scapular movement

during active abduction

ELBOWS (BOTH)
LOOK (describe) from front & side:

1. Joint and alignment (carrying angle and flexion

deformity)

2. Skin (scar, psoriatic rash, rheumatoid nodule,

olecranon bursa swelling)
3. Muscle wasting

Observe for carrying angle and flexion

deformity. Normal can be up to 5-10 degrees;
so 0 degrees may in fact be a sign of early
disease in some individuals. In unilateral
disease, comparison with the contralateral side
is helpful.

FEEL:
4. Temperature (upper arm, joint, forearm)
5. Palpate head of radius & joint line (elbow at
90) whilst supinating & pronating passively.
6. Epicondyles (medial and lateral)
7. Olecranon process
MOVE:
8. Flexion & extension (active & passive)
9. Pronation & supination (active & passive) with
arms tucked by side of body
FUNCTION:

Feel for crepitations with palm of hand over the

olecranon and thumb on the radial head.
Feel for tenderness. Feel for Medial/flexor
tendons insertion & lateral/extensor tendons
insertion
For tenderness
Assess for crepitations during passive
movement.
To assess the degree and symmetry of
pronation and supination

10. Touch mouth with hand

HANDS (BOTH)
LOOK (describe) at palms and back:
1. Muscle wasting (thenar, hypothenar, interossei
and lumbricals )
2. Skin changes (e.g. psoriatic plaques, rashes,
thinning - signs of long-tern steroid use)
3. Nail changes (e.g. pitting, onycholysis)
4. Deformities, scars,swelling, joint alignment
5. Carpal tunnel release scar
FEEL:
6. Radial Pulses bilaterally
7. Muscle bulk (thenar, hypothenar) and for
tendon thickening
8. Sensation (median, ulnar, radial)

9. Skin temperature (Forearm, wrist, and MCPs

with the dorsum of hand.)
10. Squeeze MCPJs while watching the patients
face
11. Bimanually palpate MCPJs, PIPs & DIPs

12. Bimanually palpate wrists

13. Tinels test

This is exam is most comfortable for the patient

with hands resting on a pillow.

Scar is perpendicular to the flexor retinaculum

and usually distal to the wrist crease.
May be assessed simultaneously.

Palmar surface of thumb (median) & little finger

(ulnar), dorsal surface of 1st web- thumb and
index finger webspace (radial).

Assessing for joint line, swelling, tenderness or

fluctuance. For the MCPJs place both thumbs
on the dorsum of the joint lateral to the tendon.
For the PIPs and DIPs use the thumb and
index finger as a pair; one pair assessing the
medial-lateral and the other pair anteriorlyposteriorly.
Use a similar technique as that of the MCPJs
with thumbs on the dorsum.
For Tinels, hyper-extend the wrist, percuss
over the carpal tunnel and ask the patient what
s/he feels. Numbness and tingling in the hand
is a positive test.

14. Look & feel forearm (ulnar borders) for nodules

(RA) /plaques (psoriasis)
MOVE:
15. Straighten fingers
16. Make a fist
17. Wrist flexion & extension
18. Strength of thumb abduction (median)
19. Strength of finger spread (ulnar)

Check the palmar surface to ensure each digit

is fully flexed.
Active & passive feeling for crepitations
Examiner uses own thumb to test strength
here.
Examiner uses own fingers to test strength
here.

FUNCTION:
20. Power Grip: Grip examiners 2 fingers
21. Pincer Grip: Pinch examiners fingertip
22. Pick up small object