Special tests for the upper limb
Notes
Upper limb
Special tests for the upper limb
SPECIAL TESTS OF THE SHOULDER
Apley scratch test
Instruct the patient to reach behind their head (palm facing their back) to attempt to touch the superior medial angle of the opposite scapula. This part of the test examines external rotation and abduction of the shoulder.
Next, instruct the patient to reach behind their back (dorsum of hand facing their back) to attempt to touch the inferior angle of the opposite scapula. This part of the test examines internal rotation and adduction of the shoulder.
Lastly, instruct the patient to reach across their torso to the opposite shoulder. This part of the test also examines internal rotation and adduction of the shoulder.
Next, instruct the patient to reach behind their back (dorsum of hand facing their back) to attempt to touch the inferior angle of the opposite scapula. This part of the test examines internal rotation and adduction of the shoulder.
Lastly, instruct the patient to reach across their torso to the opposite shoulder. This part of the test also examines internal rotation and adduction of the shoulder.
Apprehension / Relocation test
With the patient seated or standing, abduct and externally rotate the shoulder. Apply posterior-to-anterior pressure to the glenohumeral (GH) joint. If this causes significant discomfort and apprehension (fear of their shoulder dislocating), this is a positive test.
Then with the patient lying supine, again abduct and externally rotate the shoulder. Apply anterior-to-posterior pressure to the GH joint. If this relieves their discomfort and apprehension, this further confirms the positive test.
This test assesses for GH instability. Positive apprehension with the first maneuver followed by significant relief on the relocation (second maneuver) indicates a positive test.
Then with the patient lying supine, again abduct and externally rotate the shoulder. Apply anterior-to-posterior pressure to the GH joint. If this relieves their discomfort and apprehension, this further confirms the positive test.
This test assesses for GH instability. Positive apprehension with the first maneuver followed by significant relief on the relocation (second maneuver) indicates a positive test.
Figure 1. Shoulder apprehension and relocation test.
Drop arm test
Abduct the patient’s shoulder to 180º and instruct the patient to slowly lower the arm to their side.
This test assesses for a tear of the supraspinatus. Difficulty lowering the arm slowly and smoothly below 90º indicates a positive test.
This test assesses for a tear of the supraspinatus. Difficulty lowering the arm slowly and smoothly below 90º indicates a positive test.
Empty can (Jobe) test
Instruct the patient to internally rotate the upper limb (thumb pointing towards the ground), flex the shoulder to 90º, and abduct the shoulder to 30º (60º from midline). Apply a downward pressure on the forearm.
This test assesses for a tear of the supraspinatus. A positive test occurs when the patient is unable to abduct the shoulder against your force.
This test assesses for a tear of the supraspinatus. A positive test occurs when the patient is unable to abduct the shoulder against your force.
Figure 2. The empty can (Jobe) test.
Hawkins-Kennedy test
Instruct the patient to flex the shoulder to 90º, flex the elbow to 90º, and pronate the arm. Internally rotate the shoulder while stabilizing the patient’s upper limb.
This test assesses for subacromial impingement of the supraspinatus tendon. Pain at the shoulder indicates a positive test.
This test assesses for subacromial impingement of the supraspinatus tendon. Pain at the shoulder indicates a positive test.
Figure 3. The Hawkins-Kennedy test. Pain at the shoulder indicates a positive test.
Neer test
While stabilizing the scapula, pronate the arm and flex the shoulder to 180º (so that the upper arm is “neer the ear”).
This test assesses for impingement of the supraspinatus tendon. Pain at the shoulder indicates a positive test.
This test assesses for impingement of the supraspinatus tendon. Pain at the shoulder indicates a positive test.
O'Brien test
With the elbow extended, flex the shoulder in front of the patient, then add maximal internal rotation. Apply downward pressure on the forearm and instruct the patient to resist.
This test assesses for acromioclavicular (AC) joint dysfunction or labral tear. Weakness or pain at the shoulder indicates a positive test.
This test assesses for acromioclavicular (AC) joint dysfunction or labral tear. Weakness or pain at the shoulder indicates a positive test.
Speed test
Instruct the patient to flex the shoulder to 90º with the arm supinated. Then, apply downward pressure on the patient’s wrist while the patient resists.
This test assesses for bicipital tendonitis of the long head. Pain at the anterior shoulder indicates a positive test.
This test assesses for bicipital tendonitis of the long head. Pain at the anterior shoulder indicates a positive test.
Test for AC joint dysfunction
Instruct the patient to adduct the dysfunctional arm and place the hand on the contralateral shoulder. Raise the patient’s elbow to 90º of flexion and ask them to actively resist downward force on the elbow.
This test assesses the acromioclavicular (AC) joint. Pain at the AC joint indicates a positive test and possible sprain of the AC joint.Yergason test
Stand at the side of the patient with their elbow flexed to 90º and forearm in neutral (thumb towards the ceiling). With one hand, palpate their bicipital groove. With the other hand on the patient’s wrist, resist their force as you instruct them to flex and supinate the arm against you.
This test evaluates the stability of the long head of the biceps tendon. If the tendon pops out of the bicipital groove (subluxation), this indicates a positive test. If there is pain without subluxation, this indicates bicipital tendonitis.Figure 4. The Yergason test.
SPECIAL TESTS OF THE ELBOW
Tests for lateral epicondylitis
With the patient’s forearm pronated, push down on the dorsum of their hand while they extend their wrist against your resistance. Next, grasp the patient’s hand in yours (like shaking hands), and instruct them to supinate against you while you pronate their forearm.
Both tests assess for lateral epicondylitis. Pain at the lateral epicondyle indicates a positive test.
Both tests assess for lateral epicondylitis. Pain at the lateral epicondyle indicates a positive test.
Tests for medial epicondylitis
With the patient’s forearm supinated, push down on the palm of their hand while they flex their wrist against your resistance. Next, grasp the patient’s hand in yours (like shaking hands), and instruct them to pronate against you while you supinate their forearm.
Both tests assess for medial epicondylitis. Pain at the medial epicondyle indicates a positive test.
Both tests assess for medial epicondylitis. Pain at the medial epicondyle indicates a positive test.
Tinel test at elbow
Flex the shoulder and elbow, then tap over the patient’s cubital tunnel.
This test assesses for cubital tunnel syndrome, or ulnar nerve entrapment. A positive test includes numbness and tingling felt in the medial aspect (ulnar nerve distribution) of the hand.
This test assesses for cubital tunnel syndrome, or ulnar nerve entrapment. A positive test includes numbness and tingling felt in the medial aspect (ulnar nerve distribution) of the hand.
SPECIAL TESTS OF THE WRIST
Finkelstein test
Instruct the patient to place their thumb inside their closed fist, then apply ulnar deviation to the wrist.
This test assesses for De Quervain tenosynovitis. The test is positive if there is pain over the extensor pollicis brevis (EPB) and abductor pollicis longus (APL). Both the EPB and APL insert at the proximal phalanx of the thumb. The EPB is located just medial to the APL.
This test assesses for De Quervain tenosynovitis. The test is positive if there is pain over the extensor pollicis brevis (EPB) and abductor pollicis longus (APL). Both the EPB and APL insert at the proximal phalanx of the thumb. The EPB is located just medial to the APL.
Figure 5. A positive Finkelstein test.
Phalen test
Instruct the patient to abduct their shoulders to 90º, flex the elbows and flex the wrists to oppose the dorsal surfaces of both wrists while both arms remain parallel to the ground. This position is then held for approximately 60 seconds.
This test assesses for carpal tunnel syndrome. The test is positive if there is numbness, tingling or pain along the lateral aspect of the hand (median nerve distribution).
This test assesses for carpal tunnel syndrome. The test is positive if there is numbness, tingling or pain along the lateral aspect of the hand (median nerve distribution).
Figure 6. The Phalen maneuver. Numbness, tingling or pain along the lateral aspect of the hand indicates a positive test.
Tinel test at wrist
Extend the patient’s wrist and tap over the transverse carpal ligament.
This test assesses for carpal tunnel syndrome. Numbness, tingling or pain along the lateral aspect of the hand indicates a positive test.
This test assesses for carpal tunnel syndrome. Numbness, tingling or pain along the lateral aspect of the hand indicates a positive test.
Figure 7. The Tinel test at the wrist. It is positive when the patient experiences numbness, tingling or pain along the lateral aspect of the hand.
OTHER SPECIAL TESTS OF THE UPPER LIMB
Adson test
While not technically a test for upper limb dysfunction, this test is often performed in patients with upper limb symptoms. Instruct the patient to extend their head and turn toward the side of symptoms. With their elbow fully extended and arm at their side, palpate their radial pulse as they deeply inhale.
A weakened or absent pulse on inspiration represents compression of neurovascular structures (e.g., subclavian artery) between the anterior and middle scalene, and indicates thoracic outlet syndrome.
A weakened or absent pulse on inspiration represents compression of neurovascular structures (e.g., subclavian artery) between the anterior and middle scalene, and indicates thoracic outlet syndrome.
Figure 8. A positive Adson test.
Spurling test
While not technically a test for upper limb dysfunction, this test is often performed in patients with upper limb symptoms to assess for cervical radiculopathy. Please see the “Spurling test” learn page for more information.
Figure 9. The Spurling test is positive when the patient experiences numbness / tingling or radicular pain through the ipsilateral neck and upper extremity.
Author: Arman Israelyan, OMS-III
Editor: Matt Lipinski, DO
Editor: Robyn Hughes, MScBMC
Illustrator: Jillian Dunbar
Key Takeaways
Several special tests are used to assess upper limb conditions, such as injuries, or other pathologies. Some of the most common special tests for the upper limb include: Apley scratch test: used to assess for range of motion and flexibility in the shoulder joint. This test is used to evaluate for conditions such as adhesive capsulitis and rotator cuff conditions. Apprehension / Relocation test: this test is used to assess for anterior shoulder instability, which can occur as a result of anterior glenohumeral joint dislocation or subluxation. Drop arm test: it is used to test rotator cuff tears, specifically the supraspinatus. Empty can (Jobe) test: it is also used to assess the strength and function of the supraspinatus muscle. Hawkins-Kennedy test: it is used to test for shoulder impingement syndrome, when there is subacromial impingement of the supraspinatus tendon.