The Upper Extremity History and Physical Examination

EMG CLINIC MSK block for Med 3

Differential Diagnosis: Carpal tunnel syndrome, ulnar neuropathy at the elbow, cervical radiculopathy(nerve root)/myelopathy (spinal cord), superimposed MSK problems

The following is a minimum: supplement this if you feel it is necessary. This information is in addition to :PMHx, PSHx, Meds, Social/Occupational history

History:

  • Territory and distribution of symptoms
    • What part of the hand/arm, which fingers
    • Differentiate where is pain, numbness, tingling (paresthesias)
  • Timing of symptoms
    • Every day, how many times per day, how long does each episode last?
    • How long has this been going on for?
    • Nocturnal predominance (“does it wake you up out of a sleep?”)
  • Inciting events
    • Were there any new activities (job change/duty, new recreation, a lot of yardwork etc) preceding this?
    • Was this of sudden or gradual onset?
    • Was there an accident? (car accident or work accident)
    • Recent pregnancy
    • History of wrist/elbow fracture (ever)
  • Aggravating factors
    • Valsalva (“does sneezing or coughing change arm or hand symptoms”
    • Change in symptoms with neck movements
    • Any particular activities that make it worse
  • Relieving factors
    • Shaking the hands to relieve paresthesia – common in carpal tunnel syndrome
    • Holding the arm up to relieve arm pain (hyperabduction sign) – seen in cervical radiculopathy
  • Associated features:
    • Change in bowel/bladder function – any problems controlling the bowel/bladder, or other changes
    • Gait deterioration (“tripping and falling more than usual”)
    • Hand discoordination (difficulty with buttons, writing, typing, texting)
    • Is the other limb affected? Is one side worse than the other
    • Are there any leg symptoms? (numbness/tingling)
  • Focused musculoskeletal history if pertinent to presenting complaint (i.e. referral is for cervical radiculopathy but presentation is mostly of shoulder/arm pain)
  • Previous management:
    • Did you try braces on your wrist or elbows
    • Physio, massage, chiropractic, acupuncture
  • Family history (just ask if history of carpal tunnel syndrome in parents/siblings)

The Upper Extremity History and Physical Examination

Differential Diagnosis: Carpal tunnel syndrome, ulnar neuropathy at the elbow, cervical radiculopathy(nerve root)/myelopathy (spinal cord), superimposed MSK problems

Physical Exam

  • Power testing
    • Every(most) joint and motions from the shoulder distally (check for scapular winging)
    • Note if true weakness or due to pain inhibition
    • Think of your differential diagnosis
  • Sensory testing(pinprick)
    • Screen C5 – T1
    • Median vs. Ulnar vs. superficial radial
  • Tone/upper motor neuron signs
    • Upper extremities – check for spasticity
    • Finger flexor/Hoffman reflex
    • Ankle clonus
    • Plantars (Babinski sign)
    • Upgoing thumb sign
  • Reflexes
    • Biceps, brachioradialis, triceps, knees, ankles
  • Special tests:
    • Neck ROM (range of motion)
    • Shoulder, Elbow, Wrist ROM
    • Spurlings
    • Tinels sign at wrist/elbow
    • Phalen maneuver for carpal tunnel syndrome
  • Musculoskeletal examination
    • Focused if pertinent to presenting problem