Assessment and rehabilitation of upper limb dysfunction

Having over 15 years of post graduate experience as an Exercise Physiologist, my professional clinical practice has exposed me to a broad range of upper limb pathologies. This exposure has included providing rehabilitation for the following pathologies; rotator cuff tears, rotator cuff impingement, subacromial bursitis, labral tears, cervical disc disease and neurogenic pain, brachial plexus trauma, thoracic outlet syndrome, chronic regional pain syndrome, sternoclavicular strain, hemiplegic shoulder pain, lateral epicondylitis, medial epicondylitis, carpal tunnel syndrome, glenohumeral joint osteoarthritis, Hills Sach and Banchart lesion, meningioma, scapula winging, biceps tendinopathy and adhesive capsulitis.

In the management of upper limb injuries it is prudent to utilise upper limb anatomy, an understanding of both common and uncommon upper limb injuries and pathologies, upper limb biomechanics and diagnostics assessments for upper limb abnormalities including the use of “look, feel, move”.

It is important for clinicians to have a thorough understanding of upper limb red flags which aides in possible differential diagnosis in clinical practice. The use of red flag screenings is a common day to day clinical practice and these can be used for physical assessments, functional assessments and general prescreening prior to patients participating in rehabilitation. During clinical practice it is useful to use the WorkCover SA (2011) Guide to assessing and managing red and yellow flags for workers compensation patients to identify appropriate red flags. The red flags identified here are features of cauda equine syndrome, significant trauma, unintended weight loss, history or possibility of cancer/malignancy, osteoporosis, fevers, chills, night time sweats, being unwell or other related pathology, severe unremitting night time pain, pain that gets worse lying down, increasing neurological deficit, pulmonary or neurovascular compromise, unexplained deformity/swelling, use of intravenous drugs, high dose steroids or immunosuppresion, patient over 55 years old or under 20 years at onset of pain, thoracic pain without obvious cause, dizziness and or nausea, tinnitus, dysphagia, dysarthia, diplopia, drop attacks, vertebro-basilar insufficiency, significant or unexplained sensory/motor deficit not due to pain.  

There are also less common red flags specifically for upper limb pathologies. Masters and Burley (2007), Murphy and Carr (2009) and Mutsaers and Dolder (2008) provided additional red flags for the upper limb including chest pain, Beevors sign, Lhermitte sign, Kernigs and Bruzinskis sign, Valsava sign, hearing loss, dyspnea, orofacial pain, atrophy of the shoulder girdle, neck extensor weakness or dropped head syndrome, facial atrophy, neck mass, hoarseness, fatigue and swelling or bruising of neck, fever in combination with headache, skin lesions, headaches, globus sensation, arm pain lasting for more than 2-3 months, persistent root pain, pain that worsens after one month, pain that has no mechanical exacerbating or remitting factors, pain increased by coughing, sneezing, straining or bending forward, respiratory pain, pain in the right shoulder, severe pain with visual loss, swallowing pain with globus sensation, weight gain, changes in personality.

After the assessment of red flags the use of the “look, feel, move” approach to assessing patients is an effective way to formulate the clinical assessment. When assessing upper limb pathologies you can “feel” or palpate acromioclavicular Joints, shoulder Joints, rotator cuff tendons, bicipital grooves, rotator cuff muscles and periscapular muscles (Brukner & Kahn, 2007, pp. 247).  In moving joints for assessment we use active and passive range of motion assessments  as well as diagnostic assessments such Hawkins Kennedy, Neers, Arc sign, Drop Test, Apprehension Test and Bicep Load Test. 

In clinical practice there is use of biomechanics, kinesiology and sports medicine theory to identify diagnosis for upper limb pain. Some of the differential diagnosis to be considered for shoulder pain include; rotator cuff strain, tendinopathy, bursitis, glenohumeral dislocation, glenohumeral instability, glenoid labral tears, acromioclavicular joint sprains or seperation, osteoarthritis, fracture, thoracic outlet syndrome,  referred pain from cervical spine, myocardial infarct, cardiac failure, stroke, arterial thrombosis in drug user, neck malignancy, cervical spondylotic myelopathy, lung disease/cancer or breast cancer. (Brukner & Kahn, 2007, pp. 245-276; Houglum, 2005, pp. 564-579; Kreighbaum & Barthels, 1990; pp. 187-207; Louden et al. 2008, pp. 174-180; Soderberg, 1986, 109-147; Warfield & Bajwa, 2004 pp. 315-337). There are additional differential diagnosis that may be less commonly considered which includes  acute arterial insufficiency, shoulder hand syndrome, neuralgic amyotrophy, compartment syndrome, thrombophlebitis, mycotic aneurysm, traumatic aneurysm, facioscapulohumeral dystrophy, Brown-Vialetto-van Laere syndrome, dyophromatic, diaphragmatic paralysis, osteoblastoma, osteonecrosis, lyme disease, fibrous dysplasia, neurofibromatosis, Rhombergs disease, craniofacial tumours, branchial anomalie or cyst, skin cancer or melanoma, intracranial aneurysms, gastro-esophageal disease, laryngitis, pharyngitis or granuloma, lymphoma, increased intracranial pressure, neuroma, referred pain from diaphragm, gall bladder, perforated duodenal ulcer, heart, spleen, apex of lungs (Brukner & Kahn, 2007, pp. 246; Favero et al., 1987; Konstantakos et al., 2007; Luime et al., 2004; Masters & Burley, 2007; Murphy & Carr, 2009;  Mutsaers & Dolder,  2008; Prasarn and Oullette, 2011; Seiler et al., 2000; Warfield & Bajwa, 2004 pp. 315-337; Woodward & Best, 2000).  

Once a patient is assessed it is important to apply evidence based strength and conditioning principles to exercise prescription rehabilitation programs such as those identified by Reiman and Lorenz (2011).  Recent research on general shoulder rehabilitation (Ellenbecker & Cools, 2010) and the application of eccentric training programs for upper limb rehabilitation (Chaconas & Kolber, 2013; Cowell, 2012) can be applied to improve quality outcomes for shoulder injury patients.

References

Brukner, P. and Khan, K. (2007). Clinical sports medicine, third edition. Australia: McGraw Hill
Chaconas, E.J. and Kolber, M.J. (2013). Eccentric training for shoulder external rotators Part I: Efficacy and biophysiological evidence. Strength and Conditioning Journal, 35(1), 48-50.
Cowell, J. F. Cronin, J. and Brughelli M. (2012). Eccentric muscle actions and how the strength and conditioning specialist might use them for a variety of purposes. Strength and conditioning Journal, 34(3), 33-48.
Ellenbecker, T. S. and Cools, A. (2010). Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence based review.  British Journal of Sports Medicine, 44, 319-327.
Favero, J. K., Hawkins, R. H., and Jones, M.W. (1987). Neuralgic Amyothrophy, The Journal of Bone and Joint Surgery (69B)2, 196-198.
Houglum, P.A. (2005). Therapeutic exercise for musculoskeletal injuries, second edition. USA: Edwards Brothers Inc.

Konstantakos, E.K., Dalstrom, D.J., Nelles, M.E., Laughlin, R.T., and Prayson, M.J. (2007). Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. The American Surgeon, 73(12), 1199-209.

Kreighbaum, E. and Barthels, K.M. (1990). Biomechanics, a qualitative approach for studying human movement, third edition. USA: Macmillan publishing company.
Louden, J. Swift, M. and Bell, S. (2008). The clinical orthopaedic assessment guide, second edition. USA: Human Kinetics.
Luime, J. L., Verhagen, A. P.,  Miedema, H. S., Kuiper, J. I., Burdorf, A., Verhaar, J. A., Koes, B. W. (2004). Does this patient have a instability of the shoulder or labrum lesion? Journal of the American Medical Association, 292(16), 1989-1999.
Masters, S. and Burley, S. (2007). Shoulder pain. Australian Family Physician, 36(6) 414-420.
Murphy, R. and Carr, A. (2009). Management of shoulder pain in general practice. InnovAiT, 2(7), 402-407.
Mutsaers, B. and Dolder, R. V. (2008). Red Flags of the neck and shoulder area, a review of the literature.  DTO Special, 27-35.
Prasarn, M. L. and Oullette, E. A. (2011). Acute compartment syndrome of upper extremity. Journal of the American Academy of Orthopaedic Surgeons 19(1), 49-58.
Seiler, J. G., Casey, P.J., and Binford, S.H. (2000). Compartment Syndromes of the Upper Extremity. Journal of the Southern Orthopaedic Association, 9(4), 233-247.
Soderberg, G.L. (1986). Kinesiology, Application to pathological motion. USA: Williams and Wilkins.
Warfield, C. A. and Bajwa, Z.H. (2004). Principles and practice of pain medicine, second edition. USA: McGraw Hill.
Woodward, T. W. and Best, T.M. (2000). The painful shoulder: part I clinical examination. American Family Physician, 61(10), 3079-3088.
Woodward, T. W. and Best, T.M. (2000) The painful shoulder: part II clinical examination. American Family Physician, 61(11), 3291-3300.
WorkCover SA (2011) A guide to assessing and managing red and yellow flags for workers compensation patients. Retrieved December 20th 2012 from http://www.workcover.com/health-provider/reference-library/publications-and-forms