Arms, Hands, and Related Joints

Assessment of the arms and hands progresses from the shoulders to the fingertips. Related joints include the shoulders, elbows, wrists, and fingers. This assessment involves inspection, palpation, range of motion, and manual muscle testing, and is generally completed with the client sitting upright on the exam table. ROM and muscle testing of the shoulders requires the client to stand, so it is usually reserved until the end of the MSK assessment to minimize position changes. You may also need to modify the approach if a client is unable to stand.

Inspection

Steps for inspecting the arms and hands include:

1. Inspect for colour, symmetry, swelling, masses, deformities, and length of limbs with a focus on the muscles, bones, and joints on the whole arm and hand. This involves asking the client to stretch arms and hands out in front of them (pronation) and then turn them over (supination) so that you can inspect the anterior and posterior sides. You may need to ask the client to spread their fingers apart while they are moving their outstretched arms from pronation to supination. Next, ask the client to rest their hands on their lap while you inspect the shoulders and elbows as these cannot be fully visualized when pronating and supinating.

• • Normally, there is no discolouration, swelling, masses, and deformities, and the arms and hands and joints are symmetrical.
  • Describe the appearance and location of any discolouration, swelling, masses, and deformities.

2.   Note the findings:

• • Normal findings might be documented as: “Client’s shoulders, arms, wrists and hands are symmetrical with no redness, swelling, masses, or deformities.”
  • Abnormal findings might be documented as: “Client’s right wrist is red and swollen on the dorsal side of wrist, 5 cm x 3 cm area.”

NOTE: See Video 4 for inspection of arms and hands.

Video 4: Inspection of arms and hands [0:50]

Palpation

Steps for palpating the arms and hands:

1. Palpate for temperature from shoulders to fingertips bilaterally. Palpate over the shoulder, elbow, wrist, and finger joints as you move down the client’s arm.
   • Temperature is normally warm to touch and equal bilaterally. Temperature may get slightly cooler toward the fingertips.
   • Abnormal findings include increased temperature over a joint and sometimes a muscle.
2. Palpate for pain, masses, swelling, deformities, palpable fluid, and muscle twitching from shoulders to fingertips. Palpate the whole arm and hand including the full joint. If the client reports pain prior to assessment, assess that area last.
   • Normally, there is no pain, masses, swelling, deformities or palpable fluid.
   • If pain is present, note the location and ask client to rate the severity and describe the quality. Describe the location and characteristics of any masses, swell, deformities, or palpable fluid.
3. Note the findings:
   • Normal findings might be documented as: “Client’s shoulders, arms, wrists and hands are warm to touch to fingertips, equal bilaterally. No pain, swelling, masses, deformities, or palpable fluid noted.”
   • Abnormal findings might be documented as: “Client’s right elbow is warmer to touch in comparison to left elbow. Swelling over the olecranon area. Client reported pain as a 6/10 upon palpation.”

NOTE: See Video 5 for palpation of arms and hands.

Video 5: Palpation of arms and hands [2:03]

Range of Motion

ROM of the arms and hands is focused on the shoulders, elbows, wrists, and finger joints (see Table 5 for normal ranges). Much of this assessment can be performed in sitting position except the shoulder ROM, which is best performed in standing position (it can be performed toward the end of the MSK assessment when the client is positioned into standing). In saying this, ROM of shoulders, elbows, wrists and finger joints can all be performed in standing position if the client has no issues with mobility and balance or a supine and lying lateral position if the client is unable to stand. Begin with the unaffected arm first, then move to the affected arm for comparison.

While performing the assessment, observe the ROM, quality of the movement, listen for crepitus, and ask the client about the presence of pain. You can demonstrate the movements yourself. 

Steps for assessing ROM of the arms and hands:

1. To perform shoulder flexion, ask the client to stand with their arms hanging straight at their sides (neutral position/extension), then lift their arms in front of them above their head (keeping their arms straight) until their fingertips point toward the ceiling, and finally bring them back to a neutral position.
2. To perform shoulder extension, start with the client in a neutral position and ask them to move their arms/hands back as far as possible (keeping their arms straight with an upright posture and not leaning forward), and then return to a neutral position.
3. To perform shoulder abduction, start with the client in a neutral position and ask them to move their arms out from their body (laterally) and up over their head until the hands meet, and then back to a neutral position. Assess movement anteriorly and posteriorly.
4. To perform shoulder adduction, start with the client in a neutral position and ask them to move their arm across the midline of their body to the opposite side, keeping the arm straight, and then repeat with the other arm.
5. To perform shoulder external rotation (also called lateral rotation), ask the client to bend their arm at the elbow to a 90-degree angle keeping their elbow tightly close to their side, then ask them to move their hands out to the side while keeping their elbows tight to the side of their body until their palms face forward (this externally rotates the shoulder).
6. To perform shoulder internal rotation (also called medial rotation), ask the client to have their arms hanging straight down at side with thumbs pointing inward/medial to the body, and then move their thumbs/arms up their back as high as they can, and then back to a neutral position.
7. To perform elbow flexion, start with the client in a neutral position, and then ask them to lift their forearm/hand arms up by bending at the elbow, moving their hands toward their shoulders while keeping the elbow joint still, and finally return to a neutral position (which is elbow extension).
8. To perform elbow supination and pronation, start with the client in a neutral position, and ask them to bend their elbow at a 90-degree angle with thumbs facing up. Next, rotate the thumbs/forearms internally for pronation (palms of the hands should be facing down to the floor), and then externally for supination (palms of the hands should be facing up to the ceiling).
9. To perform wrist flexion and extension, ask the client to rest their forearms and hands on a table.
   • For wrist flexion, the client’s forearms should be resting on the table in supination position (palms of the hands facing up). Ask the client to bend at the wrist joint with fingers pointing to the ceiling while keeping the forearms/wrists on the table.
   • For wrist extension, the client’s forearm should be resting on the table in a prone position (palms of the hands facing down). Ask the client to bend their wrist joint back with fingers pointing to the ceiling by keeping the forearm and wrists on the table.
10. To perform wrist radial and ulnar deviation ask the client to rest their forearm on the table in a prone position (palms of the hands facing down).
    • For radial deviation, ask the client to flex their wrists inward/medially keeping the forearm/hands/fingers on the table as the fingers deviate midline and point toward each other, and then return to a neutral position.
    • For ulnar deviation, ask the client to flex wrists outward/laterally keeping the forearms/hands/fingers on the table as the fingers deviate away from midline and point away from each other, and then return to a neutral position.
11. To perform finger flexion and extension/abduction, first ask the client to make a fist (flexion) by bending the fingers and then stretch and spread their fingers out straight (extension). This is also considered abduction as the fingers are spread out from one another. Ask the client to put their forearm/hands/fingers flat in a prone position on a table and lift their fingers off the table in extension, while keeping their palms flat.
12. To perform thumb flexion, extension, abduction, and opposition, ask the client to rest their forearms on the table in a prone position (palms of the hands facing down), then ask the client to externally rotate their forearms so the palms are facing each other.
    • For thumb flexion and extension, ask the client to bend their thumbs into the base of the palm, and then up, pointing the tip toward the ceiling for extension.
    • For thumb abduction and adduction, ask the client to abduct their thumbs internally pointing toward each other, and then adduction moving back beside the first digit.
    • For thumb opposition, ask the client to touch their thumb tips to the tip of the 5th digit.
13. Note the findings:

• • Normal findings might be documented as: “Full ROM of shoulders, elbows, wrists and hands, movements of joints are smooth and symmetrical with no obvious misalignments, crepitation, or pain bilaterally.”
  • Abnormal findings might be documented as: “Client shoulder abduction 100 degrees, no crepitation, reported tenderness 3/10.”

NOTE: See Video 6 for ROM of shoulders, see Video 7 for ROM of elbows, see Video 8 for ROM of wrists, and Video 9 for ROM of fingers.

Video 6: ROM of shoulders [2:23] 

Video 7: ROM of elbows [1:05] 

Video 8: ROM of wrists [1:20]

Video 9: ROM of fingers [1:19]

Table 5: Normal ROM of shoulders, elbows, wrists, and fingers (adapted from American Academy of Orthopaedic Surgeons, 1965; Luttgens & Hamilton, 1997).

Manual Muscle Testing (MMT)

Perform MMT after you assess ROM. Explain the procedure before applying force and perform MMT on each joint, one at a time. Grade the resistance according to the institution’s grading scale (e.g., MRC) or just describe it and note whether it is equal bilaterally.

Steps for MMT of shoulders, elbows, wrists, and fingers:

1. To perform MMT for shoulder flexion and then extension, ask the client to stand with their arms hanging straight down at the side (neutral position). With their shoulder joints still and arms straight, place your hands on the client’s forearm and apply force while you ask the client to raise their arm straight up in front of them and resist your force. Release the force and ask them to return their arm to a neutral position. Repeat on the other arm. Then, have the client raise one arm straight out in front of them and above their head. Place your hands on their elbow/forearm, apply pressure and ask them to resist your force while pushing their arm down back to a neutral position. Release the force and ask them to return their arm to a neutral position. Repeat on the other arm.
2. To perform MMT for shoulder abduction and then adduction, ask the client to stand in a neutral position. Place your hands over the elbow/top of the forearm. Ask the client to try to raise their straight arm out to the sides while you apply force and they try to resist it. Release the force and ask them to return their arm to a neutral position. Repeat on the other arm. For adduction, assess one arm at a time: place your hand on their inner forearm and ask them to move their straight arm across the midline while you apply force and they resist it. Release the force and ask them to return their arm to a neutral position. Repeat on the other arm.
3. To perform MMT for elbow flexion and then extension, ask the client to stand in a neutral position. Place your hands in the middle of one forearm and ask the client to flex/bend their arm (at the elbow) in front of them while you apply force and they resist it. Release the force. Repeat on the other arm. Next, ask the client to bend their arm about 100 degrees (at the elbow) in front of them; place your hands on the middle area of the forearm and ask them to attempt to straighten their arm while you apply force and they resist it. Repeat on the other arm.
4. To perform MMT for wrist flexion and then extension, ask the client to rest their forearms/hands on a table in a supination position. Place one of your hands on their forearm and the other touching the palm of their hand. Ask the client to bend their wrists by pushing their palm up into your palm while you apply force and they resist it. Repeat on the opposite side. Next, ask the client to rest their forearm/hands on the table in a pronation position. Place one hand on their forearm to stabilize the arm; place the other on the dorsal side of their hand. Apply force to the dorsal side of the hand and ask the client to bend their wrist back by pushing their hand up into yours while resisting your force. Repeat the procedure on the opposite side.
5. To perform MMT for finger flexion, ask the client to grasp your two fingers with their hands (or with a handshake) to assess their strength bilaterally.
6. Note the findings:

• • Normal findings might be documented as: “full resistance equal bilaterally on all upper limb ROM with no pain.”
  • Abnormal findings might be documented as: “partial resistance on left wrist ROM with mild pain.”

NOTE: See Video 10 for MMT of shoulders, see Video 11 for MMT of elbows, and see Video 12 for MMT of wrists.

Video 10 for MMT of shoulders [1:19]

Video 11 for MMT of elbows [0:51]

Video 12: MMT of fingers [0:58]

Activity: Check your Understanding 

References

American Academy of Orthopaedic Surgeons. Joint Motion: Method of Measuring and Recording. Chicago: AAOS; 1965.

Luttgens, K. & Hamilton, N. (1997). Kinesiology: Scientific Basis of Human Motion, 9th Ed., Madison, WI: Brown & Benchmark