Examination of the Upper Limbs

Overview

Initial steps

• Briefly explain each step of the examination to the individual and obtain consent.
• Position the individual in a sitting position.
• Expose the shoulders, arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy, forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy, and hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy adequately.
• Ensure good lighting.

Components of the examination

• Inspection Inspection Dermatologic Examination
• Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination
• Range of motion
• Special tests

Anatomy

The upper limb is divided into 3 regions:

• Arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy
• Forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy
• Hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy 

The joints involved include:

• Shoulder joint
• Elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint: Anatomy
• Wrist joint Wrist joint The wrist connects the forearm to the hand. It consists of 8 carpal bones, multiple joints, and various supporting ligaments, as well as the distal bones of the forearm and the proximal portion of the 5 metacarpal bones of the hand. Wrist Joint: Anatomy
• Carpometacarpal Carpometacarpal The articulations between the carpal bones and the metacarpal bones. Wrist Joint: Anatomy (CMC) joints
• Metacarpophalangeal (MCP) joints
• Proximal interphalangeal (PIP) joints
• Distal interphalangeal (DIP) joints 

These joints are surrounded and supported by many muscles, tendons, ligaments, and fibrocartilaginous structures to ensure support and stability and to absorb shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock during locomotion.

Shoulder Examination

Inspection Inspection Dermatologic Examination

Inspect the following structures of the shoulder/shoulder girdle bilaterally:

• Bony structures:
  • Clavicle Clavicle A bone on the ventral side of the shoulder girdle, which in humans is commonly called the collar bone. Clavicle Fracture
  • Scapula
  • Humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy
• Muscular structures:
  • Deltoid
  • Pectoralis major
  • Trapezius
  • Rhomboid

Note:

• Asymmetry
• Swelling Swelling Inflammation
• Deformity
• Muscle atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation or fasciculations Fasciculations Involuntary contraction of the muscle fibers innervated by a motor unit. Fasciculations may be visualized as a muscle twitch or dimpling under the skin, but usually do not generate sufficient force to move a limb. They may represent a benign condition or occur as a manifestation of motor neuron disease or peripheral nervous system diseases. Polyneuropathy
• Abnormal positioning
• Winging

Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination

Palpate the various components of the shoulder girdle, including:

• Sternoclavicular joint
• Clavicle Clavicle A bone on the ventral side of the shoulder girdle, which in humans is commonly called the collar bone. Clavicle Fracture
• Acromioclavicular joint
• Acromion
• Coracoid process of the scapula
• Head of the humerus Head of The Humerus The upper rounded extremity of the humerus fitting into the glenoid cavity of the scapula. Arm: Anatomy
• Greater tubercle of the humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy
• Spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy of the scapula

Note:

• Swelling Swelling Inflammation
• Crepitus Crepitus Osteoarthritis
• Bony irregularities
• Tenderness (palpate tender areas last and compare with nontender areas)

Range of motion

Each shoulder joint should be assessed and compared with the others. First assess active movement and then passive movement.

• Compound movements:
  • Rapid screening Screening Preoperative Care tool for shoulder joint pathology
  • Test the rotator cuff muscles in a few movements.
  • External rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays and abduction of the shoulder joint:
    • Instruct individual to put the hands behind the head.
    • Elbows point out to the side.
  • Internal rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays and adduction of the shoulder joint:
    • Instruct individual to place the hands behind the lower back.
    • Reach as far up the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy as possible.
• Shoulder flexion:
  • Individual raises the arms forward.
  • Normal range of movement: 150–180 degrees
• Shoulder extension:
  • Individual stretches out the arms behind them.
  • Normal range of movement: 40 degrees
• Shoulder abduction:
  • Individual raises the arms out to the side in an arc-like motion until the hands touch above the head.
  • Normal range of movement: 180 degrees
• Shoulder adduction:
  • Individual keeps the arms straight and moves them across the front of the body to the opposite side.
  • Normal range of movement: 30–40 degrees
• Shoulder external rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays:
  • Individual keeps elbows by the sides flexed at 90 degrees while they move the forearms Forearms Part of the upper extremity in humans and primates extending from the elbow to the wrist. Bowen Disease and Erythroplasia of Queyrat outward in an arc-like motion.
  • Normal range of movement: 80–90 degrees
• Shoulder internal rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays:
  • Ask the individual to place each hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy behind the back and reach as far up the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy as possible.
  • Normal range of movement: able to reach level T4 T4 The major hormone derived from the thyroid gland. Thyroxine is synthesized via the iodination of tyrosines (monoiodotyrosine) and the coupling of iodotyrosines (diiodotyrosine) in the thyroglobulin. Thyroxine is released from thyroglobulin by proteolysis and secreted into the blood. Thyroxine is peripherally deiodinated to form triiodothyronine which exerts a broad spectrum of stimulatory effects on cell metabolism. Thyroid Hormones–T8

Tests for shoulder stability

Anterior/ posterior drawer test Posterior Drawer Test Knee Ligament Injuries:

• Positioning: supine, prone, or seated
• Procedure:
  • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy on the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy of the scapula and the coracoid process.
  • Manipulate humeral head Humeral head The upper rounded extremity of the humerus fitting into the glenoid cavity of the scapula. Arm: Anatomy anteriorly with the other hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy.
• Positive result: joint laxity compared to the contralateral side
• Test significance: possible ligamentous, tendinous, or capsular injury 

Inferior drawer test:

• Positioning: supine, prone, or seated
• Procedure:
  • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy on the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy of the scapula and the coracoid process.
  • Apply distal traction on the elbow.
• Positive result: 
  • Visible depression between the edge of the acromion and the humeral head Humeral head The upper rounded extremity of the humerus fitting into the glenoid cavity of the scapula. Arm: Anatomy (positive sulcus sign)
  • Joint laxity compared to the contralateral side
• Test significance: possible ligamentous, tendinous, or capsular injury 

Anterior apprehension test:

• Positioning: seated
• Procedure: 
  • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy on the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy of the scapula and the coracoid process.
  • Abduct shoulder to 90 degrees with the elbow flexed at 90 degrees.
  • Externally rotate the joint while observing for subluxation Subluxation Radial Head Subluxation (Nursemaid’s Elbow), apprehension, or discomfort.
• Positive result: subluxation Subluxation Radial Head Subluxation (Nursemaid’s Elbow), apprehension, or discomfort
• Test significance: possible ligamentous, tendinous, or capsular injury

Posterior apprehension test:

• Positioning: seated
• Procedure: 
  • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy on the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy of the scapula and the coracoid process.
  • Flex shoulder and elbow to 90 degrees and rotate internally.
  • Apply posterior force on the elbow while observing for subluxation Subluxation Radial Head Subluxation (Nursemaid’s Elbow), apprehension, or discomfort.
• Positive result: subluxation Subluxation Radial Head Subluxation (Nursemaid’s Elbow), apprehension, or discomfort
• Test significance: possible ligamentous, tendinous, or capsular injury

Rotator cuff tests

Lateral Jobe test:

• Positioning: seated
• Procedure: 
  • Abduct the shoulder to 60 degrees. 
  • Internally rotate the shoulder with the thumb pointing down toward the floor.
  • Push down on the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy as the individual resists.
• Positive result: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or weakness against examiner’s resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing
• Test significance: suggests a tear in the supraspinatus tendon or muscle

Lift-off test:

• Positioning: seated
• Procedure:
  • Individual places the dorsum of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy on the lower back with the elbow flexed to 90 degrees.
  • The examiner lifts the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy off the back against the individual’s resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing (the individual is asked to maintain the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy in this position).
• Positive result: inability to maintain the above position against resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing
• Test significance: suggests a tear in the subscapularis tendon or muscle

Resisted external rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays:

• Positioning: seated
• Procedure:
  • Individual adducts and flexes the arms to 90 degrees with the thumb turned up.
  • The examiner stabilizes the elbow with one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy and applies pressure proximal to the individual’s wrist.
  • The individual presses the wrists outward in external rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays.
• Positive result: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or weakness against examiner’s resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing
• Test significance: suggests a tear in the infraspinatus tendon or muscle

Impingement tests

Painful arc test:

• Positioning: seated
• Procedure: 
  • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy on the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy of the scapula and the coracoid process.
  • Actively and passively carry the shoulder from 0 degrees to 180 degrees of abduction.
• Positive result: shoulder pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at 60–120 degrees
• Test significance: suggests subacromial impingement

Neer test:

• Positioning: seated
• Procedure:
  • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy on the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy of the scapula and the coracoid process.
  • Adduct shoulder to 90 degrees and rotate internally. Extend elbow; forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy is pronated. 
  • Actively and passively raise the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy (shoulder flexion).
• Positive result: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at 90–120 degrees
• Test significance: suggests subacromial impingement

Hawkins-Kennedy test:

• Positioning: seated
• Procedure:
  • Shoulder and elbow are flexed at 90 degrees.
  • Stabilize the elbow and passively rotate the shoulder joint internally.
• Positive result: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways on internal rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays
• Test significance: suggests subacromial impingement 

Other provocative tests

Cross-body adduction test:

• Positioning: seated
• Procedure: 
  • Adduct the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy(s) across the chest. 
  • Assess the acromioclavicular and sternoclavicular joints.
• Positive result: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with adduction
• Test significance: acromioclavicular or sternoclavicular dysfunction

Yegason’s test:

• Positioning: seated
• Procedure:
  • The individual flexes the elbow to 90 degrees. 
  • The individual supinates the wrist and internally rotates the shoulder against the examiner’s resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing.
• Positive result: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in the bicipital groove or movement of the biceps Biceps Arm: Anatomy tendon out of the bicipital groove
• Test significance: tests for stability of the biceps Biceps Arm: Anatomy tendon in the bicipital groove and bicipital tendinitis Tendinitis Ankylosing Spondylitis

Speed’s test:

• Positioning: seated
• Procedure:
  • The individual flexes the shoulder to 90 degrees with the elbow extended and the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy supinated.
  • The examiner applies a downward force as the individual resists.
• Positive result: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways elicited in the bicipital groove
• Test significance: tests for bicipital tendinitis Tendinitis Ankylosing Spondylitis of the long head of the biceps Biceps Arm: Anatomy 

Elbow Examination

Inspection Inspection Dermatologic Examination

Inspect the following structures of the elbow bilaterally:

• Bony structures:
  • Proximal radius Radius The outer shorter of the two bones of the forearm, lying parallel to the ulna and partially revolving around it. Forearm: Anatomy
  • Proximal ulna Ulna The inner and longer bone of the forearm. Forearm: Anatomy
  • Distal humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy
• Muscular structures:
  • Bicep
  • Tricep
  • Wrist flexors
  • Wrist extensors
  • Pronators
  • Supinators 
• Normal valgus angle: 11–13 degrees (when elbow fully extended)

Note:

• Asymmetry
• Swelling Swelling Inflammation
• Deformity
• Muscle atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation or fasciculations Fasciculations Involuntary contraction of the muscle fibers innervated by a motor unit. Fasciculations may be visualized as a muscle twitch or dimpling under the skin, but usually do not generate sufficient force to move a limb. They may represent a benign condition or occur as a manifestation of motor neuron disease or peripheral nervous system diseases. Polyneuropathy
• Abnormal positioning

Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination

Palpate the various components of the elbow, including:

• Olecranon process of the ulna
• Radial head
• Medial epicondyle Medial epicondyle Arm: Anatomy of the humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy
• Lateral epicondyle Lateral epicondyle Arm: Anatomy of the humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy

Note:

• Swelling Swelling Inflammation
• Crepitus Crepitus Osteoarthritis
• Bony irregularities
• Tenderness: Palpate tender areas last and compare with nontender areas.

Range of motion

• Flexion:
  • Individual bends the elbow to touch the shoulder.
  • Normal range of motion: 0–145 degrees
• Extension:
  • Individual straightens the arms as far out as possible.
  • Normal range of motion: 0 degrees
• Pronation:
  • Individual turns the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy so that the palm is facing down.
  • Normal range of motion ( proximal radioulnar joint Proximal radioulnar joint Forearm: Anatomy): 0–85 degrees
• Supination:
  • Individual turns the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy so that the palm is facing up.
  • Normal range of motion ( proximal radioulnar joint Proximal radioulnar joint Forearm: Anatomy): 0–90 degrees

Special tests

Tennis elbow (lateral epicondylitis):

• Positioning: seated
• Procedure:
  • Individual flexes the elbow to 90 degrees with wrist pronated and flexed completely.
  • Individual is asked to extend the wrist against the examiner’s resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing.
• Positive test: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways over the lateral epicondyle Lateral epicondyle Arm: Anatomy
• Test significance: suggests lateral epicondylitis and/or wrist extensor tendinopathy 

Golfer’s elbow (medial epicondylitis):

• Positioning: seated
• Procedure: 
  • Individual flexes the elbow to 90 degrees with the wrist supinated and extended completely.
  • Individual is asked to make a fist and flex the wrist against the examiner’s resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing. 
• Positive test: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways over the medial epicondyle Medial epicondyle Arm: Anatomy.
• Test significance: suggests medial epicondylitis and/or wrist flexor tendinopathy

Wrist Examination

Inspection Inspection Dermatologic Examination

Inspect the following structures of the wrist bilaterally:

• Bony structures:
  • Distal radius Radius The outer shorter of the two bones of the forearm, lying parallel to the ulna and partially revolving around it. Forearm: Anatomy
  • Distal ulna Ulna The inner and longer bone of the forearm. Forearm: Anatomy
  • Carpal bones Carpal bones The eight bones of the wrist: scaphoid bone; lunate bone; triquetrum bone; pisiform bone; trapezium bone; trapezoid bone; capitate bone; and hamate bone. Carpal Tunnel Syndrome
• Muscular structures:
  • Wrist flexors
  • Wrist extensors
  • Pronators
  • Supinators 

Note:

• Asymmetry
• Swelling Swelling Inflammation
• Deformity
• Muscle atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation or fasciculations Fasciculations Involuntary contraction of the muscle fibers innervated by a motor unit. Fasciculations may be visualized as a muscle twitch or dimpling under the skin, but usually do not generate sufficient force to move a limb. They may represent a benign condition or occur as a manifestation of motor neuron disease or peripheral nervous system diseases. Polyneuropathy
• Abnormal positioning

Ganglion cyst:

• Synovial cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change that contain mucinous fluid.
• Most commonly found on the dorsal aspect of the wrist
• Believed to arise from repetitive microtrauma Microtrauma Small injuries caused by external force applied to the body including bones, muscles, nerves and tendons. Osgood-Schlatter Disease resulting in mucinous degeneration of connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue: Histology
• Majority are asymptomatic.
• May present with:
  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and tenderness
  • Dissatisfaction with cosmetic appearance

Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination

Palpate the various components of the wrist, including:

• Distal radius
• Distal ulna Ulna The inner and longer bone of the forearm. Forearm: Anatomy
• Carpal bones Carpal bones The eight bones of the wrist: scaphoid bone; lunate bone; triquetrum bone; pisiform bone; trapezium bone; trapezoid bone; capitate bone; and hamate bone. Carpal Tunnel Syndrome

Note:

• Swelling Swelling Inflammation
• Crepitus Crepitus Osteoarthritis
• Bony irregularities
• Tenderness: Palpate tender areas last and compare with nontender areas.

Range of motion

• Flexion: 
  • Individual puts the backs of the hands together and flexes the wrist fully.
  • Normal range of motion: 0–90 degrees
• Extension: 
  • Individual puts the backs of the hands together and extends the wrist fully.
  • Normal range of motion: 0–90 degrees
• Adduction:
  • With palm facing down, individual brings the fingers toward the midline.
  • Normal range of motion: 0–30 degrees
• Abduction: 
  • With palm facing down, individual brings the fingers away from the midline.
  • Normal range of motion: 0–30 degrees
• Pronation:
  • Individual turns the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy so the palm is facing down. 
  • Normal range of motion ( distal radioulnar Distal radioulnar Wrist Joint: Anatomy joint): 0–150 degrees
• Supination:
  • Individual turns the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy so that the palm is facing up.
  • Normal range of motion ( distal radioulnar Distal radioulnar Wrist Joint: Anatomy joint): 0–30 degrees

Special tests

Tinel test Tinel test Firm percussion over the course of the median nerve proximal to or on top of the carpal tunnel . A positive test is defined as pain and/or paresthesia in median innervated fingers on percussion over the median nerve. Carpal Tunnel Syndrome:

• Positioning: seated
• Procedure:
  • Individual flexes the elbow to 90 degrees with the wrist supinated and extended.
  • Examiner taps in the center of the transverse carpal ligament.
• Positive test: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or paresthesia in the distribution of the median nerve Median Nerve A major nerve of the upper extremity. In humans, the fibers of the median nerve originate in the lower cervical and upper thoracic spinal cord (usually C6 to T1), travel via the brachial plexus, and supply sensory and motor innervation to parts of the forearm and hand. Cubital Fossa: Anatomy
• Test significance: suggests median nerve compression Nerve Compression Brachial Plexus Injuries

Phalen test:

• Positioning: seated
• Procedure:
  • Individual flexes the elbow to 90 degrees with the dorsal aspect of the wrists pressed together in the completely flexed position.
  • Individual is asked to extend the wrist against the examiner’s resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing.
• Positive test: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, paresthesia, or numbness in the distribution of the median nerve Median Nerve A major nerve of the upper extremity. In humans, the fibers of the median nerve originate in the lower cervical and upper thoracic spinal cord (usually C6 to T1), travel via the brachial plexus, and supply sensory and motor innervation to parts of the forearm and hand. Cubital Fossa: Anatomy
• Test significance: suggests median nerve compression Nerve Compression Brachial Plexus Injuries

Finkelstein test:

• Positioning: seated
• Procedure:
  • Individual adducts the thumb into the palm and closes a fist around it and then adducts the wrist.
  • Individual attempts to abduct the wrist and thumb against the examiner’s resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing.
• Positive test: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways over radial aspect of the wrist
• Test significance: suggests tendinopathy of the extensor pollicis brevis Extensor pollicis brevis Forearm: Anatomy and/or abductor pollicis longus Abductor pollicis longus Forearm: Anatomy tendons (de Quervain tenosynovitis)

Hand Examination

Inspection Inspection Dermatologic Examination

Inspect the following structures of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy bilaterally:

• Bony structures:
  • Metacarpals Metacarpals The five cylindrical bones of the metacarpus, articulating with the carpal bones proximally and the phalanges of fingers distally. Wrist Joint: Anatomy 
  • Proximal phalanges Phalanges Bones that make up the skeleton of the fingers, consisting of two for the thumb, and three for each of the other fingers. Hand: Anatomy
  • Distal phalanges Phalanges Bones that make up the skeleton of the fingers, consisting of two for the thumb, and three for each of the other fingers. Hand: Anatomy
• Muscular structures:
  • Interosseus muscles
  • Thenar muscles Thenar muscles Hand: Anatomy
  • Hypothenar muscles Hypothenar muscles Hand: Anatomy
  • Finger flexors
  • Finger extensors 

Note:

• Asymmetry
• Swelling Swelling Inflammation
• Deformity
• Muscle atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation or fasciculations Fasciculations Involuntary contraction of the muscle fibers innervated by a motor unit. Fasciculations may be visualized as a muscle twitch or dimpling under the skin, but usually do not generate sufficient force to move a limb. They may represent a benign condition or occur as a manifestation of motor neuron disease or peripheral nervous system diseases. Polyneuropathy
• Abnormal positioning

Common abnormalities

Deformity:

• Rotational deformity due to phalangeal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
• Mallet finger:
  • Flexion at DIP
  • Can be passively reversed
• Boutonnière deformity:
  • PIP: fixed flexion
  • DIP: hyperextension
• Swan-neck deformity:
  • PIP: hyperextension
  • DIP: flexion
• Dupuytren contracture:
  • Fixed flexion of the MCP and PIP joints 
  • Usually affects the little and ring finger

Swelling Swelling Inflammation:

• Swollen MCP → loss of hill–valley–hill 
• Heberden node: nodules at the DIP
• Bouchard node: nodules at the PIP
• Ganglion cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change

Extra-articular signs:

• Muscle wasting Muscle Wasting Duchenne Muscular Dystrophy (thenar and hypothenar eminence)
• Palmar erythema Palmar Erythema Cirrhosis
• Psoriatic patches Patches Vitiligo
• Thickening of the flexor tendons or flexion contractures Contractures Prolonged shortening of the muscle or other soft tissue around a joint, preventing movement of the joint. Wound Healing in the fingers

Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination

Palpate the various components of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy, including:

• CMC joints
• PIP joints
• DIP joints

Note:

• Swelling Swelling Inflammation
• Crepitus Crepitus Osteoarthritis
• Bony irregularities
• Tenderness (palpate tender areas last and compare with nontender areas)

Palms up:

• Palpate the radial and ulnar pulses to confirm adequate blood supply to the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy.
• Palpate the muscle bulk of the thenar and hypothenar eminences. Wasting is due to:
  • Disuse atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation
  • Lower motor neuron Lower Motor Neuron Motor Neuron Lesions lesions in the ulnar and/or median nerves 
• Palpate the palm to detect the typical bands of thickened palmar fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis associated with Dupuytren contracture. 
• Assess median and ulnar nerve Ulnar Nerve A major nerve of the upper extremity. In humans, the fibers of the ulnar nerve originate in the lower cervical and upper thoracic spinal cord (usually C7 to T1), travel via the medial cord of the brachial plexus, and supply sensory and motor innervation to parts of the hand and forearm. Axilla and Brachial Plexus: Anatomy sensation:
  • Median nerve Median Nerve A major nerve of the upper extremity. In humans, the fibers of the median nerve originate in the lower cervical and upper thoracic spinal cord (usually C6 to T1), travel via the brachial plexus, and supply sensory and motor innervation to parts of the forearm and hand. Cubital Fossa: Anatomy: over the thenar eminence and index finger
  • Ulnar nerve Ulnar Nerve A major nerve of the upper extremity. In humans, the fibers of the ulnar nerve originate in the lower cervical and upper thoracic spinal cord (usually C7 to T1), travel via the medial cord of the brachial plexus, and supply sensory and motor innervation to parts of the hand and forearm. Axilla and Brachial Plexus: Anatomy: over the hypothenar eminence and little finger

Palms down:

• Assess radial nerve Radial Nerve A major nerve of the upper extremity. In humans the fibers of the radial nerve originate in the lower cervical and upper thoracic spinal cord (usually C5 to T1), travel via the posterior cord of the brachial plexus, and supply motor innervation to extensor muscles of the arm and cutaneous sensory fibers to extensor regions of the arm and hand. Axilla and Brachial Plexus: Anatomy sensation over the 1st dorsal web space.
• Gently squeeze across the MCP joints to elicit tenderness (suggestive of active inflammatory arthropathy Arthropathy Osteoarthritis).
• Palpate the joints of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy: 
  • MCP, PIP, DIP, and CMC joints
  • Assess and compare for:
    • Tenderness
    • Irregularities
    • Warmth 
• Palpate the anatomical snuffbox for tenderness (suggestive of a scaphoid fracture Scaphoid Fracture Hand and Wrist Pain).
• Palpate the wrists bimanually for joint-line irregularities or tenderness.

Range of motion

• Fingers:
  • Flexion: Individual makes a fist.
  • Extension: Individual opens the fist and splays the fingers.
  • Abduction: Individual spreads the fingers apart.
  • Adduction: Individual puts the fingers together.
• Thumb:
  • Flexion: The individual moves the thumb across the palm and touches the base of the 5th finger.
  • Extension: Move the thumb back across the palm and away from the fingers. 
  • Abduction: With the fingers and thumb in a neutral position and palm up, the individual moves the thumb away from the palm.
  • Adduction: With the fingers and thumb in a neutral position and palm up, the individual moves the thumb back down.
  • Opposition: The individual touches the thumb to each of the other fingertips.

Clinical Relevance

• Rotator cuff tears: Rotator cuff pathology is the most common condition of the shoulder for which individuals seek treatment. Rotator cuff tears are caused by degeneration, impingement, and overload. Presentation is with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and weakness at the shoulder joint. On examination, there may be a positive painful arc sign, positive drop arm test Drop arm test Conversion Disorder, or weakness in external rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays. Physical examination findings are dependent on the muscles involved. Imaging studies such as musculoskeletal ultrasonography and MRI can be done to confirm the diagnosis. Management is with physical therapy Physical Therapy Becker Muscular Dystrophy or surgical repair.
• Carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome syndrome: complex of signs and symptoms caused by compression Compression Blunt Chest Trauma of the median nerve Median Nerve A major nerve of the upper extremity. In humans, the fibers of the median nerve originate in the lower cervical and upper thoracic spinal cord (usually C6 to T1), travel via the brachial plexus, and supply sensory and motor innervation to parts of the forearm and hand. Cubital Fossa: Anatomy as it crosses the carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome. Presentation may be with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, paresthesia, weakness, and atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation over the median nerve Median Nerve A major nerve of the upper extremity. In humans, the fibers of the median nerve originate in the lower cervical and upper thoracic spinal cord (usually C6 to T1), travel via the brachial plexus, and supply sensory and motor innervation to parts of the forearm and hand. Cubital Fossa: Anatomy dermatome Dermatome Spinal Disk Herniation and myotome Myotome Development of the Limbs distribution. On examination, a positive Tinel test Tinel test Firm percussion over the course of the median nerve proximal to or on top of the carpal tunnel . A positive test is defined as pain and/or paresthesia in median innervated fingers on percussion over the median nerve. Carpal Tunnel Syndrome and Phalen test are elicited. Management can be with splinting, physical therapy Physical Therapy Becker Muscular Dystrophy, or surgical correction. 
• Rheumatoid arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis: chronic, systemic, autoimmune, inflammatory disorder of unknown etiology that primarily involves synovial joints. The arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis is usually symmetrical Symmetrical Dermatologic Examination and leads to erosion Erosion Partial-thickness loss of the epidermis Generalized and Localized Rashes of cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology and bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types, causing joint deformities. During the onset of disease, individuals present with joint pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, stiffness (especially morning stiffness), and swelling Swelling Inflammation of many joints. On examination, joint tenderness and swelling Swelling Inflammation may be noted on the small joints of the hands, wrist, and forefoot. Individuals with poorly controlled disease have significant joint deformities (e.g., swan-neck deformity). Management is with early use of disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects. Disease-Modifying Antirheumatic Drugs (DMARDs) ( DMARDs DMARDs Disease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects. Disease-Modifying Antirheumatic Drugs (DMARDs)) and antiinflammatory agents. 
• Elbow tendinopathy: Chronic pain Chronic pain Aching sensation that persists for more than a few months. It may or may not be associated with trauma or disease, and may persist after the initial injury has healed. Its localization, character, and timing are more vague than with acute pain. Pain Management at the lateral or medial epicondyle Medial epicondyle Arm: Anatomy of the elbow is a relatively common condition, particularly among tennis players and golfers, respectively, and among manual laborers. On examination, there is localized tenderness over the lateral or medial epicondyle Medial epicondyle Arm: Anatomy, with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways elicited during resisted wrist flexion or extension. The diagnosis is primarily clinical. Management may include activity modification, bracing, oral analgesics, or physical therapy Physical Therapy Becker Muscular Dystrophy. 
• Ganglion cyst: one of the most common soft tissue Soft Tissue Soft Tissue Abscess swellings in the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy and the wrist. A ganglion cyst is a fluid-filled swelling Swelling Inflammation overlying a joint or tendon sheath. These cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change are benign Benign Fibroadenoma but may occasionally lead to pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, weakness, and loss of function Loss of Function Inflammation. On examination, an obvious swelling Swelling Inflammation that is firm, smooth, rounded, rubbery, and at times tender is noted. Management is with reassurance Reassurance Clinician–Patient Relationship for asymptomatic cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change, aspiration, or surgical therapy.