With that, let's start talking about some
specific diagnoses that patients oftentimes
present with that we're trying to assess.
So the first of which is carpal tunnel syndrome.
Patients with carpal tunnel syndrome
have entrapments of the median nerve
as it courses through the carpal tunnel.
And there's a number of classic findings
that we associate with carpal tunnel syndrome,
the first of which is just called Tinel's
sign, which I always remember starts with T,
which makes me think of tapping.
Simply tap on the carpal tunnel itself, overlying
the median nerve in an effort to try and reproduce
that median nerve neuropathy and the
paresthesias that typically have it in the thumb,
the index finger and then the
radial side of the middle finger.
The next test is Phalen's test.
I'm just going to have you put your
hands together like this and apply pressure
to that to your wrists.
This is essentially a
compression of the tunnel.
You're trying to essentially
induce ischemia to the median nerve
to the vasa vasorum, the blood supply to
the median nerve in an effort to recreate
the symptoms that the patient has been having.
You can relax now.
Essentially, a patient with carpal tunnel
syndrome has a chronic ischemic neuropathy
where there's damage to the nerve
because of impaired blood supply.
So you're just trying to do these
maneuvers to recreate that sensation.
And the third one is going
to be the hand elevation test,
which is kind of a newer
kid on the block, so to speak.
And can you put your
hands and elevate them?
You'll have a patient do
this for upwards of a minute.
And oftentimes I'll be getting more history from
them once I'm suspecting carpal tunnel syndrome
while I have their hands up in the air.
And the reason that this test works is,
again, because of this idea of ischemia,
by putting your hand up in the air, you're
making a little bit harder for gravity to deliver
blood through this already damaged and
compressed blood supply to the median nerve.
So you're trying to reproduce
the symptoms in that way.
thank you for bringing your arms down again.
Patients with, for example,
a C6 radiculopathy,
so nothing to do with the blood supply
to the median nerve, but a radiculopathy,
they tend to get better when
they put their hands up in the air
because you're actually taking tension off the
C6 nerve root by putting your hands up in the air.
Next up, we'll take a look at
De Quervain's tenosynovitis.
This is also a relatively common condition
and it's going to be essentially inflammation
in the extensor tendon
sheaths here going to the thumb.
And the most common test that we do for
that is just put your thumb in your hand like this
and I'm going to tilt your wrist down.
It's actually uncomfortable, even at baseline for
folks who don't have the De Quervain's tenosynovitis
So you want to compare one side to the other.
I'll tell you that folks who really
have the De Quervain's tenosynovitis,
it's not just uncomfortable,
they'll like jump off their seat
because you're putting
tension on that tendon sheath.
That test is called the Eichhoff's test.
Oftentimes, it's mistakenly called the
Finklestein test, but it's actually Eickhoff test.
In addition, a simpler test even
than that is just to have the patient
lift up their thumb against resistance.
Lift against me, sorry.
Just by basically activating her
extensor tendons of her thumb,
that may reproduce the pain
of De Quervain's tenosynovitis.
And then lastly, we want to look for another
common complaint, which is also in the same area.
So it's important to which test, and how to
interpret these tests is basal joint arthritis,
also known as first CMC arthritis
or carpometacarpal joint arthritis
I mentioned before how the CMC of the thumb
is one of the few joints that actually is mobile
compared with the CMCs
in the rest of the hand.
And this joint can classically
develops arthritis right in this spot.
And you could certainly have tenderness
in that spot, though a person with
De Quervain's tenosynovitis
would also have tenderness there.
So the test we used to distinguish
that is called the Grind test
where you're taking that metacarpal
bone, this is the metacarpal bone here
and you're grinding it into the, you're
grinding it proximally into the CMC joint.
Patients with osteoarthritis will
not feel great when you do that.
And that will reproduce the
discomfort from CMC arthritis.
Whereas since I'm not affecting
the tendon sheath overlying that joint,
it helps me to exclude
De Quervain's tenosynovitis
and to distinguish amongst
those two conditions.
And lastly, we always say when
you're doing the musculoskeletal exam
to examine the joint above and below
the place that the person is reporting pain.
Patients with pain radiating down the forearm may
actually have a problem with their elbow in particular,
medial or lateral epicondylitis,
so-called tennis elbow and golfer's elbow.
And you'll have tenderness
right over the epicondyles.
And that's where there's basically
the insertion of these muscles
and the tendons running
past them is inflamed.
And what we simply do to test for
those is all the extensors of the wrist
are inserting on the lateral epicondyle.
So I just want you to make a fist and I want
you to lift it up and I'm going to push down.
If doing this causes her pain
around the lateral epicondyle,
that supports the diagnosis
of lateral epicondylitis.
In contrast, rotate your
wrist, and round and I'll flip up.
All these muscles of flexion of the
wrist insert onto the medial epicondyle.
So tenderness that's reproduced
in that area during this maneuver
would support medial epicondylitis.