Trusted medical expertise in seconds.

Access 1,000+ clinical and preclinical articles. Find answers fast with the high-powered search feature and clinical tools.

Try free for 5 days
Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer.

Upper extremity osteopathy

Last updated: May 4, 2020

Summarytoggle arrow icon

The flexibility of the upper extremity results in a wide range of movements across the shoulder, elbow, and wrist joints, which often leads to excessive and directionally awkward stress. The upper extremity is attached to the torso through multiple muscular attachments and one bony attachment (the sternoclavicular joint). Therefore, osteopathic examination and treatment are often first directed at the cervical and thoracic spine. Dysfunction can be present in any of the cardinal directions of each joint, as well as the radial head of the humerus. Osteopathic treatment in this region mostly consists of articulatory techniques, muscle energy, and high-velocity low-amplitude.

Shoulder

Bones

Osteopathic landmarks of the shoulder

Range of motion

Elbow

Bones

  • See article on arm and elbow.

Osteopathic landmarks of the elbow

Range of motion

Wrist

Bones

Osteopathic landmarks of the wrist

Range of motion

Shoulder

Apley scratch test

Shoulder apprehension tests

Neer sign

Hawkins-Kennedy test

Adson test

Wright test

Drop arm test

  • Function: assesses supraspinatus tendon integrity
  • Position: seated
  • Procedure: starting from ∼ 90 degrees, ask patient to slowly adduct arms
  • Positive test: inability to lower arms slowly or smoothly

Yergason test

Costoclavicular syndrome test (military posture test)

  • Function: assesses for thoracic outlet syndrome
  • Position: seated or standing
  • Procedure
    1. Ask patient to bring back and depress the shoulders (assuming a military posture).
    2. Stabilize the patient's scapula.
    3. While monitoring the radial pulse, slightly abduct and extend the shoulder.
    4. Add lateral traction.
  • Positive test: reproduction of symptoms or a diminished radial pulse

Elbow

Tinel test

Wrist

Watson test

  • Function: assesses for instability between the scaphoid and lunate
    Position: seated
  • Procedure
    1. Place thumb on the scaphoid tubercle with patient's wrist in ulnar deviation.
    2. Apply dorsal pressure while the patient deviates hand radially.
  • Positive test: pain or laxity

Shuck test

  • Function: assesses for perilunate instability
  • Position: seated
  • Procedure
    1. Hold patient's wrist in flexion.
    2. Ask patient to extend fingers against equal resistance.
  • Positive test: pain over the dorsum of the wrist

Allen test

Finkelstein test

Phalen test

Tinel sign

Spencer technique (seven steps of Spencer)

Shoulder flexion dysfunction

Diagnosis

  • Shoulder extension restriction (flexion freedom of motion)

Treatment

Muscle energy

  • Position: lateral recumbent with dysfunctional side up
  • Procedure
    1. Place shoulder into extension barrier.
    2. Ask patient to flex shoulder against equal resistance for 3–5 seconds.
    3. Relax for 5 seconds.
    4. Re-engage barrier and repeat.
    5. Reassess.

Shoulder extension dysfunction

Diagnosis

  • Shoulder flexion restriction (extension freedom of motion)

Treatment

Muscle energy

  • Position: lateral recumbent with dysfunctional side up
  • Procedure
    1. Place shoulder into flexion barrier.
    2. Ask patient to extend shoulder against equal resistance for 3–5 seconds.
    3. Relax for 5 seconds.
    4. Re-engage barrier and repeat.
    5. Reassess.

Shoulder abduction dysfunction

Diagnosis

Treatment

Muscle energy

  • Position: lateral recumbent with dysfunctional side up
  • Procedure
    1. Place shoulder into adduction barrier.
    2. Ask patient to abduct shoulder against equal resistance for 3–5 seconds.
    3. Relax for 5 seconds.
    4. Re-engage barrier and repeat.
    5. Reassess.

Shoulder adduction dysfunction

Diagnosis

Treatment

Muscle energy

  • Position: lateral recumbent with dysfunctional side up
  • Procedure
    1. Place shoulder into abduction barrier.
    2. Ask patient to adduct shoulder against equal resistance for 3–5 seconds.
    3. Relax for 5 seconds.
    4. Re-engage barrier and repeat.
    5. Reassess.

Shoulder internal rotation dysfunction

Diagnosis

Treatment

Muscle energy

  • Position: seated
  • Procedure
    1. Flex elbow to ∼ 90 degrees.
    2. Place shoulder into external rotation barrier.
    3. Ask patient to internally rotate shoulder (push wrist and forearm toward the midline) against equal resistance for 3–5 seconds.
    4. Relax for 5 seconds.
    5. Re-engage barrier and repeat.
    6. Reassess.

Shoulder external rotation dysfunction

Diagnosis

Treatment

Muscle energy

  • Position: seated
  • Procedure
    1. Flex elbow to ∼90 degrees.
    2. Place shoulder into internal rotation barrier.
    3. Ask patient to externally rotate shoulder (push wrist and forearm laterally) against equal resistance for 3–5 seconds.
    4. Relax for 5 seconds.
    5. Re-engage barrier and repeat.
    6. Reassess.

Anterior radial head dysfunction

Diagnosis

Treatment

Muscle energy

  • Procedure
    1. Place elbow in pronation barrier.
    2. Ask patient to supinate against equal resistance for 3–5 seconds.
    3. Relax for 5 seconds.
    4. Re-engage barrier and repeat.
    5. Reassess.

High-velocity low-amplitude

Posterior radial head dysfunction

Diagnosis

Treatment

Muscle energy

  • Procedure
    1. Place elbow in supination barrier.
    2. Ask patient to pronate against equal resistance for 3–5 seconds.
    3. Relax for 5 seconds.
    4. Re-engage barrier and repeat.
    5. Reassess.

High-velocity low-amplitude

Radial deviation dysfunction

Diagnosis

Treatment

Muscle energy

  • Procedure
    1. Place wrist into ulnar deviation restriction.
    2. Ask patient to radially deviate against equal resistance for 3–5 seconds.
    3. Relax for 5 seconds.
    4. Re-engage barrier and repeat.
    5. Reassess.

Ulnar deviation dysfunction

Diagnosis

Treatment

Muscle energy

  • Procedure
    1. Place wrist into radial deviation restriction,
    2. Ask patient to ulnar deviate against equal resistance for 3–5 seconds.
    3. Relax for 5 seconds.
    4. Re-engage barrier and repeat.
    5. Reassess.
  1. Destefano L. Greenman's Principles of Manual Medicine. Wolters Kluwer Law & Business ; 2015
  2. Nicholas A. Atlas of Osteopathic Techniques. LWW ; 2015