FOREARM, WRIST, AND HAND
SELECTED MOVEMENTS
INDICATIONS OF A POSITIVE TEST
Pronation and supination. Active pronation and supination of the forearm and wrist are approximately 85° to 90°, although this varies from individual to individual. It is more important to compare the movement with that of the normal side. Approximately 75° of supination or pronation occurs in the forearm articulations. The remaining 15° is the result of wrist action.
Wrist flexion and extension. Wrist flexion is 80° to 90°; wrist extension is 70° to 90°. The end feel of each movement is tissue stretch.
Radial and ulnar deviation. Radial and ulnar deviations of the wrist are 15° and 30° to 45°, respectively. The normal end feel of these movements is bone to bone.
Finger flexion. Flexion of the fingers occurs at the metacarpophalangeal joints (85° to 90°), followed by the proximal interphalangeal joints (100° to 115°) and the distal interphalangeal joints (80° to 90°).
Finger extension. Extension occurs at the metacarpophalangeal joints (30° to 45°), the proximal interphalangeal joints (0°), and the distal interphalangeal joints (20°). The end feel of finger flexion and extension is tissue stretch.
Finger abduction and adduction. Finger abduction occurs at the metacarpophalangeal joints (20° to 30°); the end feel is tissue stretch. Finger adduction (0°) occurs at the same joint.
Thumb flexion. Thumb flexion occurs at the carpometacarpal joint (45° to 50°), the metacarpophalangeal joint (50° to 55°), and the interphalangeal joint (80° to 90°). It is associated with medial rotation of the thumb as a result of the saddle shape of the carpometacarpal joint.
Thumb extension. Extension of the thumb occurs at the interphalangeal joint (0° to 5°); it is associated with lateral rotation. Flexion and extension take place in a plane parallel to the palm of the hand.
Thumb abduction and adduction. Thumb abduction is 60° to 70°; thumb adduction is 30°. These movements occur in a plane at right angles to the flexion-extension plane.
• Pathological conditions in structures other than the joint may restrict ROM (e.g., muscle spasm, tight ligaments/capsules). If the examiner suspects a problem with these structures, passive movement end feels will help differentiate the problem.
• Most functional activities of the hand require the fingers and thumb to open at least 5 cm (2 inches), and the fingers should be able to flex within 1 to 2 cm (0.4 to 0.8 inches) of the distal palmar crease.
• If the patient complains of pain on supination, the examiner can differentiate between the distal radioulnar joint and the radiocarpal joints by passively supinating the ulna on the radius with no stress on the radiocarpal joint. If this passive movement is painful, the problem is in the distal radioulnar joint, not the radiocarpal joints. The normal end feel of both movements is tissue stretch, although in thin patients, the end feel of pronation may be bone to bone.
• Wrist flexion decreases as the fingers are flexed, just as finger flexion decreases as the wrist flexes, and movements of flexion and extension are limited, usually by the antagonistic muscles and ligaments.
• The digits are medially deviated slightly in relation to the metacarpal bones. When the fingers are flexed, they should point toward the scaphoid tubercle. In addition, the metacarpals are at an angle to each other.
SPECIAL TESTS FOR LIGAMENT, CAPSULE, AND JONT INSTABILITY2–5
Relevant Special Tests
Ligamentous instability test for the fingers
Thumb ulnar collateral ligament laxity or instability test
Suspected Injury
Relevant Signs and Symptoms
• Localized pain may occur over the injured tissue, especially when the individual is gripping, using the hand, or weight bearing on the hand.
• Generalized pain may be present.
• Swelling may or may not be present.
• Clicking or catching may be noted with functional use.
• The patient may complain of weakness in the hand and wrist.
Mechanism of Injury
THUMB ULNAR COLLATERAL LIGAMENT LAXITY OR INSTABILITY TEST6,7 
LUNOTRIQUETRAL BALLOTTEMENT (REAGAN’S) TEST8–10 
TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) LOAD TEST16 
INDICATIONS OF A POSITIVE TEST
Pain, clicking, or crepitus in the area of the TFCC indicates a positive test result.
• Degeneration of the TFCC begins in the third decade of life and progressively increases in frequency and severity in subsequent decades. Studies have observed no normal-appearing triangular fibrocartilage complexes after the fifth decade of life.
• Gymnasts (males more than females) incur TFCC injuries as a result of using the wrist as a weight-bearing joint.
• The patient may complain of pain when putting weight on the hand (wrist extended) and then pronating the forearm.
SPECIAL TEST FOR MUSCLE OR TENDON PATHOLOGY17–19
Relevant Special Test
Relevant History
• Recurrent episodes are common.
• Work requiring repetitive wrist motion often is cited as a factor.
• The condition may appear in women after giving birth, probably because of altered hand use in lifting the infant and positioning the baby for breast-feeding. Research also has demonstrated laxity in the wrist joint postpartum, which may contribute to the development of pain in the region.
SPECIAL TESTS FOR NEUROLOGICAL SYMPTOMS22–32
Relevant Special Tests
Mechanism of Injury
• First-degree neuropraxia involves distortion of myelin about the nodes of Ranvier caused by ischemia, mechanical compression, or electrolyte imbalance, resulting in temporary loss of nerve conduction.
• Second-degree axonotmesis involves interruption of the axon with secondary wallerian degeneration but preservation of the supporting tissue around the axon. Recovery may be complete but takes longer and depends on the distance between the site of injury and the end structure (denervated muscle).
• Third-degree neurotmesis involves extensive disruption of the nerve and its supporting structures; however, although the endoneurium is disrupted, the perineurium and epineurium remain intact.
• Fourth-degree neurotmesis involves disruption of all neural components except the epineurium.
• Fifth-degree neurotmesis involves complete transection and discontinuity of the nerve, with no capacity for regeneration. Neurotmesis rarely occurs as a result of entrapment. However, when continuity has been disrupted, complete recovery is not possible, even with surgical techniques, and the eventual outcome depends on the individual circumstances.
RELIABILITY/SPECIFICITY/SENSITIVITY COMPARISON30–32
| Validity | Interrater Reliability | Intrarater Reliability | Specificity | Sensitivity | |
| Tinel’s Sign | No association with the severity of carpal tunnel syndrome and test results p > 0.11 | 0.77 | 0.80 | 87% | 23% |
| Phalen’s Test | Patients with more severe carpal tunnel syndrome are more likely to have a positive test result p < 0.05 | 0.65 | 0.53 | 76% | 51% |
| Reverse Phalen’s Test | Unknown | Unknown | Unknown | Unknown | Unknown |
• This test gives an indication of the rate of regeneration of sensory fibers of the median nerve. The most distal point at which the abnormal sensation is felt represents the limit of nerve regeneration.
• Tinel’s sign can be used to test any superficial nerve along its pathway.
• Tests for neurological dysfunction are highly suggestive of a particular nerve lesion if they produce a positive result, but they do not rule out the problem if the result is negative. In fact, test results may be negative 50% of the time or more often even when the condition actually exists. Electrodiagnostic tests are more conclusive.
PHALEN’S (WRIST FLEXION) TEST37 
• Tests for neurological dysfunction are highly suggestive of a particular nerve lesion if they produce a positive result, but they do not rule out the problem if the result is negative. In fact, test results may be negative 50% of the time or more often even when the condition actually exists. Electrodiagnostic tests are more conclusive.
SPECIAL TESTS FOR CIRCULATION AND SWELLING IN THE WRIST AND HAND
Relevant Special Tests
Relevant Signs and Symptoms
• Swelling is more obvious on the dorsum of the hand, where the skin is looser.
• Tightness and stiffness in the hand joints often are seen.
• Rings and jewelry on the hands and fingers may fit tightly.
• Coldness or weakness in the hands and arms may be noted.
• Color changes may be seen in the upper extremity.
Mechanism of Injury
JOINT PLAY MOVEMENTS
ANTERIOR-POSTERIOR GLIDE OF THE WRIST 
Step 1: Radiocarpal joint. The examiner first places the forearm in a supinated or pronated position. The examiner’s stabilizing hand then is placed around the distal end of the radius and ulna, just proximal to the radiocarpal joint, and the other hand is placed around the proximal row of carpal bones. If the examiner’s hands are positioned properly, they should touch. The examiner applies an anteroposterior gliding movement of the proximal row of carpal bones on the radius and ulna, testing the amount of movement and end feel.
Step 2: Midcarpal joint. The examiner moves the stabilizing hand slightly distally (less than 1 cm [0.4 inch]) so that it is around the proximal row of carpal bones and places the mobilizing hand around the distal row of carpal bones. An anteroposterior gliding movement is applied to the distal row of carpal bones on the proximal row to test the amount of movement and end feel (midcarpal joint).
Step 3: Carpometacarpal joint. The examiner then moves the stabilizing hand slightly distally again (less than 1 cm [0.4 inch]); the hand will be around the distal carpal bones. The mobilizing hand is placed around the metacarpals. An anteroposterior gliding movement is applied to the base of the metacarpals to test the amount of joint play and end feel.
SHEAR TEST OF THE INDIVIDUAL CARPAL BONES 
• Because the carpal bones are small, correct hand position is critical for the success of this test.
• A firm grasp of anatomy is required for success when doing these movements. Carpal joint locations are difficult to palpate; therefore, an understanding of the anatomical location of the individual bones helps the examiner identify their position and facilitates testing of the joint.
• Reagan’s test, Watson’s test, and the lunotriquetral test are done in a similar fashion.
LONG AXIS EXTENSION OF THE JOINTS OF THE FINGERS 
ANTERIOR-POSTERIOR GLIDE OF THE JOINTS OF THE FINGERS 
• A minimal amount of traction may be applied to bring about slight separation of the joint surfaces before the anterior or posterior movement is done.
• The examiner must position both hands close to the joint line so that the motion tested reflects true joint play and not finger flexion or extension.
ROTATION OF THE JOINTS OF THE FINGERS 
