16.2 Elbow, Wrist, and Hand Pathologies
Key Takeaways
Localized lateral elbow pain during gripping or resisted wrist extension supports lateral epicondylalgia. Progress wrist extensor exercise according to irritability and task tolerance.
The anterior UCL bundle resists valgus load. The moving valgus stress test applies valgus as the elbow extends from full flexion and checks for familiar medial pain.
Use a cluster of findings in suspected CTS. A near-neutral nighttime orthosis can help mild to moderate symptoms. Progressive thenar weakness or sensory loss warrants assessment.
De Quervain tenosynovitis involves the APL and EPB tendons. Interpret provocation tests alongside local symptoms and examination findings.
TFCC injury can cause ulnar-sided pain with loading and rotation. Examine the joint for instability and consider other causes before referral or treatment.
Elbow, Wrist, and Hand Pathologies
Ask the patient to locate the symptoms and show the activity that provokes them. Gripping pain, pain during a valgus load and paresthesias require different examination and management decisions, even when they occur in the same arm.
Lateral and Medial Epicondylalgia
Lateral elbow pain
Lateral epicondylalgia commonly involves the common wrist extensor origin, including the extensor carpi radialis brevis (ECRB). Degenerative changes have been described in surgical tissue. Clinical examination establishes a working diagnosis from pain location, behavior and loading findings.
Cozen testing uses resisted wrist extension, often with radial deviation and the forearm pronated. Mill testing lengthens the wrist extensors with wrist flexion, forearm pronation and elbow extension. Maudsley testing uses resisted middle finger extension. Local reproduction of familiar pain can support the working diagnosis. These tests cannot isolate a tendon or confirm a particular tissue change. Check painful grip, range of motion and neurologic findings as indicated.
The 2022 lateral elbow pain guideline recommends resisted wrist extensor exercise for subacute or chronic lateral elbow tendinopathy. Isometric, concentric or eccentric exercise can be selected and progressed according to irritability and task demands. A small trial by Tyler and colleagues tested adding a controlled eccentric exercise with a flexible resistance bar. The patient uses the other wrist to pretension the bar and the symptomatic wrist slowly controls its release into flexion. Select the load and volume from tolerable performance and the response after exercise. Isometric exercise does not reliably produce immediate analgesia.
Medial elbow pain
The common flexor–pronator tendon origin includes the pronator teres and wrist flexors. Familiar pain around the medial epicondyle with resisted wrist flexion or forearm pronation can support medial epicondylalgia. Passive wrist extension with the elbow extended can also provoke symptoms. Distinguish pain on local muscle loading from pain during a valgus stress test, ulnar-distribution paresthesias or mechanical symptoms. Adjust gripping or pronation demands and progress tolerated loading when the findings support tendinopathy.
Elbow Ligamentous Injuries: Ulnar Collateral Ligament (UCL) Insufficiency
The medial ulnar collateral ligament (UCL) has anterior, posterior and transverse bundles. The anterior bundle is a major static restraint to valgus stress. The bony articulation and surrounding muscles also contribute. Repetitive valgus loading during overhead throwing can stress the ligament, especially around late cocking and early acceleration.
- Static valgus stress: Stabilize the humerus and apply controlled valgus stress with the elbow slightly flexed. Record familiar pain, excursion and the endpoint. Compare with the other side.
- Milking maneuver: With the elbow flexed beyond 90° and the forearm supinated, pull gently on the thumb to apply valgus stress. Assess medial pain or apprehension and compare with the rest of the examination.
- Moving valgus stress: In O'Driscoll's test, start in full elbow flexion. Maintain moderate valgus torque while extending the elbow. Familiar pain localized to the ligament and most prominent from roughly 120° to 70° of flexion is a positive finding. The original surgical series detected 17 of 17 affected cases and was negative in three of four unaffected cases. Diagnostic performance may differ in a general clinic.
A sudden pop with loss of throwing function, persistent medial pain or instability warrants sports medicine assessment. A positive test supports suspicion of a UCL injury. The history, other examination findings and imaging when indicated help define the lesion and guide a return-to-throwing plan.
Carpal Tunnel Syndrome (CTS)
Carpal tunnel syndrome (CTS) is compression of the median nerve at the wrist. Common findings include nocturnal paresthesias in the thumb, index, middle or radial half of the ring finger. Longer-standing or more severe cases can have persistent sensory loss and weakness of thumb abduction or opposition.
Compression can affect nerve function. Examine symptom distribution, thumb abduction, thenar bulk and sensation. Consider cervical radiculopathy, proximal median neuropathy or a generalized neuropathy when the pattern is atypical.
| Provocation maneuver | Technique and finding |
|---|---|
| Carpal compression (Durkan) | Apply pressure over the median nerve at the tunnel for up to 30 seconds. Check for familiar median-distribution symptoms. |
| Phalen | Sustain wrist flexion, as tolerated, for up to a minute and note symptom distribution. |
| Tinel at the wrist | Tap over the nerve and note whether it reproduces distal median-distribution paresthesias. |
Combine the history and examination. The 2024 AAOS guideline supports using the CTS-6 clinical tool in place of routine ultrasound or electrodiagnosis in typical presentations. The CTS-6 combines median-distribution numbness, nocturnal symptoms, thenar weakness or atrophy, Phalen, Tinel and two-point discrimination. Individual test accuracy varies. Electrodiagnostic evaluation can assist with atypical cases or questions about severity or another neuropathy. Interpret latency and conduction velocity using the recording distance, temperature and the testing laboratory's reference values.
The 2026 physical therapy guideline recommends a forearm-based, near-neutral wrist orthosis worn at night for short- or mid-term symptom and function improvement in mild to moderate CTS managed nonsurgically. Discuss positions or tasks that reproduce symptoms. Tendon or nerve gliding can be considered if tolerated. A trial in mild CTS did not show an added benefit from gliding exercises over splint use alone during six weeks. If teaching tendon motion, demonstrate straight hand, hook fist, full fist, tabletop and straight fist without provoking persistent symptoms.
Warning
Progressive thenar weakness or wasting and persistent sensory loss warrant prompt medical or hand specialist assessment. A provocative test result or single two-point discrimination measurement cannot establish axonal loss or the need for a specific operation.
De Quervain Tenosynovitis
De Quervain tenosynovitis affects the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons in the first dorsal compartment at the radial styloid. Assess tenderness at that site and whether lifting, grasping or resisted thumb movement reproduces familiar pain. Consider thumb carpometacarpal joint pain, intersection syndrome and superficial radial nerve symptoms when location or behavior differs.
- Finkelstein and Eichhoff: In Wu and colleagues' comparison, the Finkelstein maneuver combined wrist ulnar deviation with examiner-guided thumb flexion. Eichhoff encloses the thumb in the fist before ulnar deviation. Finkelstein caused fewer false positives in asymptomatic wrists in that study. It did not establish sensitivity in patients with the condition. Use controlled movement and assess where familiar symptoms occur.
- WHAT test: Resist thumb abduction with the wrist in flexion. Goubau's referred radial styloid pain cohort reported 99% sensitivity and 29% specificity versus ultrasound. A positive test alone provides limited confirmation.
- Management: Discuss adaptations to aggravating tasks such as lifting an infant with the thumb spread and the wrist deviated. A thumb spica can help limit painful motion during selected tasks. Progress tolerated use and discuss medical options, including local corticosteroid injection, if symptoms remain limiting.
Dupuytren Contracture, Trigger Finger, and TFCC Lesions
Dupuytren contracture
Nodules and cords in the palmar and digital fascia can progressively limit finger extension, often in the ring and small fingers. Use the tabletop test to observe whether the patient can place the palm and fingers flat. Document joint-specific extension loss and how the condition affects hand use. Refer when contracture progresses or limits function. The tabletop finding alone does not select an intervention.
Trigger finger
Restricted flexor tendon glide at the A1 pulley near the metacarpal head can cause painful catching or locking. Check for tenderness at the pulley and observe active flexion and extension. Options for symptomatic adults include an orthosis that limits provoking motion or medical review for corticosteroid injection. Persistent locking or functional loss warrants hand specialist assessment.
Triangular fibrocartilage complex (TFCC)
The articular disc, radioulnar ligaments and related ulnar-sided soft tissues help stabilize the distal radioulnar joint and transfer load across the wrist. The central disc has limited vascularity compared with the peripheral attachment. Palmer's classification distinguishes traumatic and degenerative lesions. Location and instability affect management.
Ulnar-sided pain with forearm rotation, gripping or axial loading can fit a TFCC lesion. In the ulnocarpal stress test, combine controlled axial loading and ulnar deviation, with forearm rotation as tolerated. For the fovea sign, palpate the soft interval just distal to the ulnar head between the styloid and flexor carpi ulnaris tendon. A painful fovea can accompany injuries of the foveal or ulnotriquetral attachments. Accuracy varies by setting and reference diagnosis. Assess distal radioulnar stability and consider other causes of ulnar wrist pain. Traumatic instability, persistent clicking with loss of function or failure to improve warrants further assessment.
Clinical Case Scenario: Elbow and Hand Complex
A 44-year-old administrative data analyst and competitive amateur tennis player presents with severe pain over the lateral aspect of her dominant right elbow lasting 7 weeks. She reports that shaking hands, carrying a grocery bag, and clicking a computer mouse provoke sharp lateral elbow pain. She also notes occasional tingling in the palmar surface of the thumb, index, and middle fingers after prolonged typing.
Examination reproduces familiar lateral elbow pain with gripping, resisted wrist extension and common extensor palpation. Carpal compression and Phalen reproduce tingling in the thumb, index and middle fingers. Thenar bulk and thumb abduction strength are preserved.
- Elbow decision: The local examination supports lateral epicondylalgia. Temporarily modify heavy gripping and begin wrist extensor exercise at a tolerable load. Recheck grip and gradually restore the demands of tennis.
- Hand decision: The paresthesia distribution and wrist provocation support possible CTS. Evaluate the rest of the clinical pattern and screen for other sources if needed. For intermittent symptoms without progressive weakness or sensory loss, discuss a near-neutral night orthosis. Reassess symptom frequency and hand function.
A dental hygienist reports nocturnal paresthesias in the thumb, index and middle fingers. Which assessment best supports a clinical diagnosis of carpal tunnel syndrome?
Use Tinel alone and confirm the diagnosis whenever tapping reproduces tingling.
Use the CTS-6 history and examination findings and consider other causes if the pattern is atypical.
Use Eichhoff to test sensory conduction through the carpal tunnel.
Use resisted middle finger extension to confirm median nerve compression at the wrist.
A carpenter has six weeks of lateral elbow pain during gripping and familiar pain with resisted wrist extension. What initial rehabilitation approach fits these findings?
Immobilize the elbow until gripping is pain-free and then resume the usual workload.
Begin at the full work load and increase repetitions whenever pain occurs.
Adjust the provoking tasks and progressively load the wrist extensors according to tolerance.
Use passive ultrasound as the primary treatment and delay active exercise until symptoms resolve.
A pitcher reports medial elbow pain during late cocking. The therapist maintains moderate valgus torque while extending the elbow from full flexion, reproducing familiar pain from 120° to 70°. Which finding does this support?
A positive Cozen test that supports a common wrist extensor problem
A positive milking maneuver that supports suspicion of UCL injury
A positive flexor–pronator loading test that supports medial epicondylalgia
A positive moving valgus stress test that supports suspicion of UCL injury
A patient has focal pain at the radial styloid with lifting and resisted thumb abduction. What does a positive WHAT test add when considering De Quervain tenosynovitis?
It reproduces symptoms during thumb abduction with the wrist flexed. The original study found low specificity, so interpret it with the rest of the examination.
It rules in De Quervain tenosynovitis because the original study found 95% specificity.
It localizes the cause of symptoms to the median nerve within the carpal tunnel.
It confirms that the wrist pain originates at the distal radioulnar joint.
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