Patients arrive with a complaint and a place — “my shoulder hurts,” “my fingers tingle.” This is a regional examination built for exactly that: screen the whole patient first, then examine the region they point to — and know the nerve that imitates each common diagnosis.
Examine the region the patient points to — but screen the whole patient first.
Patients do not present with a diagnosis. They present with a complaint and a location: a sore shoulder, a clicking finger, pins and needles in the hand. So the examination should be organised the way the patient is — by region. Shoulder, elbow, wrist, hand and thumb, each with its own short, focused routine.
Two things, though, do not respect the region. The first is serious pathology — cervical myelopathy, a Pancoast tumour, brachial neuritis — which can surface as shoulder ache or a clumsy hand and be quietly mistaken for something mechanical. The second is nerve compression: where a symptom is felt is very often not where the nerve is trapped.
So the structure is a brief universal screen run on everyone — it catches what does not respect anatomy — followed by the regional examination. And within each region, one idea does most of the work: every region has a headline mechanical diagnosis and a nerve that imitates it. Knowing the pair, and the one test that separates them, is the skill.
Symptom location is not compression location.
The principle that makes a regional examination safeThe universal screen means a red flag hiding inside an ordinary regional complaint does not get past you.
For every region you will know the nerve mimic and the single test that exposes it — before an injection, not after.
Your referral letter will name the pattern, and the named pattern routes the patient to the right clinic.
The universal screen — run this on everyone
Around thirty seconds. It is the gate above the regional modules: it catches the pathology that does not respect the area the patient points to.
History — two questions
Progressive weakness, or severe pain followed by patchy weakness, does not belong in any regional pathway.
Look — head to hand
- Gait, as the patient walks in
- Face — ptosis and miosis (Horner’s)
- Wasting — deltoid, thenar, first dorsal interosseous
- Fasciculations, with the limb relaxed
- Scapular winging on a wall push
Hoffmann’s — the cord
Flick the middle fingernail, both sides. Then one question: “Any recent change in your handwriting, doing up buttons, or your balance?”
A positive Hoffmann’s with a gait or fine-motor change points at the cervical cord, not the arm.
How to grade strength
Each regional module lists its motor tests. They are only as good as the way you perform them.
- Compare sides on every test. The patient is their own control; never grade one side alone.
- Push firmly. Test at the patient’s true maximum. Tentative testing finds no weakness and misses the diagnosis.
- Watch the face. Wincing is pain inhibition, not weakness — reposition to remove the painful joint, or record the test as uninterpretable.
- Test for fatigue. Full strength on the first effort but weaker on repetition is the signature of dynamic nerve compression. Test twice.
Grading — three states, not a scale
Give-way weakness — resists then collapses — is effort-dependent; do not flag it. Fatigue weakness on repeat testing is genuine; flag it.
Shoulder
“My shoulder hurts.” “I can’t lift my arm.” “It aches all night.”
Frozen shoulder
Passive external rotation is restricted, elbow tucked in — both active and passive range are lost. A cuff problem keeps its passive range.
Rotator cuff / impingement
A painful arc on abduction, 60–120°, with a positive Hawkins–Kennedy.
Weakness on resisted abduction or external rotation suggests a tear, not impingement.
AC joint
Pain localises to one finger placed on the joint; the scarf (cross-body) test reproduces it.
C5 radiculopathy
A C5 nerve root imitates shoulder pathology closely: weak deltoid and biceps, sensory disturbance over the lateral arm — the regimental-badge area — and a dampened biceps reflex. The shoulder is also where brachial neuritis and a Pancoast tumour first declare themselves.
Don’t miss — refer now
- Severe shoulder or arm pain that eased as weakness appeared — brachial neuritis (Parsonage–Turner).
- Shoulder or scapular pain in a smoker, with Horner’s or weight loss — Pancoast tumour.
- Unable to externally rotate after a seizure or fall — locked posterior dislocation until proven otherwise.
- Hot, swollen, systemically unwell — septic joint.
Refer direct — don’t delay
- Cuff weakness (M4) with a tear pattern, especially after trauma in a younger patient — to a shoulder surgeon, not a prolonged physiotherapy trial.
- Frozen shoulder in a person with diabetes, or not improving by three months.
Shoulder abduction (C5 · axillary · deltoid). Elbow flexion (C5–6 · musculocutaneous · biceps).
“Restricted passive external rotation, likely adhesive capsulitis” — or — “deltoid and biceps weakness with lateral arm sensory loss; screening the cervical spine.”
Elbow
“My elbow hurts — on the outside.” “On the inside.” “It hurts to grip.”
Tennis elbow
Tenderness over the lateral epicondyle; positive Maudsley’s — resisted middle finger extension — and resisted wrist extension.
Golfer’s elbow
Tenderness over the medial epicondyle; pain on resisted wrist flexion and pronation with the elbow extended.
Olecranon bursitis
Swelling over the olecranon.
A hot, tender bursa with systemic features is septic until proven otherwise.
Three nerves — and the tender point names which
Each aspect of the elbow has a nerve that imitates its mechanical diagnosis, and each is tender in a different, specific place — so palpation localises the culprit. Lateral — radial tunnel syndrome (posterior interosseous nerve) imitates tennis elbow: tenderness sits three to four fingerbreadths distal to the epicondyle over the supinator, and the Hagert ECU test is positive. Medial — cubital tunnel (ulnar nerve) imitates golfer’s elbow: little and ring finger tingling, weak first dorsal interosseous, a positive elbow flexion test — golfer’s elbow itself does not tingle. Volar — lacertus syndrome: the median nerve is compressed under the lacertus fibrosus in the antecubital fossa. It imitates carpal tunnel, but the giveaways are at the elbow — point tenderness directly over the lacertus, weakness of FPL, FCR and FDP2 (the lacertus triad), proximal forearm aching, and crucially no night waking.
The discriminator for radial tunnel
The most over-diagnosed condition at the lateral elbow is tennis elbow. This separates a tendon problem from a compressed nerve.
- The elbow is fully extended — flexion slackens the supinator and gives a false negative.
- The forearm is pronated.
- The patient ulnar-deviates the wrist as far as it will go.
- The examiner tries to force the wrist into radial deviation against the patient’s sustained hold.
- Reduced resistance on the symptomatic side is positive — with a positive Maudsley’s, this is radial tunnel syndrome.
Don’t miss — refer now
- Sudden pain on lifting, weak supination, a Popeye deformity and a palpable gap — distal biceps tendon rupture. Time-critical; repair is best within about three weeks.
- A hot, swollen olecranon bursa — septic bursitis.
- A locked elbow or a mechanical block — loose body.
Refer direct — don’t delay
- A tennis elbow that has not settled, or one with any motor weakness — reconsider radial tunnel; refer rather than re-inject.
- Volar forearm aching with weak FPL or FCR and no night-time symptoms — query lacertus syndrome; refer to hand surgery.
- Cubital tunnel with M4 weakness or any wasting — direct to hand surgery.
Elbow flexion (C5–6 · biceps). Elbow extension (C7 · triceps). Wrist extension (C6–7 · radial / PIN). Lacertus triad — FPL, FCR and FDP2 (median).
“Lateral epicondyle tenderness, Maudsley’s positive, ECU test negative — lateral epicondylitis” — or — “lateral elbow pain with a positive ECU test; please assess for radial tunnel before any injection.”
Wrist
“My wrist hurts.” “My fingers tingle, especially at night.” “There’s a lump.”
De Quervain’s
Tenderness over the first dorsal compartment at the radial styloid; positive Finkelstein’s (Eichhoff’s) test — thumb in the fist, wrist ulnar-deviated.
Carpal tunnel syndrome
Tingling in the thumb, index and middle fingers, worse at night and on driving; test APB strength.
Confirm it is median, and screen the whole nerve — see the rule below.
Ganglion
A smooth, well-defined dorsal or volar swelling that transilluminates. Reassure; refer if painful or limiting.
The whole median nerve — not just the wrist
Tingling in the median fingers is not automatically carpal tunnel. The median nerve can be compressed at the neck (C6), at the elbow (lacertus syndrome — weak FCR, FPL and FDP2, tenderness in the medial antecubital fossa, and crucially no night waking) and in the forearm (anterior interosseous nerve — weak FPL and FDP2). And base-of-thumb osteoarthritis is routinely mislabelled as carpal tunnel.
Don’t miss — refer now
- Tenderness in the anatomical snuffbox after a fall on the outstretched hand — scaphoid fracture until proven otherwise; missed, it leads to non-union and avascular necrosis.
- Constant numbness, not just nocturnal, or severe pain — particularly after a distal radius fracture or a crush — acute carpal tunnel syndrome, a surgical emergency.
Refer direct — don’t delay
- Carpal tunnel with thenar wasting or constant symptoms — direct to hand surgery, not a six-month splint trial.
- De Quervain’s that has failed a splint and an injection.
APB (T1 · median at the wrist). Thumb-to-index pinch / FPL (C8–T1 · AIN). Wrist extension (C6–7 · radial).
“Nocturnal median tingling, APB weak, whole-nerve screen otherwise normal — carpal tunnel syndrome” — or — “snuffbox tenderness after a fall; query scaphoid fracture, imaging requested.”
Hand & Thumb
“My thumb hurts at the base.” “My finger catches.” “My finger won’t straighten.”
Base-of-thumb OA
A squared, adducted thumb base; positive grind test.
It mimics carpal tunnel — test APB; normal strength separates the two.
Trigger finger
A palpable nodule at the A1 pulley, with catching or locking on flexion and extension.
Dupuytren’s
Palpable cords and nodules in the palm; a positive Hueston tabletop test.
PIPJ involvement should be referred earlier — it does not fully release if left late.
Mallet finger
The DIP joint droops and cannot be actively extended.
Splint within four weeks to prevent a permanent deformity.
Where the numbness is felt is not where the nerve is trapped
Numbness in the ring and little fingers can be the ulnar nerve at the elbow (cubital tunnel) or at the wrist (Guyon’s canal). The single most useful discriminator is the dorsal ulnar hand: sensation there is affected in cubital tunnel and spared in Guyon’s, because the dorsal cutaneous branch leaves the nerve before the wrist.
Don’t miss — refer now
- A wound over the knuckle from a clenched-fist injury — a fight bite, with a high risk of septic arthritis.
- A finger held flexed, fusiform swelling, pain on passive extension and tenderness along the flexor sheath — flexor sheath infection (Kanavel’s signs), a surgical emergency.
- A high-pressure injection injury — it looks trivial and is an emergency.
Refer direct — don’t delay
- Dupuytren’s with a PIPJ contracture, or rapid progression.
- A mallet finger presenting beyond four weeks — still refer.
- Trigger finger that has failed conservative treatment, or in a person with diabetes.
APB (T1 · median). First dorsal interosseous (C8–T1 · ulnar). FDP to the little finger (C8–T1 · ulnar).
“Squared thumb base, positive grind, normal APB — base-of-thumb osteoarthritis, not carpal tunnel” — or — “mallet finger, presented within four weeks, for splinting.”
The referral letter — name the pattern
Three destinations. The sentence that names the pattern is the most valuable thing in the letter — it survives into the next clinician’s assessment.
Red — urgent
A universal-screen red flag, or frank weakness. Bypass routine triage.
“Hoffmann’s positive bilaterally with a gait change. Concerned about cervical myelopathy. Please see urgently.”
Yellow — direct
A nerve mimic, or subtle weakness. Straight to the right specialist.
“APB and FPL weak on the right, no wasting. Pattern suggests a problem proximal to the carpal tunnel. Requesting a direct hand surgery opinion.”
Green — routine
A clear regional diagnosis, no flags. MSK pathway, diagnosis named.
“Squared thumb base, positive grind, normal APB. Base-of-thumb osteoarthritis. Referring via the standard MSK pathway.”
Why the wording matters: “APB and FPL are weak” gets the patient to the right clinic; “?carpal tunnel” does not. Name the region, name the pattern, name the nerve if one is involved.
The handout and the slides
Two ways to keep the framework — a double-sided A5 card for the desk, and the full slide deck from the talk.
Download the handout
A two-page A5 PDF. Download it, then print double-sided to keep on the desk or pass to a colleague.
Download the slides
The full presentation from the talk — the universal screen, all four regions, and the referral framework.
History & cord
- Hoffmann’s, both sides
- “Handwriting, buttons, balance?”
Look — head to hand
- Gait
- Face — ptosis, miosis
- Wasting — deltoid, thenar, FDI
- Fasciculations
- Scapular winging
Strength — 3 states
- Equal — M5 · no flag
- Gives slightly — M4 · yellow
- Easily overcome — ≤M3 · red
Weak deltoid & biceps, lateral arm sensory loss, dull biceps reflex.
Rule: shoulder pain + weakness not fitting the cuff → screen the neck.
- Severe pain that eased as weakness appeared → brachial neuritis
- Scapular pain + Horner’s + smoker → Pancoast
- No external rotation after seizure / fall → posterior dislocation
Lateral → radial tunnel (ECU test +, tender 3–4 fb distal). Medial → cubital tunnel (ulnar tingling, weak FDI). Volar → lacertus syndrome (median): tender over the lacertus, weak FPL/FCR/FDP2, no night waking.
Rule: ECU test before you inject; palpate the lacertus before calling tingling fingers carpal tunnel. ECU: elbow extended · forearm pronated · resist radial deviation.
- Sudden pain lifting + weak supination + Popeye + gap → distal biceps rupture (refer within days)
- Hot, swollen olecranon bursa → septic bursitis
- Locked elbow / mechanical block → loose body
Lacertus (elbow): weak FCR/FPL, antecubital tenderness, no night waking. AIN: weak FPL/FDP2. C6 root. CMC OA mimics CTS.
Rule: think CTS → screen the whole nerve, neck to palm; confirm with APB.
- Snuffbox tenderness after a fall → scaphoid fracture until proven otherwise
- Constant numbness / severe pain, esp. after distal radius fracture → acute CTS, surgical emergency
Ring/little numbness: test the dorsal ulnar hand — affected = cubital tunnel (elbow); spared = Guyon’s (wrist).
Rule: numbness location is not compression location — localise the nerve.
- Knuckle wound from a punch → fight bite, septic-arthritis risk
- Finger held flexed + fusiform swelling + pain on passive extension → flexor sheath infection (Kanavel’s)
- High-pressure injection injury — looks trivial, is an emergency
Red · urgent
“Hoffmann’s positive with a gait change — concerned about cervical myelopathy. Please see urgently.”
Yellow · direct
“APB and FPL weak, no wasting — problem proximal to the carpal tunnel. Requesting a direct hand surgery opinion.”
Green · routine
“Squared thumb base, positive grind, normal APB — base-of-thumb OA. Referring via the MSK pathway.”
The evidence behind the framework
