Upper limb conditions

Upper limb musculoskeletal conditions are among the most common presentations in general practice, encompassing disorders of the shoulder, elbow, wrist, and hand. This overview provides a systematic approach to assessing upper limb pain, integrating clinical anatomy with structured history and examination principles applicable across the spectrum from acute injuries to chronic degenerative and inflammatory conditions. In Australian general practice, upper limb conditions account for a substantial proportion of work-related musculoskeletal claims, sports injuries, and age-related degenerative complaints. A structured regional approach — identifying the anatomical structure, mechanism, and underlying pathology — guides appropriate investigation and management.

Upper limb pain arises from multiple tissue types including tendon, bursa, bone, cartilage, nerve, and synovium. Understanding the underlying pathological process guides treatment selection.

Tendon Pathology

• Tendinopathy (overuse) — disorganised collagen matrix and neovascularisation without true inflammation; mechanical load-related; characteristic mid-substance thickening on ultrasound; responds to graduated loading programs rather than anti-inflammatory medication
• Tendinitis (acute inflammation) — acute tendon inflammation with genuine inflammatory infiltrate; less common than tendinopathy; responds to NSAIDs and activity modification
• Tendon tear — partial or complete; acute traumatic or degenerative (chronic); rotator cuff and biceps most clinically significant in upper limb

Entrapment Neuropathy

• Median nerve (carpal tunnel) — compression at wrist; nocturnal paraesthesia, thenar wasting; most common entrapment neuropathy; confirmed by NCS
• Ulnar nerve (cubital tunnel) — compression at elbow; ring and little finger numbness; intrinsic wasting in severe cases
• Radial nerve — posterior interosseous nerve compression at radial tunnel; lateral elbow pain mimicking epicondylopathy; finger extension weakness

Inflammatory Arthritis

• Synovitis — inflammatory joint disease (RA, psoriatic, crystal) presents with synovial thickening, morning stiffness, symmetry, and response to anti-inflammatory treatment; distinguished from degenerative conditions by pattern and serology
• Crystal arthropathy — gout (MTP, wrist, MCPs) and CPPD (wrist, MCPs); acute monoarticular flares; aspiration diagnostic and therapeutic

A structured regional assessment of the upper limb integrates symptom characterisation, anatomical localisation, functional assessment, and identification of red flags requiring urgent investigation or referral.

Assessment of Shoulder Pain

• Symptom localisation — anterior shoulder (biceps, ACJ, GHJT), lateral (subacromial, rotator cuff), posterior (posterior capsule, posterior labrum); radiation to deltoid insertion (subacromial impingement); radiation to hand (cervical referral)
• Painful arc (60–120° of abduction) — subacromial impingement or rotator cuff tendinopathy; positive Neer and Hawkins-Kennedy tests; pain with overhead activity
• Loss of all shoulder movement — adhesive capsulitis (frozen shoulder); equal restriction of active and passive movement in a capsular pattern (external rotation most restricted); insidious onset; may follow minor trauma or immobilisation
• AC joint pain — superior shoulder pain; tenderness over ACJ; positive cross-body adduction test; pain at end of abduction arc (>120°); degenerative or post-traumatic
• Acute loss of shoulder abduction after trauma — full-thickness rotator cuff tear; weakness of shoulder abduction and external rotation; urgent MRI shoulder; surgical referral if young active patient

Assessment of Elbow Pain

• Lateral elbow pain — lateral epicondylopathy (tennis elbow); point tenderness over lateral epicondyle; pain with resisted wrist extension and grip; no neurological deficit (distinguishes from posterior interosseous nerve entrapment)
• Medial elbow pain — medial epicondylopathy (golfer’s elbow); tenderness over medial epicondyle; pain with resisted wrist flexion; assess ulnar nerve (cubital tunnel) concurrently; positive Tinel at medial elbow
• Posterior elbow swelling — olecranon bursitis; fluctuant swelling over olecranon; septic bursitis (warm, tender, cellulitis) requires aspiration and antibiotics; traumatic and gout-related bursitis managed conservatively
• Elbow locking or mechanical symptoms — loose body, osteochondritis dissecans; requires imaging; orthopaedic referral

Assessment of Wrist Pain

• Radial wrist pain — De Quervain tenosynovitis (1st extensor compartment); positive Finkelstein test; pain over radial styloid; carpal tunnel syndrome causes nocturnal radial-sided hand paraesthesia
• Anatomical snuffbox tenderness after fall on outstretched hand — scaphoid fracture until proven otherwise; X-ray may be normal; MRI or CT required if high clinical suspicion; immobilise and refer if suspected
• Ulnar wrist pain — TFCC injury; pain on ulnar deviation; ECU tendinopathy; hamate fracture; ulnar tunnel syndrome
• Dorsal wrist swelling — ganglion cyst (most common, transilluminates); scapholunate ligament injury; extensor tendon tenosynovitis

Assessment of Hand Pain

• Trigger finger — flexor tendon catching or locking at A1 pulley; tender nodule on palmar surface of MCP; may be locked in flexion; associated with diabetes, RA, hypothyroidism
• CMC thumb OA (basal joint arthritis) — pain at base of thumb; positive grind test; X-ray confirms; common in women >50 years; affects pinch and grip
• MCP and PIP synovitis — RA, psoriatic, or crystal arthropathy; morning stiffness; soft tissue swelling; positive squeeze test (MCP compression); bilateral in RA
• Dupuytren contracture — palmar fascia fibrosis; ring and little finger MCP and PIP flexion contracture; firm palmar nodules; cannot place hand flat on table (positive tabletop test)

Investigation selection is guided by clinical diagnosis, need to exclude red flag conditions, and surgical planning. Most upper limb conditions are clinical diagnoses; imaging is confirmatory or excludes differentials.

• Essential
  X-ray (plain radiograph)

  First-line imaging for suspected fracture, dislocation, significant joint disease, or bony lesion. X-ray shoulder for subacromial calcification (calcific tendinitis), glenohumeral OA, AC joint degeneration. X-ray wrist for suspected scaphoid fracture (initial screen; may be normal in first 2 weeks), Colles fracture, carpal dislocation. X-ray hand for MCP/PIP/DIP OA, erosive arthritis, gout (tophi), fracture.
• Essential
  Musculoskeletal ultrasound

  First-line for soft tissue assessment of the upper limb. Diagnoses rotator cuff tears (partial and full-thickness), tendinopathy, bursitis, De Quervain tenosynovitis, trigger finger, ganglion cysts. Doppler confirms active tendon/bursal inflammation. Guides diagnostic and therapeutic injections. Less expensive and more accessible than MRI; operator-dependent.
• Recommended
  MRI

  For complex or surgical planning cases. MRI shoulder: full-thickness rotator cuff tears (surgical planning), labral tears (SLAP, Bankart), avascular necrosis. MRI wrist: scaphoid fracture (gold standard), TFCC tear, scapholunate ligament injury, Kienbock disease. MRI hand: early inflammatory arthritis (synovitis, erosions), tumour. MRI with contrast for infection.
• Recommended
  Nerve conduction studies (NCS)

  Carpal tunnel syndrome (median nerve motor and sensory latency); cubital tunnel syndrome (ulnar nerve conduction velocity across elbow); radial nerve entrapment. NCS confirms diagnosis, grades severity, and guides management (conservative vs surgical decompression). Performed by neurophysiology.
• Specialised
  Inflammatory markers and serology

  If inflammatory arthritis suspected: ESR, CRP, RF, anti-CCP, ANA, urate. Synovial fluid aspiration if septic arthritis, crystal arthropathy, or uncertain monoarthritis. Not required for mechanical upper limb conditions.

Severity assessment in upper limb conditions determines urgency of referral, need for imaging, and appropriateness of conservative versus procedural or surgical management.

Pharmacological treatment of upper limb conditions is primarily analgesic and anti-inflammatory, with targeted corticosteroid injection for specific inflammatory conditions. Most upper limb conditions resolve with physiotherapy and activity modification.

Specific upper limb conditions require targeted management in addition to general analgesic and anti-inflammatory measures.

Shoulder Conditions

• Subacromial impingement / rotator cuff tendinopathy — physiotherapy with progressive rotator cuff strengthening and scapular stabilisation (12–16 weeks); subacromial corticosteroid injection for severe pain limiting physiotherapy; surgical referral (subacromial decompression) only after 3–6 months conservative failure
• Adhesive capsulitis — see separate guideline; intra-articular corticosteroid injection (early frozen phase) plus physiotherapy; hydrodilatation (distension arthrography) for refractory cases; time-limited condition (12–24 months resolution in most)
• Full-thickness rotator cuff tear — urgent orthopaedic referral for acute traumatic tears in patients <60 years; older patients or small tears may be managed with physiotherapy; MRI guides surgical decision-making
• Calcific tendinitis — barbotage (needling and aspiration of calcium deposit) under ultrasound guidance; subacromial corticosteroid injection for acute calcium dissolution crisis

Elbow Conditions

• Lateral epicondylopathy — physiotherapy with eccentric wrist extensor loading program is most effective long-term treatment; corticosteroid injection provides short-term relief but worse 12-month outcomes; tennis elbow brace reduces loading at insertion; extracorporeal shockwave therapy (ESWT) for refractory cases
• Septic olecranon bursitis — aspirate and gram stain/culture; oral flucloxacillin 500 mg QID for 2 weeks for mild cellulitis; IV antibiotics and surgical drainage if severe or immunosuppressed; drain needle aspiration may be required if reaccumulating

Wrist and Hand Conditions

• Carpal tunnel syndrome — nocturnal wrist splinting (neutral position); corticosteroid injection provides temporary relief; surgical carpal tunnel release indicated for moderate-severe or NCS-confirmed disease; high success rate
• Trigger finger — corticosteroid injection into tendon sheath (A1 pulley); 50–70% success rate; surgical A1 pulley release for recurrent or locked trigger finger
• De Quervain tenosynovitis — see separate guideline; thumb spica splint; corticosteroid injection into 1st extensor compartment; surgical decompression for refractory cases

Non-pharmacological management is the cornerstone of upper limb musculoskeletal conditions. Physiotherapy, occupational therapy, activity modification, and orthotic support form the primary treatment approach for most conditions.

Physiotherapy

• Progressive loading programs — eccentric and isometric loading for tendinopathy (rotator cuff, lateral epicondyle); Curwin-Stanish protocol for elbow tendinopathy; evidence-based over passive modalities
• Manual therapy — mobilisation and manipulation of shoulder, elbow, and wrist joints; cervical spine mobilisation if cervical referred pain contributing; soft tissue techniques
• Exercise programs — scapular stabilisation (shoulder); proprioceptive training (wrist after ligament injury); grip strengthening (generalised upper limb reconditioning)

Orthoses and Splints

• Wrist splint — neutral position nocturnal splint for carpal tunnel syndrome; thumb spica splint for De Quervain tenosynovitis and scaphoid fracture immobilisation
• Tennis elbow brace (counterforce strap) — reduces strain on lateral epicondyle during gripping activities; used during activity rather than continuously
• Sling — short-term for acute shoulder conditions and post-injection rest; avoid prolonged immobilisation which worsens adhesive capsulitis

Occupational Therapy and Ergonomic Assessment

• Workplace ergonomic assessment — essential for work-related upper limb disorders; keyboard height, mouse position, monitor placement; WorkCover-funded assessments available
• Activity modification — identify and reduce provocative activities during acute phase; graduated return to full activity as symptoms allow; avoidance is counterproductive long-term for tendinopathy
• Hand therapy — specialised occupational therapy for post-operative rehabilitation, Dupuytren’s disease, and complex hand injuries

Monitoring of upper limb conditions focuses on functional recovery, symptom progression, response to treatment, and identification of complications or failure of conservative management requiring escalation.

Red Flags Requiring Urgent Action

• Scaphoid fracture: Anatomical snuffbox tenderness after FOOSH — X-ray may be negative; MRI or CT; immobilise in thumb spica; urgent orthopaedic review if positive
• Septic arthritis or bursitis: Hot, swollen joint with fever or immunosuppression — aspirate immediately; blood cultures; urgent orthopaedic or emergency referral
• Progressive motor deficit: Thenar wasting (median nerve) or intrinsic wasting (ulnar nerve) — urgent NCS and surgical referral; irreversible with prolonged delay
• Vascular injury: Cold, pale, pulseless hand after trauma — vascular surgery emergency

Specific considerations apply to upper limb conditions in particular patient populations.

Older Adults (>65 Years)

• Rotator cuff tears — common in older adults; full-thickness tears are often asymptomatic; surgical repair outcomes less predictable above age 70; physiotherapy-led rehabilitation is primary management for most
• CMC thumb OA — very common in post-menopausal women; corticosteroid injection provides short-term relief; trapeziectomy highly effective for refractory cases
• NSAID caution — renal impairment, cardiovascular risk, and anticoagulant use limit NSAID prescribing; topical NSAIDs preferred; paracetamol first-line

Occupational and Work-Related Upper Limb Disorders

• WorkCover considerations — document mechanism, work duties, time of onset, and functional limitations at first presentation; early workplace assessment and physiotherapy improves return-to-work outcomes; avoid prolonged certification without active treatment
• Repetitive strain injury (RSI) / occupational overuse syndrome — affects keyboard workers, tradespeople, healthcare workers; ergonomic modification is key; early physiotherapy; multidisciplinary pain team for chronic cases

Diabetes

• Diabetic cheiroarthropathy — limited joint mobility in hands of long-standing diabetes; check prayer sign and tabletop test; associated with HbA1c control; no specific treatment beyond glycaemic optimisation
• Higher trigger finger and Dupuytren’s prevalence — corticosteroid injection causes transient hyperglycaemia in diabetic patients; warn and advise monitoring of BSL for 24–48 hours post-injection

Stewardship in upper limb conditions focuses on appropriate imaging, avoiding overuse of corticosteroid injections, prioritising physiotherapy over pharmacotherapy for chronic conditions, and timely surgical referral when indicated.

GP Role in Upper Limb Conditions

• Clinical diagnosis — most upper limb conditions are clinical diagnoses; avoid reflexive imaging before examination; structured regional assessment guides investigation
• Early physiotherapy referral — physiotherapy is first-line for rotator cuff tendinopathy, lateral epicondylopathy, wrist ligament injuries, and hand conditions; refer early rather than waiting for pharmacotherapy failure
• Judicious injection use — corticosteroid injections are adjuncts to physiotherapy, not replacements; advise patients of short-term nature and importance of rehabilitation program
• Surgical referral thresholds — full-thickness rotator cuff tears in young patients, progressive carpal tunnel neuropathy, trigger finger refractory to injection, and Dupuytren’s with 30°+ MCP contracture are indications for surgical referral

Most upper limb musculoskeletal conditions resolve with appropriate conservative management. Preventing recurrence requires addressing underlying biomechanical factors, strengthening programs, and ergonomic optimisation.

Prevention

• Rotator cuff strengthening — graduated rotator cuff and periscapular muscle strengthening prevents subacromial impingement recurrence; ongoing maintenance program after physiotherapy discharge
• Ergonomic workplace design — reduces repetitive strain and work-related upper limb disorders; mouse and keyboard positioning; regular micro-breaks
• Load management in sport — gradual increase in training load; technique correction for racquet sports (lateral epicondylopathy); appropriate warm-up and cool-down

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