Hand & Wrist Assessment
- Fysiobasen
- Oct 4
- 8 min read
The hand–wrist region is a complex assembly of multiple joints, muscles, and tendons that work together to deliver precision and function. As the most active part of the upper limb, optimal hand and wrist function is essential for daily activities (work, leisure, self-care). A systematic, structured examination is therefore critical to identify the correct diagnosis and initiate appropriate treatment.
Diagnosing hand and wrist disorders can be challenging due to dense anatomy and overlapping symptom profiles. Comparing both hands and wrists often helps reveal asymmetries or deficits [1].
Hand & Wrist Conditions: Prevalence and Societal Impact
Common presentations in primary care and physiotherapy include:
Carpal Tunnel Syndrome (CTS):The most frequent compressive neuropathy; prevalence ~3–6% in the general population [2].
Trigger Finger (Stenosing Tenosynovitis):Painful locking/clicking of fingers; prevalence ~2–3% and up to ~10% in people with diabetes [3].
De Quervain’s Tenosynovitis:Typical in repetitive thumb/wrist users.
Fractures & Trauma:Distal radius fractures account for ~16% of all fractures, common in older adults with osteoporosis [4].
Osteoarthritis :A frequent cause of hand/wrist pain and stiffness, particularly in older adults [5].
Purpose of This Guide
Subjective assessment: symptoms, history, functional limits.
Objective exam: proximal screening, mobility, neurology.
Diagnostic tools: special tests and imaging.
Practical advice: targeted clinical strategies.
By pairing anatomy/biomechanics with a structured work-up, clinicians can better meet patient needs and restore function and quality of life.
Subjective History
A thorough history underpins diagnosis and management.
Key elements
Mechanism of injury: e.g., FOOSH can suggest distal radius fracture.
Acute vs gradual onset.
Hand dominance & occupation: overuse/ergonomic risks.
Pain location & distribution.
Neurological symptoms: numbness/tingling/sensory change.
Aggravating/relieving factors.
Functional limits: ADLs, work, hobbies.
Prior investigations: X-ray/MRI results.
Objective Examination: Proximal Joints
Screen cervical spine, shoulder, elbow to identify proximal contributors.
Observation
Starts as the patient enters.
Hand function: resting posture and movement during tasks.
Deformity & posture: visible abnormalities.
Palmar surface
Lines and creases: symmetry and architecture.
Thenar/Hypothenar eminence: swelling or atrophy.
Arches & impressions: overall hand architecture (“hills and valleys”).
Dorsal surface
Metacarpal head heights.
Deformities:
Ganglion cysts.
Boutonnière deformity: PIP flexion with DIP hyperextension.
Swan-neck deformity: PIP hyperextension with DIP flexion.
OA nodes: Heberden’s (DIP), Bouchard’s (PIP).
Dupuytren’s: palmar fascial thickening.
Rheumatoid arthritis: MCP swelling, swan-neck, ulnar drift, tendon nodules [1].
Muscle Atrophy & Nerve Dysfunction
Median nerve: thenar atrophy; radial half of 4th finger + digits I–III weakness.
Radial nerve: dorsal hand/forearm extensors.
Ulnar nerve: hypothenar atrophy; 5th digit and ulnar half of 4th intrinsic weakness.
Functional Tests
Goal: define measurable “asterisk signs” for pre/post comparison.
Examples: turning a doorknob, key turn, pain-free power/key pinch, opening a jar, turning a tap, lifting a pot.
Grip strength measurement provides reliable, low-cost objective data.
Grepstyrke:Måling av grepstyrke kan være en pålitelig og kostnadseffektiv metode for evaluering, og gir objektive data om pasientens funksjonelle forbedring.
Palpation
Wrist (Dorsal to Volar)
Palpation of the wrist is carried out methodically, covering both dorsal and volar aspects. The clinician should assess for tenderness, crepitus, temperature differences, and anatomical irregularities. The following key structures should be evaluated:
Anatomical Landmarks:
Radial styloid
Scaphoid
1st Carpometacarpal (CMC) joint / Trapezium
Lunate
Lister’s tubercle
Ulnar styloid
Triangular Fibrocartilage Complex (TFCC)
Triquetrum
Pisiform
Hook of hamate (Hamulus ossis hamati)
Guyon’s Canal – assess for potential neural or vascular compression【1】
Hand Palpation
Bony Structures
Metacarpals (5) and Phalanges (14):Palpate the entire length of each metacarpal and phalanx for tenderness, swelling, deformity, or step-offs indicating possible fractures.
Soft Tissues
The Six Dorsal (Extensor) Compartments
These compartments transmit extensor tendons and are frequent sites of pathology, such as De Quervain’s Tenosynovitis and Intersection Syndrome.
Compartment | Tendons | Common Pathology |
1 (Radial) | Abductor pollicis longus, Extensor pollicis brevis | De Quervain’s disease |
2 | Extensor carpi radialis longus/brevis | Intersection syndrome |
3 | Extensor pollicis longus | – |
4 | Extensor digitorum communis, Extensor indicis | – |
5 | Extensor digiti minimi | – |
6 (Ulnar) | Extensor carpi ulnaris | – |
Palmar Tunnels
The palmar region contains two major tunnels that carry tendons, arteries, and nerves. Compression in these tunnels can lead to significant functional impairment.
Structure | Clinical Relevance |
Pisiform and Hamate | Landmark for ulnar nerve and artery |
Guyon’s Canal | Site of potential ulnar nerve compression |
Carpal Tunnel | Median nerve compression (Carpal Tunnel Syndrome) |
Flexor Carpi Radialis (FCR) | Important for wrist flexion |
Flexor Carpi Ulnaris (FCU) | Ulnar-sided wrist stabilizer |
Palmar Surface
Thenar Eminence: Contains muscles controlling thumb motion (abductor, flexor, opponens pollicis). Atrophy may indicate median nerve compression (Carpal Tunnel Syndrome).
Hypothenar Eminence: Contains muscles controlling the little finger. Atrophy suggests ulnar nerve compression.
Palmar Aponeurosis: Palpate for thickening or nodules — typical in Dupuytren’s Contracture【1】.
Neurological Assessment
Purpose: reproduce the patient’s symptoms when peripheral nerve compression is suspected, helping to clarify diagnosis and localise irritability [4].
1) Median Nerve
Proximal: Patient supine, shoulder 90° abduction, elbow extension; palpate medial to biceps (mid-humerus).
Distal: Palpate at the wrist.
2) Radial Nerve
Proximal: Shoulder at 0° abduction; palpate just proximal to the lateral epicondyle.
Distal: Palpate around the distal radius and within the anatomic snuffbox.
3) Ulnar Nerve
Proximal: With shoulder ~90° abduction and elbow ~120° flexion, palpate the medial mid-humeral region.
Cubital tunnel: Evaluate by palpation for signs of compression.
Reflexes
Reflex testing helps identify potential neurological abnormalities and assesses the functional integrity of the cervical spinal segments. These findings can indicate nerve root involvement or peripheral nerve injury.
Reflex | Spinal Level | Description |
Biceps Reflex | C5 | Tests the integrity of the musculocutaneous nerve and spinal root C5. |
Brachioradialis Reflex | C6 | Evaluates the radial nerve and spinal root C6. |
Triceps Reflex | C7 | Assesses the radial nerve and spinal root C7. |
A diminished or absent reflex may indicate peripheral neuropathy or nerve root compression, while hyperreflexia suggests an upper motor neuron lesion.
Myotomes
Myotome testing evaluates the motor function of muscles supplied by specific cervical spinal nerve roots. This assessment helps localize potential nerve root dysfunction and identify weakness patterns.
Myotome | Spinal Level | Primary Movement |
C5 | C5 | Shoulder abduction (deltoid muscle) |
C6 | C6 | Elbow flexion (biceps brachii) and wrist extension |
C7 | C7 | Elbow extension (triceps brachii) and wrist flexion |
C8 | C8 | Finger flexion (flexor digitorum profundus/superficialis) |
T1 | T1 | Finger abduction and adduction (interossei muscles) |
Clinical interpretation should consider symmetry, pain inhibition, and muscle atrophy to ensure accurate grading of muscle strength.
Dermatomes
Dermatome testing assesses the sensory distribution of each cervical spinal level by evaluating light touch, pinprick, and temperature perception. Abnormal findings may indicate sensory nerve dysfunction or nerve root compression.
Dermatome | Spinal Level | Sensory Area |
C5 | C5 | Lateral shoulder |
C6 | C6 | Lateral forearm and thumb |
C7 | C7 | Middle finger and central palm |
C8 | C8 | Medial forearm and little finger |
T1 | T1 | Medial elbow and upper arm |
Testing should be performed bilaterally for comparison, and any sensory loss should be documented precisely by area and modality (light touch, pinprick, temperature).
Range of Motion (ROM) Testing
Range of motion (ROM) testing provides critical information about joint mobility, symptom provocation, and overall functional capacity. When no pain is present at the end of the movement, the clinician may apply gentle overpressure to assess the end-feel of the joint.
Wrist Movements
Flexion and Extension
Radial and Ulnar Deviation
Thumb – Carpometacarpal (CMC) Joint (Basal Joint)
Extension
Abduction
Opposition
Metacarpophalangeal (MCP) Joints
Flexion
Extension
Abduction / Adduction
Interphalangeal (IP) Joints – PIP and DIP
Flexion
Extension
Assessing active, passive, and resisted movements helps identify structural or functional limitations in the wrist and hand complex. Pain during specific ranges can help localize pathology such as ligament sprain, tendinopathy, or joint degeneration.
Strength Testing
Strength testing provides insight into functional capacity, neuromuscular integrity, and muscle balance. Manual muscle testing and grip dynamometry are frequently used to quantify function.
Wrist Movements
Flexion
Extension
Forearm Movements
Pronation
Supination
Grip Strength
General grip strength (power grip)
Key pinch and tip pinch strength
Reduced strength may result from pain inhibition, tendon injury, or nerve involvement (e.g., median or ulnar nerve compression). Comparing both hands is essential for accurate assessment.
Special Tests
Special tests are selected based on the patient’s symptoms and clinical suspicion of specific pathologies. The following are among the most commonly used tests for the hand and wrist.
1. Scaphoid Fracture
Anatomical Snuffbox Tenderness: Palpate the snuffbox for localized pain.
Scaphoid Tubercle Tenderness: Palpate over the tubercle on the volar aspect.
Axial Thumb Compression: Apply axial pressure along the thumb to reproduce pain.
2. Neurodynamic Tests
Median Nerve
ULTT 1 (Upper Limb Tension Test 1)
ULTT 2a
Radial Nerve
ULTT 2b
Ulnar Nerve
ULTT 3
These tests help determine neural tissue irritability and differentiate nerve entrapment from musculoskeletal causes.
3. Carpal Tunnel Syndrome
Carpal Compression Test: Apply firm pressure over the carpal tunnel to reproduce symptoms.
Tinel’s Sign: Tap gently over the median nerve to test for irritability.
Wrist Ratio Index: Used to assess risk factors for carpal tunnel syndrome.
4. Scapholunate Instability
Scaphoid Shift Test (Watson’s Test): Evaluates the stability between the scaphoid and lunate bones.
5. De Quervain’s Tenosynovitis
Finkelstein’s Test: The patient places the thumb inside a clenched fist while the examiner moves the wrist into ulnar deviation to provoke pain along the radial side.
Red Flags
Screening for serious pathology is vital before initiating treatment. The following red flags require medical referral or further diagnostic evaluation.
Infection
Signs suggesting infection include:
Heat: Local temperature increase.
Swelling: Visible or palpable edema.
Pain: Persistent or worsening pain.
Redness: Skin discoloration over the affected area.
Inflammation: Combination of the above findings often requires urgent medical management.
Fractures / Dislocations
Top five clinical findings indicating potential wrist fracture:
Local tenderness
Pain with active movement
Pain with passive movement
Pain on gripping
Pain during forearm supination
Recommendation:If any of these findings are present following trauma, the patient should be referred for radiographic imaging.
Other Potentially Serious Conditions
Scapholunate instability
Osteoarthritis or rheumatoid arthritis
Infectious diseases (e.g., Lyme disease, tuberculosis)
Peripheral vascular disease
Peripheral neuropathy
FOOSH injury (Fall on Outstretched Hand), especially in adults over 65
Peripheral Nerve Involvement
Nerve injuries in the upper limb may affect:
Median nerve – carpal tunnel, anterior interosseous syndrome
Radial nerve – posterior interosseous syndrome, radial tunnel
Ulnar nerve – Guyon’s canal compression
Common Diagnoses from Clinical Examination
Carpal Tunnel Syndrome
Anterior Interosseous Syndrome
Posterior Interosseous Syndrome
Distal Radius Fracture
First CMC Osteoarthritis
De Quervain’s Tenosynovitis
Radial Tunnel Syndrome
Ulnar Nerve Compression (Guyon’s Canal)
Non-specific Mechanical Wrist Pain
Trigger Finger (Stenosing Tenosynovitis)
Complex Regional Pain Syndrome (CRPS)
Triangular Fibrocartilage Complex (TFCC) Injury
Dupuytren’s Contracture
Standardized Outcome Measures
Standardized tools help quantify functional limitations and symptom severity, allowing for progress tracking and treatment evaluation.
Outcome Measure | Purpose | Use / Description |
DASH (Disabilities of the Arm, Shoulder and Hand) | Evaluates upper-limb function and grip strength. | Comprehensive tool for activity limitation. |
QuickDASH | Shorter version of DASH. | Provides rapid screening of function and symptoms. |
Symptom Severity Scale | Measures symptom intensity and discomfort. | Often used for carpal tunnel syndrome. |
Patient-Specific Functional Scale (PSFS) | Allows patients to identify difficult activities. | Tracks individualized functional improvements over time. |
Conclusion
Hand and wrist disorders are among the most common reasons for physiotherapy consultation. Some clinics even specialize as dedicated hand therapy centers. The ability to perform a comprehensive examination is essential to differentiate between acute and chronic pathologies.
Common Acute Conditions
Fractures
Tendonitis
Trigger Finger
Common Chronic Conditions
Carpal Tunnel Syndrome
Ganglion Cysts
Osteoarthritis and Rheumatoid Arthritis
Both osteoarthritis and rheumatoid arthritis can cause significant structural and soft-tissue changes. Recognizing these patterns allows clinicians to adapt interventions for optimal recovery and function.
A systematic, evidence-based assessment — combined with strong anatomical knowledge — enables physiotherapists to provide targeted and effective treatment for patients with hand and wrist disorders.
Sources:
1. Shane Cass, DO UNM Primary Care Sports Medicine Clinical Examination of the Hand and Wrist Available from: http://unmfm.pbworks.com/w/file/fetch/50237999/HandandWristExammaster.pdf
2. Ascension Via Christi Joint-by-Joint Musculoskeletal Physical Exam: Hand and Wrist Available from: https://www.youtube.com/watch?v=DxW0rodKOGs (last accessed 29.3.2020)
3. Wikimedia commons Wrist extensor compartments Available from: https://commons.wikimedia.org/wiki/File:Wrist_extensor_compartments_(numbered).PNG
4. Schmid AB, Brunner F, Luomajoki H, et al. Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC Musculoskelet Disord. 2009;10:11.
5. Cevik AA, Gunal I, Manisali M, et al. Evaluation of physical findings in acute wrist trauma in the emergency department. Ulus Travma Acil Cerrahi Derg. 2003;9(4):257-261.
6. Medistudents Wrist and hand examination Available from: https://www.medistudents.com/en/learning/osce-skills/musculoskeletal/hand-wrist-examination/ (last accessed 29.3.2020)
