Muscle Testing of the Upper and Lower Extremities

Physiotherapy Division

Dr. Mikhled Maayah

Guide muscle testing

• This guide was developed out of a need to assist the therapist in utilizing a standard method of muscle testing in patients at this facility.

• It is based on the denials and Worthingham method of muscle testing.

• It was originally developed approximately a long time ago as a procedure to assist physiotherapy students who working with the physically disabled.

• Since that time it has been utilized by staff, who have given suggestions over a period of years to make it more meaningful and useful to gain proficiency and consistency in muscle testing.

Introduction

• The general direction of treatment today is to consider the whole patient in terms of what we do to help him gain maximum recovery and independence.

• To accomplish this we must think of him in terms of his status at the beginning of treatment, the prognosis, the plan of treatment and the progress noted under this plan.

• It should be a matter of professional pride that we be able to provide accurate and meaningful information, when it is requested of us.

Introduction- continue

As therapists, we consider muscle evaluations from two points of view:

• For our use own as guides to planning of specific treatment routines and to determine the success or failure of these routines.

• To provide the physicians with whom we work with information which will be helpful to them in:– diagnosis– prescription for treatment– prescription for bracing – determination of progress and prognosis.

Introduction- continue

• There are certain specific things which we want to knew. These are:– Is the muscle active?– Is the muscle functional?– How functional is it?– Is spasticity present?– What substitute patterns are present?– What positions the patients assumes at rest?– What positions the patients assumes on activity?– What deformities are present and to what degree?– What stage of motor development has been reached?– What are the specific motor handicaps which keep him

developing more rapidly or becoming more independent?

• In addition, the therapist must be able to convey to the patient what is expected of him in a testing procedure and then be able to record the results of the test in concise way.

• Testing by a well trained therapist saves time for the physician and can be great help to him.

• Objective testing done at stated intervals serves not only to record progress, or lack of it, but gives us an excellent opportunity to evaluate the technique used.

• It also gives information needed to report intelligently to the physician on the status of the patient.

Introduction- continue

Definition of muscle test

A muscle test is an attempt to determine the ability of a patient to activate skeletal muscle.

Available range of motion: this is the passive range which is easily obtained by the examiner without feeling resistance.

Example: If passive range measured in elbow flexion is 0 – 90 degree and patient actively moves 0 – 90 degree, then he will have moved through complete available range of motion.

Muscle test is used as:-• Basis of muscle re-education and

exercise.• Determining factor for supportive

apparatus.• Aid in determining diagnosis.• Aid in prognosis of a patient.

Requisites for good muscle testing

– Knowledge of anatomy as well as functional.– Correct starting position-changes with muscle being tested.– Stabilization of proximal segment and body as a whole.– Area of palpation-knowledge of where and how to palpate.– knowledge of the substitutions muscles (synergic muscles,

assisting muscles, direct fixation muscles, indirect fixation muscles and antagonistic muscles).

– Recognition of substitution.– Knowledge of normal muscle and muscle groups (action

and appearances).– Ability to convey ideas to patient and guide the movement.– Record deformities, limitations in motion, spasticity and

tremor, strength within range must be recorded (grade low when in doubt about strength of a muscle).

Terminology

• Test Range: is set up for specific test of specify muscle – not necessarily complete ROM.

• Easy Test: gravity eliminated test or position that will give you a grade of 0, Trace, Poor -, Poor.

• Hard Test: anti-gravity (against), method used to obtain grades from Fair+ to normal.

• Palpation: ability of therapist to feel contraction of muscle being tested.

• Resistance: applied at the end of ROM, pressure should be applied in a direction as nearly

opposite to the line of pull of the muscle or group, as possible.

Muscle grading techniques

• Grades are obtained on varies of gravity, gravity eliminated, against gravity, gravity plus manual resistance.

• Some grades are obtained by palpation.• Stretch range used for some grades – range

beyond neutral position, usually used in rotation.

Grades• The following muscle grades are described in

comparison with a normal muscle.• It is important to keep in mind that muscles of normal

strength vary in strength tremendously within the body., owing to the size of the muscle and to the work each muscle is normally required to perform.

• Normal strength likewise varies between individuals, owing to differences in age and body requirements.

• Therefore, in grading muscles above ‘fair’, the degree of objectivity increases with the therapist’s increasing knowledge of normal strength of various age groups and body requirements for that particular muscle, prior to illness or injury.

Grades• Zero (O): No movement of part; contraction cannot be palpated• Trace (T): Contraction can be palpated; no movement of part.• Poor minus (P-): Gravity eliminated, part moves through only a

portion of the range of available, not necessarily normal, passive ROM.

• Poor (P): Gravity eliminated, part moves through complete available ROM.

• Fair: Against gravity, part moves through complete available ROM, but cannot take additional resistance.

• Fair Plus (F+): Part moves through complete available ROM against gravity with ‘slight’ resistance (for that muscle) at end of range.

• Good (G): Part moves through complete available ROM against gravity and takes “moderately strong” resistance (for that muscle) at end of range.

• Normal (N): Part moves through complete available ROM against gravity and takes “strong” resistance (for that muscle) at the end of range.

Recording

• All grades below fair are recorded in red for easily identifiable areas of weakness; grades of fair and above are recorded in blue or black ink and dated.

• Indicate all muscles not tested during any evaluation by marking “N.T” in the appropriate place.

Outline of technique for administering the manual muscle test

• Determine the ROM of joint (joints) passively.• Line up the part with fibers of the muscle to be

tested.• Provide adequate stabilization.• Have the patient attempt motion through the test

range.• Look at the muscle or movement first.• Palpate at the tendon or muscle belly.• Apply resistance at the end of the range if the

muscle is strong enough (Break Test).

Outline of technique for administering the manual muscle test

• Resistance should be applied firmly and smoothly in line with direction of the muscle of segment of a muscle being tested.

• You may compare the strength of the normal segment with the one being tested to aid in determine the strength grade.

• Never give a grade on motion alone. It must possible to palpate the muscle.

• Record grade and date and initial the test form.• Normal in relation to muscle testing: normal for

are, sex and sounded parts.

Some basic principles

1. Take your time.2. Start with a gross observation of function

around a joint.3. Patient instruction.4. Be consistent.5. Grading.6. Check yourself. 7. Suggested sequence of extremities muscle

test.

Some basic principles

1. Take your time: – Don’t rush to a conclusion about a grade.– Use plus or minus if patient’s performance is

consistent with stated definitions of grades.– If patient’s performance is not consistent

with stated definitions, use descriptive terminology, e.g. biceps remains F+ but is taking more resistance than last test.

2. Start with a gross observation of function around a joint:– Observe the ROM around the joint as it is often a clue

to muscle imbalance.– Then observe gross movement around the joint before

touching with hands.– Observe muscle atrophy.– Observe and check muscle tone.– The presence of spasticity may negate the value and

appropriateness of performing a manual muscle test.– Be aware of sensory deficits as they may affect

patient’s ability to follow directions.

3. Patient instruction:– It is important to give patients all sensory

and verbal clues needed for best performance.

– This may include:• Demonstrations• Taking part through motion desired• Allowing patient to see part being tested• Allowing practice through muscle re-education

techniques (when appropriate) • Using simple instructions.

4. Be consistent:– Begin by testing the muscle against-gravity,

then test in a gravity-eliminated position if muscle is below “Fair”.

– Always apply resistance at the end of the motion rather than during the motion.

– Resistance is usually applied at the distal end of the part and opposite to the direction of pull.

5. Grading:– When utilizing the grading system above, examiner

must observe proper testing position of the patient for the muscle being tested.

– When it is not possible to assume proper testing position, e.g. due to contractures, casts, medical precautions, it is important to determine presence or absence of muscle in question.

– In this case, the degree of contraction can be determined as weak or strong, utilizing palpation and observable active motion.

– Because some body parts cannot be positioned to work against gravity, the grading of some muscles is modified, as indicated in the procedure to follow.

– Recognize that larger muscles would take maximum effort by tester to resist a strong muscle and proportionally less effort for smaller muscles.

The gravity factor in Grading

• For other muscles, the gravity free and ant-gravity positions are impractical because gravity may not be an important factor (Finger flexors, toe flexors, forearm pronators and supinators, rotators of the shoulders and hips).

• From a mechanical stand-point this is true because the weight of the part is so small in comparison with strength of the muscle.

• Foot, hand or their range of motion is much that if the initial position is anti-gravity, the end position is with gravity.

• Supinators and pronators could be scored:• Tr : perception of attempted assistance in stretch range

6. Check yourself on the following factors:– What is the primary action of the muscle

being tested?– Is the patient in the proper test position?

For example, if patient’s biceps is less than F in a sitting position, have I repositioned for gravity eliminated grading?

– Have I stabilized the part proximal to the part on which the muscle acts?

– Have I observed to see that the motion produced is the motion requested, e.g. is there extraneous motion at joints proximal and/or distal to the part being tested?

– Have I palpated after observing the motion?– Have I applied resistance in the proper place

at the end of motion?– Have I graded, using the proper definition of

grades.

7. Suggested sequence of extremities muscle test

• The following suggested sequence first provided to enable the tester to efficiently perform all the tests with the least amount of re-positioning of the patient.

• Note that all muscles which can be tested for both above and below F are grouped together.

Suggested sequence of upper extremity muscle test

A. UPRIGHT:– Elbow, Forearm, wrist and Hand.– Serratus anterior and pectoral is major

(clavicular).– Anterior deltoid– Middle deltoid– Upper trapezius– Latissimus dorsi F+ and above

B. PRONE:

• Triceps• External rotators• Internal rotators• Posterior deltoid• Rhomboids• Middle trapezius• Lower trapezius• Latissimus F- and below.

C. Sideling: with weight of arm supported on a smooth board.– Anterior deltoid

D. SUPINE– Pectoralis major (sternal)– Triceps (alternate position) support weight.– Elbow flexors (alternate position of arm on smooth

Middle deltoid).E. Upright (below Fair):

Posterior deltoidPectoral is major (sternal).External rotatorsInternal rotators

Suggested sequence of lower extremity muscle test

• Turning the patient from one position into another is fatiguing to the patient and wasting for the therapist’s time.

• Supine: Toe flexors and extensors, tibialis posterior and anterior, peroneals and triceps.

• Side lying: Gluteus medius and minimums adductors, lateral abdominals and tensor fascia lata.

• Prone: Hamstrings, gluteus maximums.• Sitting: Quadriceps, internal and external

rotators of the hip, iliopsoas, sartorious

Manual Muscle Testing

Mikhled Maayah PhD, PT

Jordan university of science and technology

JUST

Neck Manual Muscle Testing

Neck Flexion

SternocleidomatioideusSternocleidomatioideus

SternocleidomatioideusSternocleidomatioideus Origin: Anterior and superior manubrium and superior medial

third of clavicle

Insertion: Lateral aspect of mastoid process and anterior half of superior nuchal line

Nerve supply: Axillary N.

Note

• Factors Limiting Motion:1- Tension of posterior longitudinal ligament, ligamenta

flava, and interspinal and supraspinal ligaments2- Tension of posterior muscles of neck3- Apposition of lower lips of vertebral bodies anteriorly

with surfaces of subjacent vertebrae4- Compression of intervertebral fibrocartilages in front• Fixation:1- Contraction of anterior abdominal muscles2-Weight of thorax and upper extremities

Normal & Good

• Position: Supine.• Stabilization: Stabilize lower thorax.• Desired Motion: Patient flexes cervical spine through

range of motion. • Resistance: Is given on forehead

Note►If there is a difference in strength of the two

Sternocleidomastoideus muscles, they may be tested separately by rotation of head to one side and flexion of neck.

► Resistance is given above ear.

Fair & Poor• Position: supine.• Stabilization: Stabilize lower thorax.• Desired Motion: Patient flexes cervical spine through

full ROM for fair grade and through partial range for poor.

Trace & Zero

• The Sternocleidomastoideus muscles maybe palpated on each side of neck as patient attempts to flex.

Muscles contribute to Neck Extension

Splenius capitis Trapezius (superior fibers) Splenius cervicis Semispinalis capitisSplenius capitis Trapezius (superior fibers) Splenius cervicis Semispinalis capitis

Splenius capitisSplenius capitis • Origin: Lower ligament nuchae, spinous

processes and supraspinous ligaments T1-3 • Insertion: Lateral occiput between superior

and inferior nuchal lines • Nerve supply: Greater occipital nerve

Trapezius (superior fibers)Trapezius (superior fibers)

• Origin: Base of the skull & posterior ligaments of the neck

• Insertion: Posterior aspect of the lateral 3rd of clavicle

• N. supply: Greater occipital nerve

Splenius cervicisSplenius cervicis

• Origin: Spinous processes and supraspinous ligaments of T3-T6

• Insertion: Posterior tubercles of transverse processes of C1-C3

• Action: Neck Extension

• Nerve supply:

Semispinalis capitisSemispinalis capitis

• Origin: Transverse processes of first 6 or 7 thoracic and 7th cervical vertebrae & Articular processes of fourth, fifth and sixth cervical vertebrae

• Insertion: Between superior & inferior nuchal lines of occipital bone

• Nerve supply: Greater occipital nerve

Note

• Factors Limiting Motion:

1-Tension of anterior longitudinal ligament of spine

2-Tension of ventral neck muscles

3-Approximation of spinous processes• Fixation:

1-Contraction of spinal extensor muscles of thorax and depressor muscles of scapulae and clavicles

2- Weight of trunk and upper extremities

Normal & Good• Position: Prone with neck in flexion.• Stabilization: Stabilize upper thoracic area and scapulae.• Desired Motion: Patient extends cervical spine through

ROM. • Resistance: Is given on occiput.

Note: Extensor muscles on right may be tested by rotation of head to right with extension, and vice versa

Fair & Poor• Position: Prone with neck flexed.• Stabilization: Stabilize upper thoracic area and

scapulae.• Desired Motion: Patient extends cervical spine

through full ROM for fair grade or through partial range for poor

Trace & Zero

• Position: Prone• A trace may be determined by observation and

palpation of the muscles of the dorsal area of the neck. (Test may be given with head resting on table.)

Note

• Be sure patient completes full range of motion of neck extension. Back muscles may contract and lift upper trunk from table, giving the appearance of extension in cervical

Scapular Motions

Muscles contribute to Scapular Abduction & Upward Rotation

Serratus Anterior

Serratus Anterior

• Origin: lateral, anterior surface of the upper 8th- 9th ribs

• Insertion: Anterior aspect of the medial vertebral border of the scapula

• Action: Shoulder Abduction to 90º

• Nerve supply: Long thoracic nerve (C5 – C7)

Note

• Factors Limiting Motion:1-Tension of trapezoid ligament (limits forward

rotation of scapula upon clavicle).2-Tension of trapezius and Rhomboid major and

minor muscles• Fixation:1- In strong scapular abduction, pull of external

Obliquus externus abdominus on same side. 2-Weight of thorax

Normal & Good• Position: Supine with arm flexed to 90º with slight abduction,

and elbow in extension.

• Stabilization & Palpation Point: None

• Desired Motion: Patient moves arm upward by abducting the scapula.

• Resistance: Is given by grasping around forearm and elbow. Pressure is downward and inward toward table.

AlternateAlternate

Fair• Position: Supine with arm flexed to 90º and scapula

resting on table.• Stabilization and Palpation: None• Desired Motion: Patient forces arm upward. Scapula

should be completely abducted without "winging' (If extensor muscles of elbow are weak, elbow may be flexed or forearm may be supported.

Alternate

Poor

• Position: Sitting with arm flexed to 90º and arm resting on table.

• Stabilization: Stabilize thorax.• Desired Motion: Patient moves arm forward by

abducting scapula

Alternate

Trace & Zero

• Examiner lightly forces arm backward to determine presence of a contraction of Serratus anterior.

• Scapula should be observed for "winging." • Digitations of Serratus anterior may be palpated on

outer surface of ribs for a contraction

Muscles contribute to Scapular Elevation

Upper Trapezius Levator scapulae

Upper Trapezius

• Origin: Base of the skull & posterior ligaments of the neck

• Insertion: Posterior aspect of the lateral 3rd of clavicle

• Nerve supply: Accessory nerve (C3 – C4)

Lavetor scapulae

• Origin: Transverse process of 1st four cervical • Insertion: Medial border of the scapula • Nerve supply: Dorsal Scapular Nerve (C5)

Note

• Factors Limiting Motion:

1-Tension of costoclavicular ligament

2- Tension of muscles depressing scapula and clavicle: Pectoralis minor, subclavius, and Trapezius (lower fibers).

• Fixation:

1-Flexor muscles of cervical spine (for tests done in sitting position).

2-Weight of head (foe tests done in prone position).

Normal & Good• Position: Sitting with arms at sides.• Stabilization: No fixation necessary.• Palpation point: Between lateral neck and acromion.• Desired Motion: Patient raises shoulders as high as

possible • Resistance: Is given downward on top of shoulders.

Fair

• Position: Sitting with arms at sides.• Desired Motion: Patient elevates shoulders through

ROM.

Poor

• Position: Prone with shoulders supported by examiner and forehead resting on table.

• Desired Motion: Patient moves shoulders toward ears through ROM.

Trace & Zero

• Examiner palpates upper fibers of Trapezius parallel to cervical Vertebrae and near their insertion above clavicle.

Note

Muscles contribute to Scapular Adduction

Middle Trapezius

Middle Trapezius

• Origin: Spinous process of 7th cervical & 1st -3rd thoracic

• Insertion:

– Medial border of acromion process

– Upper border of scapular spine

• Nerve supply: XI Accessory nerve (C3 – C4)

Note

• Factors Limiting Motion:1-Tension of conoid ligament (limits backward rotation

of scapula upon clavicle)2-Tension of Pectoralis major and minor and Serratus

anterior muscles.3-Contact of vertebral border of scapula with spinal

musculature.• Fixation:• Weight of trunk.

Normal & Good• Position: Prone with arm abducted to 90º and laterally rotated, elbow

flexed to a right angle.• Stabilization: Stabilize thorax.• Palpation point: Base of spine of scapula, fibers run horizontally down

to vertebra• Desired Motion: • Patient raises arm in horizontal abduction, motion taking place

primarily between the scapula and thorax and not at glenohumeral joint.

• Scapula is adducted and fixed by middle section of the trapezius.• Resistance: Is given on lateral angle of scapula. (no pressure is placed on

the humerus).

Fair

• Position: Prone with arm abducted to 90º and laterally rotated, elbow flexed to a right angle.

• Stabilization: Stabilize thoracic• Desired Motion: Patient raises arm and adducts

scapula

Poor

• Position: Sitting with arm resting on table midway between flexion and abduction.

• Stabilization: Stabilize thorax• Desired Motion: Patient horizontally abducts arm

and adducts scapula.

Trace & Zero

• Position: Sitting or Face lying.• Palpation: Middle fibers of Trapezius are palpated

between root of spine of scapula and vertebral column to determine presence of a contraction.

Scapular Depression & Adduction

Lower Trapezius

Lower Trapezius

• Origin: Spinous process of 4th - 12th Thoracic • Insertion: Triangular space at the base of the

scapular spine• Nerve supply: Accessory nerve

Note

• Factors Limiting Motion:1- Tension of interclavicles ligament and articular disk

of sternoclavicular joint.2- Tension of Trapezius (upper fibers), Levator scapular

and sternocleidomastoideus (clavicular head).• Fixation:1-Contraction of spinal extensor muscles2- Weight of trunk.

Normal & Good

• Position: Prone with forehead resting on table and arm to be tested extended overhead.

• Palpation point: • Diagonally down and medially from

the base of the spine of scapula.• Desired Motion: • Patient raises arm and fixates scapula

strongly with lower part of Trapezius. • Resistance: • Is given on lateral angle of scapula in

upward and outward direction. If shoulder flexion is limited, arm may be placed over edge of table.)

Normal & Good ***(Alternate)***

• Note: • If Deltoideous is weak, arm is passively raised by

examiner.• Patient attempts to assist. • Resistance is given on scapula.

Fair & Poor• Position: • Prone with forehead resting on

table and arm overhead.• Desired Motion: • Patient lifts arm from table

through full range of motion without upward movement of the scapula or forward sagging of the acromion process for F grade or through partial range for P grade.

Trace & Zero

• Examiner palpates fibers of lower part of Trapezius between last thoracic vertebrae and scapula.

Scapular Adduction & Downward Rotation

Rhomboid Major

Rhomboid Minor

Rhomboid Major

• Origin: Spinous process of T 2 –T 7 vertebrae • Insertion: Medial border of scapula inferior

to spine • Nerve supply: Dorsal Scapular nerve (C5)

Rhomboid Minor

• Origin: Spinous process of C7 –T 1 vertebrae • Insertion: Medial border of scapula superior to

spine • Nerve supply: Dorsal Scapular nerve (C5)

Note• Factors Limiting Motion:1-Tension of conoid ligament (limits backward rotation of scapula

upon clavicle).2-Tension of Pectoralis major and minor and Serratus anterior

muscles3-Contact of vertebral border of scapula with spinal musculature• Fixation:• Weight of trunk• Substitutions:1-Middle trapezius2-Pectoralis Minor3-Lower trapezius4-Latissimus Dorsi5-Levator Scapula

Caution !!!!

Normal & Good• Position: Prone with arm medially rotated and adducted

across back, with the elbow flexed and hand on buttocks. Shoulders relaxed.

• Stabilization: Roll the shoulder forward to pull vertebral border of scapula, to eliminate Pectoralis major.

• Palpation Point: Along vertebral border of scapula.

• Desired Motion: Patient raises arm and adducts scapula.

• Resistance: Is given on vertebral border of scapula in outward and slightly downward direction.

Fair• Position: • Prone with arm medially

rotated and adducted across back and shoulders relaxed.

• Desired Motion: • Patient raises arm and adducts

scapula through range of motion. (If the glenohumeral muscles are weak, slight resistance may be given to the scapula for a fair grade.)

Poor

• Position: • Sitting with arm medially rotated

and add net ed behind back.• Stabilization: • Stabilize trunk with anterior and

posterior pressure to prevent flexion and rotation.

• Desired Motion: • Patient adducts scapula through

range of motion.

Trace & Zero

• Examiner palpates Rhomboid muscles at the angle formed by the vertebral border of the scapula and the lateral fibers of the lower Trapezius.

Testing theMuscles of the

Upper Extremity

Shoulder Joint

Shoulder Flexion

Anterior Deltoid

Ccoracobrachialis

Muscles contribute to Shoulder Flexion Anterior Deltoid

• Origin: • Anterior lateral third of the clavicle • Insertion:• Deltoid tuberosity on the lateral humerus • Action:• Shoulder Flexion • Nerve supply:

Muscles contributes to Shoulder Flexion Ccoracobrachialis

• Origin: • Coracoid process of the scapula • Insertion:• Middle 1/3 of the medial surface of the

humerus • Action:• Shoulder Flexion • Nerve supply:

Normal and Good• Position: • Sitting with arm at side and elbow slightly

flexed• Stabilization: • Stabilize scapula.• Palpation Point: • Between lateral portion of clavicle and

coracoid process.• Desired motion: • Patient flexes arm to 90º (palm down to

prevent lateral rotation with substitution by the Biceps brachii)

• Resistance: • Is given above elbow.( Patient should not be

allowed to rotate or horizontally adduct or abduct arm)

Fair

• The same as Normal and Good techniques but without given resistance

Poor

• Position: • Patient sideling with arm at side

resting on smooth board (or supported by examiner) and elbow slightly flexed.

• Stabilization: • Stabilize scapula.• Palpation Point: • Between lateral portion of

clavicle and coracoid process.• Desired motion: • Patient brings arm forward to

90º of flexion

Trace and Zero

• Position: • Back lying.• Palpation: • Examiner palpates fibers

of anterior portion of Deltoid on anterior aspect of shoulder joint.

Caution!!!!

Notes

• Range Of motion: 0-90º• Factors Limiting Motion: None, Rang of

motion is incomplete

• Fixation: • Contraction Trapezius & Serratus anterior

muscles. • Serratus anterior and upper fibers of Trapezius

assist in upward rotation of scapula as well as in fixation

Shoulder Extension

Latissimus dorsi Teres Major Teres Minor

Muscles contribute to Shoulder Extension Latissimus dorsi

• Origin: • a- Spines of lower 6 thoracic and lumbar vertebrae• b- Posterior surface of sacrum& Posterior aspect of

crest of ileum• c- Lower 3-4 ribs• d- Inferior angle of scapula • Insertion:• Intertubercle groove of humerus • Action: Shoulder Extension• Nerve supply:

Muscles contribute to Shoulder Extension Teres Major

• Origin:

• Lower 1/3 of the axillary border of the scapula

• Insertion:

• Medial lip of intertubercular groove of humerus

• Action:

Shoulder Extension

• Nerve supply:

Muscles contribute to Shoulder Extension Teres Minor

• Origin:

• Posteriorly on upper & middle aspect of lateral border of scapula

• Insertion:

• Posterior surface of greater tubercle of the humerus

• Action:

Shoulder Extension

• Nerve supply:

Normal & Good

• Position: • Prone with arm medially rotated

and Adducted (palm up to prevent lateral rotation).

• Stabilization: • Stabilize scapula. • Desired Motion: • Patient extends arm through

range of motion. • Resistance: • Is given proximal to elbow.

Fair

• Position: • Prone with arm at side. • Stabilization: • Stabilize scapula.• Desired Motion: • Patient extends arm through

range of motion.

Poor

• Position: • Sideling with arm flexed and

resting on smooth board (or supported by examiner).

• Stabilization: • Stabilize scapula.• Desired Motion: • Patient extends arm in position

of medial rotation through range. of motion.

Trace & Zero• Position: • Prone.• Examiner palpates fibers of Teres major on lower part

of axillary border of scapula (not shown) and fibers of Latissimus dorsi slightly below.

Note

• Range Of motion: 0-50º• Factors Limiting Motion:• 1-Tension of shoulder flexor muscles.• 2-Contact of greater tubercle of humerus with

acromion posteriorly.• Fixation:• Contraction of Rhomboideous major and minor and

Trapezius muscles. • Weight of trunk

Shoulder Horizontal Abduction

Deltoid (posterior portion)

Muscles contribute to Shoulder Horizontal Abduction

Deltoid (posterior portion)

• Origin:

• Inferior edge of the scapular spine • Insertion:

• Deltoid tuberosity on the lateral humerusDeltoid tuberosity on the lateral humerus • Action:

Shoulder Horizontal Abduction

• Nerve supply:

Normal & Good• Position: • Prone with shoulder abducted to 90º, upper arm

resting on table and lower arm hanging vertically over edge.

• Stabilize: • scapula in adduction.• Palpation point: • Below the spine of the scapula.• Desired motion: • Horizontal abduction of humerus to the level of

the table 90º.• Resistance :• Is given proximal to elbow. • Motion takes place primarily at glenohumeral

joint and not between scapula and thorax

Fair• Position:• Prone with shoulder abducted

to 90 degrees, upper arm resting on table and lower arm hanging vertically over edge.

• Stabilization: • Stabilize scapula.• Desired motion: • Patient abducts upper arm

through range of motion

Poor• Position: • Sitting with arm supported in

a position of 90º of flexion.• Stabilization: • Stabilize scapula. • Desired Motion: • Patient horizontally abducts

arm through range of motion.

Trace & Zero

• Muscle fibers of posterior portion of Deltoid are palpated on posterior aspect of shoulder joint.

Note

• Factors Limiting Motion:1-Tension of anterior fibers of capsule of glenohumeral joint 2- Tension of Pectoralis major and Deltoid (anterior fibers)• Fixation:• Contraction of Rhomboid major and minor and Trapezius

(primarily) middle and lower fibers)• Substitution: • 1- Adduction of scapula with Trapezius.• 2- Long head of the triceps.• 3- Teres Major • 4- Latissimus to some extend

Caution !!!!!

Shoulder Horizontal Adduction

Upper pectoralis major Lower pectoralis major

Muscles contribute to Shoulder Horizontal Adduction

Upper pectoralis major • Origin:

• Medial half of anterior surface of clavicle

• Insertion:

• Intertubercle groove of humerus

• Action:

• Shoulder Horizontal Adduction

• Nerve supply:

Muscles contribute to Shoulder Horizontal Adduction

Lower pectoralis major • Origin:

• Anterior surface of costal cartilage of first six ribs, adjacent portion of sternum

• Insertion:

• Intertubercle groove of humerus

• Action:

• Shoulder Horizontal Adduction

• Nerve supply:

Normal & Good

• Position: • Supine with arm abducted to 90

degrees.• Stabilization: • Stabilize scapula to prevent abduction

of the scapula.• Palpation: • Below and near the origin at sternal

end of the clavicle.• Desired Motion: • Patient adducts arm through range of

motion.• Resistance:• Is given proximal to elbow joint.

Palpation

Fair

• Position: • Supine with arm abducted to

90º.• Stabilization: • Stabilize scapula to prevent

abduction of the scapula.• Palpation: • Below and near the origin at

sternal end of the clavicle.• Desired motion: • Patient adducts arm to

vertical position.

Poor

• Position: • Sitting with arm resting on

table in 90º of abduction. • Stabilization: • Stabilize trunk.• Palpation: • Below and near the origin at

sternal end of the clavicle.• Desired motion: • Patient brings arm forward

through ROM.

Trace & Zero

• Examiner palpates tendon of Pectoralis major near insertion on anterior aspect of upper arm.

• Muscle fibers of both sternal and clavicular portions may be observed and palpated on upper anterior aspect of thoracic.

Note

• Factor limiting Motion:• Tension of shoulder extensor muscles• Contact of arm with trunk.• Fixation:• In forceful horizontal adduction, contraction of

Obliquus externus abdominus muscle on same side.• Substitution: • 1-Anterior portion of deltoid• 2-Coracobrachialis• 3- Short Head of biceps.

Shoulder External Rotation

Teres Minor Infraspinatus

Muscles contribute to Shoulder External Rotation

Teres Minor • Origin:

• Posteriorly on upper & middle aspect of lateral border of scapula

• Insertion:

• Posterior surface of greater tubercle of the humerus

• Action:

Shoulder Extension

• Nerve supply:

Muscles contribute to Shoulder External Rotation

Infraspinatus• Origin:

• Posteriorly on upper & middle aspect of lateral border of scapula

• Insertion:

• Posterior surface of greater tubercle of the humerus

• Action:

Shoulder Extension

• Nerve supply:

Normal & Good• Position: • Prone with shoulder abducted to 90º,

upper arm supported on table and lower arm hanging vertically over edge.

• Stabilization: • Stabilize scapula with hand and

forearm, but allow freedom for rotation.• Palpation point: • None• Desired motion: • Patient swings lower arm forward and

up ward and 'laterally rotates shoulder through range of motion.

• Resistance: • Is given above wrist on forearm.

Fair

• Position: • Prone with shoulder abducted to 90º,

upper arm supported on table and lower arm hanging vertically over edge.

• Stabilization: • Stabilize scapula and place hand against

anterior surface of arm to prevent abduction (without interfering with motion).

• Palpation: • None• Desired motion: • Patient swings lower arm forward and

up ward and laterally rotates shoulder through ROM.

Poor• Position: • Prone with entire arm over edge table

in medially rotated positron. • Stabilization: • Stabilize scapula. • Palpation: • None • Desired Motion: • Patient laterally rotates arm through

range of motion. (supination of the forearm should not be allowed to substitute for full range in lateral rotation.)

Trace & Zero

• The Teres minor may be palpated on axillary border of scapula, and Infraspinatus over body of scapula below the spine.

Note

• Factors Limiting Motion:• a- Tension of superior portion of scapular ligament.• b- Tension of lateral rotator muscles of shoulder.• Fixation:• a- Weight of trunk.• b- Contraction of Trapezius and Rhomboid major

and minor muscles to fix scapula• Substitutions:1. Wrist extensors2. Roll the shoulder backwards.

Shoulder Internal Rotation

Subscapularis U. Pectoralis Major Latissimus DorsiL. Pectoralis Major

Muscles contribute to Shoulder Internal Rotation

Subscapularis• Origin:

• Anterior surface of subscapular fossa

• Insertion:

• Lesser tubercle of the humerus • Action:

• Shoulder Internal Rotation

• Nerve supply:

Muscles contribute to Shoulder Internal Rotation

Upper pectoralis major • Origin:

• Medial half of anterior surface of clavicle

• Insertion:

• Intertubercle groove of humerus

• Action:

• Shoulder Internal Rotation

• Nerve supply:

Muscles contribute to Shoulder Internal Rotation

Lower pectoralis major • Origin:

• Anterior surface of costal cartilage of first six ribs, adjacent portion of sternum

• Insertion:

• Intertubercle groove of humerus

• Action:

• Shoulder Internal Rotation

• Nerve supply:

Muscles contribute to Shoulder Internal Rotation

Latissimus dorsi • Origin: • a- Spines of lower 6 thoracic and lumbar vertebrae• b- Posterior surface of sacrum& Posterior aspect of

crest of ileum• c- Lower 3-4 ribs• d- Inferior angle of scapula • Insertion:• Intertubercle groove of humerus • Action:• Shoulder Internal Rotation• Nerve supply:

Normal & Good• Position: • Prone with shoulder abducted to 90 degrees,

upper arm supported on table and lower arm hanging vertically over edge.

• Stabilization: • Stabilize scapula with hand and forearm, but

allow freedom for rotation.• Palpation: • None• Desired Motion: • Patient swings lower arm backward and up

ward and medially rotates shoulder through range of motion.

• Resistance: • Is proximal to wrist on forearm.

Fair• Position:

• Prone with shoulder abducted to 90 degrees, upper arm supported on table and lower arm hanging vertically over edge.

• Stabilization:

• Stabilize scapula.

• Palpation:

• None

• Desired Motion:

• Patient swings lower arm backward and up ward and medially rotates shoulder through range of motion.

Poor• Position: • Prone with arm over edge of table in lateral rotation. • Stabilization: • Stabilize scapula. • Palpation: • None• Desired Motion: • Patient medially rotates arm through range of motion.

(Pronation of the forearm should not be allowed to substitute for full range in medial rotation.)

Trace & Zero

• Fibers of Subscapularis may be palpated deep in axilla near insertion.

Shoulder Abduction to 90º

Middle Deltoid Supraspinatus

Muscles contribute to Shoulder Abduction to 90º

Middle Deltoid • Origin:

• Acromion process

• Insertion:

• Deltoid tuberosity on the lateral humerus

• Action:

• Shoulder Abduction to 90º

• Nerve supply:

Muscles contribute to Shoulder Abduction to 90º

Supraspinatus• Origin:

• Supraspinatus fossa

• Insertion:

• Greater tubercle of the humerus

• Action:

• Shoulder Abduction to 90º

• Nerve supply:

Note

• Factors Limiting Motion:

• None: range of motion incomplete.

• Fixation:

• Contraction of Trapezius and Serratus anterior muscles.

• Serratus anterior and upper fibers of trapezius assist in upward rotation of scapula as well as in fixation.

Normal & Good

• Position: • Sitting with arm at side in mid-position

between medial and lateral rotation.• Elbow flexed a few decrees.• Stabilization: • Stabilize scapula.• Palpation: • Just below the acromion process of the

scapula.• Desired Motion: • Patient abducts the humerus to 90º(palm

down).• Resistance :• Is given proximal to elbow

Fair

• Position:

• Sitting with arm at side in midposition between medial and lateral rotation.

• Elbow flexed a few degrees.

• Stabilization:

• Stabilize scapula.

• Palpation:

• Just below the acromion process.

• Desired Motion:

• Patient abducts arm to 90º (palm down).

Poor

• Position:

• Supine with arm at side in midposition between medial and lateral rotation.

• Elbow slightly flexed.

• Stabilization:

• Stabilize scapula over acromion.

• Desired Motion:

• Patient abducts arm to 90º without Lateral rotation at shoulder joint

Alternate

Trace & Zero

• Examiner palpates middle section of Deltoid on lateral surface of upper third of arm

Note

• Patient may laterally rotate arm and attempt to substitute Biceps brachii during abduction.

• Arm should be kept in midposition between medial and lateral rotation.

Note

• Range of Motion: 0° TO 90°

• Factors Limiting Motion:

• Tension of expansions of extensor ten dons of fingers.

• Fixation:

• Weight of arm

Shoulder Goniometry

Introduction1. It is the measuring of angles created by the bones

of the body at the joints. 2. These joints are measured by a goniometer. 3. It has a moving arm, stationary arm, and the

fulcrum. 4. The fulcrum or body is placed over the joint being

measured and on it is a scale from 0 to 180. 5. The stationary arm will be aligned with the inactive

part of the joint measured, while the moving arm is placed on the part of the limb which is moved in the joint’s motion.

6. For example, when measuring knee flexion, the stationary arm will be aligned over the thigh in line with the greater trochanter of the femur.

Introduction - continue

7. The fulcrum is aligned over the knee joint or lateral epicondyle of the femur, and the moving arm with the midline of the leg or lateral malleolus.

8. Performing these tests is important for many reasons. • The mobility of joints is important for diagnosis and

determining the presence or absence of dysfunction. 9. In a chronic condition, goniometry can measure the progression

of the disorder. • An example of this is the progression of rheumatoid

arthritis. 10. Furthermore, joint motion measurement can evaluate

improvements or lack of progression during rehabilitation. 11. This not only provides motivation for the patient when there are

improvements, but also can decipher if modifications need to be made if treatment is not effective.

Flexion

Patient Instructions: • Once the goniometer is aligned

properly ask the patient to lift the arm up just as if they were raising their hand to ask a question.

• Be sure that the patient keeps the palm of their hand facing in toward their body.

Starting Position

• Patient is supine with arm at side and the palm of the hand facing the body.

• The fulcrum of the goniometer is placed over the acromion process.

• The stationary and moving arms are aligned with the midline of the humerus and lateral epicondyle.

Ending Position

• The moving arm remains in line with the lateral epicondyle and midline of the humerus.

• The examiner supporting the patient’s extremity.

• The stationary arm should remain in its starting position, only now it should be in line with the lateral midline of the thorax.

• Normal ROM for glenohumeral flexion is 160 to 180º; in the picture the patient is in 180º of flexion.

Extension

• Patient Instructions:• Ask the patient to simply lift their arm off

the table as far as they can.

Starting Position• Patient is prone with arm

at side; make sure the head is facing away from the shoulder being tested.

• Elbow bent slightly and the palm facing in toward the body.

• The fulcrum is placed over the acromion process.

• The stationary and moving arms are aligned with the lateral midline of the humerus and the lateral epicondyle.

Ending Position

• The moving arm remains in line with the lateral epicondyle and the examiner should support the patient’s extremity.

• The stationary arm in line with the midline of the thorax.

• Normal ROM for glenohumeral extension is 40 to 60º; in the picture the patient is in 61º of extension.

Abduction

• Patient Instructions:• Have the patient bring their arm out to

their side and as close to their head as they can.

• Make sure that their palm faces upward throughout the motion.

Starting Position

• The patient is supine with arm at side; the palm should be facing interiorly.

• The fulcrum is placed at the acromion process.

• The stationary and moving arms are aligned with the anterior midline of the humerus.

Ending Position

• The stationary arm should remain still and parallel to the sternum.

• The moving arm should still be resting at the anterior midline of the humerus.

• Normal ROM between 160 and 180º; the patient in the picture is in 174º of abduction

Medial (Internal) Rotation

• Patient Instructions:• Ask the patient to rotate their arm

down as far as they can.

Starting Position

• Supine with 90º of shoulder abduction and the elbow is in 90º of flexion.

• The table should not support the elbow.

• The fulcrum centered over the olecranon process.

• The moving arm is aligned with the ulnar styloid and the stationary arm should be perpendicular to the floor.

Ending Position

• Same as above• Normal ROM is 60-

70˚; the patient is in 68º of internal rotation.

Lateral (External) Rotation

• Patient Instructions:• Ask the patient to rotate their arm up

toward their head as far as they can.

Starting and Ending Position

• Supine with 90º of shoulder abduction and 90º of elbow flexion.

• The table should not support the elbow.  (Refer to above picture)

• Fulcrum on the olecranon process.

• The moving arm should be aligned with the ulnar styloid and the stationary arm should be perpendicular to the floor.

• Ending Position:• Same as before

Normal ROM Reference Values

Shoulder Typical ROM

Flexion 160 - 180˚

Extension 40 - 60˚

Abduction 160 - 180˚

Internal Rotation 60-70˚

External Rotation 40 - 45˚

Painful Elbow Joint

Clinical Examination of the Elbow

Anatomy Of the elbow

SURFACE ANATOMY OF THE ELBOW

• Lateral elbow - labeled

OlecranonOlecranon

Lateral EpicondyleLateral Epicondyle

The bones (Figs. 1-4)

Figure 1 Diagrammatic AP view of elbow jointFigure 2 Diagrammatic lateral view of elbow joint. Note that the elbow is slightly twisted in respect of the axis of the ulna.

• Figure 5 Diagrammatic view of the medial collateral ligament, with its three bundles. The anterior bundle is the most important functionally, since it provides valgus and anteroposterior stability. Figure 6 Diagrammatic view of the lateral ligament complex. It would appear that the most import structure is the lateral collateral ligament, which blends with the annular ligament. The lateral ulnar collateral ligament is indissociable from the lateral collateral ligament, at its attachment to the lateral epicondyle. Distally, it branches off, and attaches to the supinator crest. The role of the accessory lateral collateral ligament is poorly understood.

Figure 7 Diagrammatic view of the origin and insertion of anconeus, which covers the capsule and collateral ligaments on the lateral side.

Diseases of the elbow joint

• Arthritis

• Fractures

• Bursitis

• Tendonitis (Tinness elbow and Glover's elbow)

• Cubital Tunnel Syndrome

Bursitis

Tinness elbow

Cubital Tunnel Syndrome

CLINICAL EXAMINATION

INSPECTION

• The patient should be standing, with shoulders slightly braced back, to display the elbow.

• When the forearm is in full extension and supination, there will be a physiological valgus ("carrying angle") of 9-14°; in women, the angle will be 2-3° greater

• This angle has been found to be 10-15° greater in the dominant arm of throwing athletes

• This angle allows the elbow to be tucked into the waist depression above the iliac crest; it increases when a heavy object is being lifted

• Any increase in, or loss of, this physiological angle is indicative either of major elbow instability or of malunion.

• However, the angle varies from valgus in extension to varus in flexion, and its measurement is not of any practical importance.

Inspection

• Sometimes, on the side of the elbow, bulging in the para-olecranon groove will be seen; such a swelling is produced by an effusion or by synovial tissue proliferation

• On the back, prominence of the olecranon is a sign of posterior subluxation of the elbow, a feature commonly found in RA .

• Rheumatoid nodules are extremely common

• Bursitis is also a frequently encountered pathology, especially in RA patients.

• Skin atrophy at steroid injection sites, or scars from previous surgery.

Figure 8 The physiological valgus (“carrying angle”) of the elbow is increased when a load is being carried. Normally, the angle is between 9 and 14° when the elbow is extended and the forearm is supinated.

PALPATION

• Palpation starts at the posterior aspect, with the patient standing with his or her shoulder braced backwards.

• The three palpation landmarks - the two epicondyles and the apex of the olecranon - form an equilateral triangle when the elbow is flexed 90°, and a straight line when the elbow is in extension (Figs. 9, 10).

PALPATION

Figures 9, 10 Three bony landmarks - the medial epicondyle, the lateral epicondyle, and the apex of the olecranon - form an equilateral triangle when the elbow is flexed 90°, and a straight line when the elbow is in extension

PALPATION

• Since the elbow is a very superficial joint, it can be readily palpated from behind and from the sides.

• The posterior aspect has the olecranon mid-way between the medial and the lateral condyle.

• Slight elbow flexion will bring the olecranon out of the olecranon fossa, in which it lodges in extension; in this position, the proximal portion of the fossa on either side of the triceps tendon may be palpated (Fig. 11)

• Figure 11 Flexing the elbow allows palpation of the olecranon fossa on either side of the triceps tendon.

• Figure 12 Anatomical landmarks on the lateral aspect of the elbow: The lateral epicondyle continues proximally in the supracondylar ridge.

• Two 2cms distally, the main landmark is formed by the radial head.

PALPATION

• The olecranon bursa is not in communication with the synovial cavity.

• This is why the elbow may be mobilized in bursitis, and why even massive bursitis will not be tender.

• In chronic bursitis, a boggy globular mass may be palpated; the overlying skin will be thickened. Flat, hard nodules may be felt under the palpating fingertips.

• In infected bursitis, the skin will be tight and shiny; streaks of lymphangitis will be commonly seen; while in 25% of the cases, the axillary lymph nodes will be enlarged.

• On the lateral side, the main landmarks are the lateral epicondyle proximally and the radial head distally.

• The supracondylar ridge is also very accessible to palpation; its chief value is that of a landmark for surgical approaches (Fig. 12).

• Sometimes, palpation may be carried out all the way up to the deltoid tuberosity.

• The radial head is palpated with the examiner’s thumb, while the other hand is used to pronate and supinate the forearm (Fig. 13).

• The head is about 2 cm distal to the lateral epicondyle

• Inside the triangle formed by the bony prominences of the lateral epicondyle, the radial head and the olecranon, the joint itself is palpated, to detect even very minor effusions or low-grade synovitis (Fig. 14(

Figure 13 • Anatomical landmarks on the lateral aspect of the elbow: • The radial head is palpated with the thumb, while the examiner’s other hand is used to

pronate and supinate the forearm

.Figure 14• The elbow joint may be palpated inside a triangle formed by the bony prominences of

the lateral epicondyle, the radial head, and the olecranon. • This palpation will reveal even minor effusions or mild synovitis. • Puncture for joint aspiration is performed inside this triangle. • Similarly, an arthroscopy portal may be placed there (posterolateral portal(

PALPATION

• Figure 15 Palpation and testing of brachioradialis, a forearm flexor.

• Figure 16 Palpation and testing of the wrist extensors

PALPATION

PALPATION• From the medial side, the joint is not very accessible to palpation, and the

small amount of synovial tissue on the medial border of the olecranon makes joint palpation difficult

• Palpation of the ridge that provides insertion for the intermuscular septum is useful mainly as a guide for surgical approaches. Also, the supracondylar lymph nodes may be palpated at this site (Fig. 17).

• Over, and slightly anterior to, the supracondylar ridge, a bony excrescence may be palpated; this outgrowth may irritate the median nerve

• This supracondylar process is present in 1-3% of the population, and is seen at a distance of 5-7 cm above the joint line

• Behind the septum, the ulnar nerve may be palpated; in patients with a very mobile nerve, it may be seen to roll on the medial condyle(10) (Fig. 18).

• Ulnar nerve instability is more easily tested with the arm in slight abduction and external rotation, with the elbow flexed between 20 and 70°.

Figure 17• Palpation of the medial aspect of the elbow. • Above the medial epicondyle is the ridge on

which the intermuscular septum inserts. • Two centimetres above the epicondyle is the

site used for lymph node palpation.

Figure 18 The ulnar nerve is palpated behind the intermuscular septum. It may sometimes sublux or roll on the epicondyle. Ulnar nerve instability is more readily demonstrated if the elbow is flexed 60° and the upper limb is abducted and externally rotated.

PALPATION• Anteriorly, the bulk of the flexor-pronator group restricts the

extent of joint palpation. • The flexor-pronator muscles must be tested as a unit, by

asking the patient to perform wrist adduction and flexion against resistance (Fig. 19).

• Next, each one of these muscles should be tested individually. • The anterior aspect does not lend itself to palpation, since it is

tucked away behind the muscles.• Laterally, brachioradialis will be felt; and in the middle, the

biceps tendon is readily accessible if the patient is made to flex the forearm against resistance.

• Lacertus fibrosus is palpated medial to the biceps tendon; the pulse of the brachial artery will be felt deep to this aponeurosis (Fig. 20).

• Sometimes anterior protrusion cysts produced by herniated synovial membrane may be felt.

Figure 19 Diagrammatic view of the pattern of the flexor-pronator group: The thumb represents pronator teres; the index, flexor carpi radialis; the middle finger, palmaris longus; and the ring finger, flexor carpi ulnaris.

Figure 20 Palpation of the medial biceps expansion (lacertus fibrosus), which courses over the brachial vessels and the median nerve.

MOBILITY

• The main function of the elbow is to bring the hand to the mouth; this is why the investigation of the elbow range of movement (ROM) is an important part of the examination process.

• Any difference between passive and active mobility is usually due to reflex inhibition from pain

• The end-feel - the feeling transmitted to the examiner’s hands at the extreme range of passive motion - must also be assessed (Table 1)

• If the feel is abnormal, there is usually something wrong with the joint.

Table 1 Classification and description of end-feels (modified from TS Ellenbecker & AJ Mattalino)(12a(

Bony Two hard surfaces meeting, bone to bone (elbow extension(

Capsular Leathery feel, further motion available (forearm pronation and supination(

Soft tissue approximation Soft tissue contact (elbow flexion(

Spasm Muscle contraction limits motion

Springy block Intra-articular block; rebound is felt

Empty Movement causes pain, pain limits movement

ELBOW JOINT

• The elbow is a complex joint with three different articulations.

• The humeroulnar joint is a hinge joint, and allows the forearm to flex and extend, and provides stability.

• The radiohumeral and radioulnar joints allow for flexion, extension and rotation of the radius on the ulna, which in turn allows the forearm to pronate and supinate.

RANGE OF MOTION

• Flex and extend, and supinate and pronate.

• Normal elbow range of motion

• Extension: 0°

• Flexion: 150°

• Pronation: 70°

• Supination: 90°

Elbow Goniometry

Flexion

• Patient Instructions:• Ask the patient to bend their elbow as far as

they can, try and touch their shoulder.

Starting Position

• Position: Supine, arm in the anatomical position with arm of the patient is resting on the edge of the table.

• The fulcrum aligned with the lateral epicondyle of the humerus.• The stationary arm is positioned along the midline of the humerus• The moving arm is aligned with the radial styloid process.

Ending Position

• The arm is now flexed at the elbow, the goniometer should still be aligned with the correct anatomical landmarks as described below.

• Normal ROM is between 150-160º, the patient has 155º of elbow flexion.

Pronation• Patient Instructions:• Have the patient turn their wrist down toward the ground.

• Starting Position:• Patient sitting up with elbow bent 90 degrees and at patient’s

side, wrist in a handshake position.• The fulcrum is placed just behind the ulnar styloid process. • The moving arm and stationary arm are parallel with the anterior

midline of the humerus.

Ending Position• The fulcrum should remain in the same position as above.• The stationary arm will still be aligned parallel to the midline of

the humerus, the moving arm will lie across the dorsum of the forearm just behind the ulnar and radial styloid processes.

• Normal ROM is 90-96º, the patient has 95º of pronation.

Supination• Patient Instructions:• Have the patient turn their palm up as if they are holding

something in the palm of their hand.• Starting Position:• Patient position is the same as for pronation.• The goniometer is placed on the medial aspect of the forearm

with the fulcrum at the radioulnar joint.• The arms are both aligned with the anterior midline of the

humerus.

Ending Position• The moving arm will be resting on the medial forearm at

the radioulnar joint. • The moving arm should remain parallel to the midline of

the humerus. • Normal ROM is 81-93º, the patient has 90º of Supination.

Normal ROM Reference Values

Elbow Typical ROM

Flexion 150-160º

Extension 0

Pronation 90-96º

Supination 81-93º

Elbow Joint

Elbow Flexion

Brachialis Brachioradialis Biceps Brachii

Muscles contribute to Elbow Flexion Brachioradialis

• Origin:

• Upper 2/3 of lateral supracondylar ridge of humerus

• Insertion:

• Styloid process of radius

• Action:

• Elbow Flexion

• Nerve supply:

Muscles contribute to Elbow Flexion Biceps Brachii

• Origin:

• Long head: supraglenoid tubercle

• Short head: coracoid process

• Insertion:

• Radial tuberosity

• Action:

• Elbow Flexion

• Nerve supply

Muscles contribute to Elbow Flexion Brachialis

• Origin:

• Lower portion of anterior surface of humerus

• Insertion:

• Coronoid process of ulna • Action:

• Elbow Flexion

• Nerve supply

Normal & Good• Position: • Sitting with slight shoulder flexion and the

elbow flexed past 90, forearm is supinated. • Ask the patient to, “hold your elbow bent,

and don’t let me straighten it out.” • Palpation: • Muscle belly or just medial on crease of

elbow tendon.• Stabilization: • Stabilizing hand is placed on the shoulder.  • Desired Motion: • Patient flexes elbow through range of

motion. • Resistance • Is given at the wrist in a downward direction.

Normal & Good

Brachioradialis: forearm in midposition between pronation and supination

Biceps brctchii : forearm in supination Brachialis : forearm in pronation

Fair

• Position: • Sitting with arm at side and

forearm supinated • Stabilization: • Stabilize upper arm.• Desired Motion: • Patient flexes elbow through

range of motion.

Poor• Position:

• Supine with shoulder abducted to 90 and laterally rotated ْ.

• Stabilization:

• stabilizing hand is placed on the shoulder.  

• Desired Motion:

• Patient slides forearm along table through complete range of elbow flexion.

• (If range of motion is limited in lateral rotation at shoulder joint, test may be given with arm medially rotated.)

Trace & Zero

• Examiners palpate the flexors on the forearm; muscle fibers may be found on anterior surface of arm.

Alternate Test for Elbow Flexion

• This alternate test is performed if the biceps and brachialis are weak.

• Pronating the hand will instead use the brachioradialis, extensor carpi radialis longus, pronator teres, and other wrist flexors.

• Patients positioning is the same, except the forearm is now pronated and the stabilizing hand is under the elbow joint.

• Testing procedure is the same as before.

Note

• Note:• The wrist flexors may be contracted for assistance in

elbow flexion. • Wrist will be strongly flexed as a result. Wrist should

be relaxed.

Note

• Range of motion: 0º to 145º - 160º• Factors Limiting Motion: 1-Contact of muscle masses volar aspect of arm and forearm.2-Contact of coronoid process with coronoid fossa of humerus• Fixation:1-Weight of arm2-Fixator muscles of scapula• Substitutions:1. Brachioradialis2. Flexors group of the wrist and fingers:FCR, FCU, palmaris

longus, FDS, FPL and pronator teres.

Elbow Extension

Triceps Brachii

Muscles contribute to Elbow Extension

Triceps Brachii • Origin: • Long head: Scapula, infraglenoid tubercleScapula, infraglenoid tubercle • Lateral head: Humerus, 1/3 lateral-posterior surface • Medial head: Humerus, lower 3/4 of posterior surface • Insertion: Olecranon process of ulna • Nerve supply

Note

• Range of Motion: 145º – 160º to 0º• Factors Limiting Motion:1-Tension of anterior, radial and ulnar collateral ligaments of

elbow joint.2-Tension of flexor muscles of forearm.3-Contact of olecranon process with olecranon fossa on posterior

aspect of humerus.• Fixation:1-Weight of arm2-Contraction of Fixator muscles of scapula.• Substitutions Muscles:1-Rotators2-Wrist extensors3-Anconeous

Normal & Good• Position: • Patient is prone on the table with the shoulder abducted to 90,

the entire arm should be off the table and the therapist can stabilize the arm at the humerus just above the elbow. The elbow should be in full extension.

• Palpation: Proximal to olecranon process.• Stabilization: Stabilize arm.• Desired Motion: Patient extends elbow through ROM. • Resistance: Is applied at wrist in a downward direction.

Fair

• Position: Supine with shoulder flexed to 90 ْ and elbow flexed.• Palpation: The same as before• Stabilization: Stabilize arm.• Desired Motion: Patient extends elbow through range of

motion

Alternate

Poor• Position: Supine with arm abducted to 90 degrees and laterally

rotated. Elbow is flexed.• Stabilization: Stabilize arm.• Desired Motion: Ask the patient to, “straighten your elbow,

don’t let him bend it down. (if range of motion is limited in lateral rotation at shoulder joint, test may be given with arm medially rotated)

Trace & Zero

• Examiner may palpate tendon of Triceps brachii at the elbow joint and muscle fibers on posterior surface of arm.

Muscles contribute to Forearm Supination

Biceps Brachii Supinator Teres

Biceps Brachii

• Origin:

• Long head: supraglenoid tubercle

• Short head: coracoid process

• Insertion: Radial tuberosity

• Nerve supply

Muscles contribute to Forearm Supination

Supinator Teres • Origin:

• lateral epicondyle lateral epicondyle of Humerusof Humerus

• posterior part of ulnaposterior part of ulna

• Insertion: upper 1/3 lateral surface of Radius.

• Nerve supply

Note

• Range of motion: 0ºTO 90º Supination from midposition

• Factors Limiting Motion:1-Tension of Volar radioulnar ligament and ulnar

collateral ligament of wrist joint.2-Tension of oblique cord and lowest fibers of

interosseous muscles of forearm.• Fixation:• Weight of arm

Normal & Good• Position: Sitting with arm at side, elbow flexed to 90 degrees and

forearm pronated to prevent rotation at the shoulder. Muscles of wrist and fingers are; relaxed.

• Stabilization: Stabilize arm.• Desired Motion: Patient supinates forearm. • Resistance: Is given on dorsal surface of distal end of radius.

(Resistance may be given by grasping around the dorsal surface of the hand instead of the position illustrated.)

Fair & Poor

• Position:

• Silting with arm at side, elbow flexed to 90º, forearm pronated and supported by examiner.

• Muscles of wrist and fingers are relaxed.

• Desired Motion:

• Patient supinates forearm through full range of motion for fair grade and through partial for poor grade.

Fair

Poor

Trace & Zero

• Supinator muscle is palpable on radial side of forearm if overlying extensor muscles are not functioning. Tendon of Biceps brachii is found in antecubital space

Note

• Patient should not be allowed to laterally rotate arm and move elbow across thorax as forearm is supinated.

• As a result of this movement the forearm may appear to be supinated, but range of motion is incomplete.

• This motion may "roll" the forearm into supination without a muscular contraction taking place.

Forearm Pronation

Pronator Teres

Muscles contribute to Forearm Pronation

Pronator Teres

• Origin:

• Humerus, medial epicondyleHumerus, medial epicondyle

• Insertion:

• Radius, middle 3rd of lateral surface

• Action:

• Forearm Pronation

• Nerve supply

Note

• Range of motion: 0º to 90º Pronation from midposition

• Factors Limiting Motion:1-Tension of dorsal radioulnar, ulnar collateral and

dorsal radiocarpal ligaments.2-Tension of lowest fibers of interosseous membrane.• Fixation:• Weight of arm

Normal & Good

• Position: • Sitting with arm at side, elbow flexed to 90º

to prevent rotation at the shoulder and forearm supinated. Muscles of wrist and fingers are relaxed.

• Stabilization: • Stabilize arm.• Desired Motion: • Patient pronates forearm through ROM. • Resistance :• Is given on volar surface of distal end of

radius with counterpressure against the dorsal surface of the ulna.

Fair & Poor

• Position:

• Sitting with arm at side, elbow flexed to 90º, forearm supinated and supported by examiner. Muscles of wrist and fingers are relaxed.

• Desired Motion:

• Patient pronates forearm through full range of motion for fair grade and through partial range for poor grade

Fair

Poor

Trace & Zero

• Position:

• Sitting.

• Palpation:

• Examiner palpates fibers of Pronator teres on upper third of volar surface of forearm on a diagonal line from medial condyle of humerus to lateral border of radius

Note

• Patient should not be allowed to medially rotate or abduct upper arm during pronation.

• This movement makes the ROM in pronation appear complete and allows forearm to roll into pronated position

Wrist Joint

Painful Wrist

• Trigger finger

• De Quvarian syndrome

• Fractures

• Arthritis

• Tendonitis

• Peripheral nerve Injuries

Trigger finger

Muscles contribute to Wrist Flexion Wrist Flexion

Flexor carpi radialis Flexor carpi ulnarisFlexor carpi radialis Flexor carpi ulnaris

Flexor carpi radialisFlexor carpi radialis • Origin: Medial epicondyle of humerusMedial epicondyle of humerus • Insertion: Base of 2nd & 3rd metacarpals,

anterior surface • Nerve supply: Median Nerve (C6, C7)

Flexor carpi ulnarisFlexor carpi ulnaris

• Origin: Medial epicondyle of humerusMedial epicondyle of humerus • Insertion: Pisiform, hamate & base of 5th

metacarpal • Nerve supply: Ulnar Nerve C7, T1)

Note

• Range of Motion: Wrist flexion: 0 to 90 ْ• Factors Limiting Motion:

• Tension of dorsal radiocarpal ligament

• Fixation:

• Weight of arm

Normal & Good

• Position: Sitting with forearm resting on table with forearm supinated.

• Muscles of thumb and fingers relaxed.• Stabilization: Stabilize forearm.• Desired Motion: Patient flexes wrist

Note

• To test Flexor carpi radialis, resistance is given at base of second metacarpal bone in direction of extension and ulnar deviation

Note

• To test Flexor carpi ulnaris, resistance is given at base of fifth metacarpal bone in direction of extension and radial deviation

Fair

• Position: Sitting with forearm resting on table with forearm supinated. Muscles of thumb and fingers relaxed.

• Stabilization: Stabilize forearm.

• Desired Motion: Patient flexes wrist with radial deviation or ulnar deviation

Flexor carpi radialis Flexor carpi ulnaris

Poor• Position: Sitting, forearm supported, hand resting on medial

border. Muscles of thumb and fingers relaxed.

• Stabilization: Stabilize forearm.

• Desired Motion: Patient flexes wrist, sliding hand along table. Deviation should be observed and muscles graded accordingly.

Trace & Zero

• Examiner palpates tendon of Flexor carpi radialis on lateral palmar aspect of wrist and tendon of Flexor carpi ulnaris on medial palmar surface.

Muscles contribute to Wrist Extension

Extensor carpi radialis longus Extensor carpi radialis Brevis Extensor carpi UlnarisExtensor carpi radialis longus Extensor carpi radialis Brevis Extensor carpi Ulnaris

Muscles contribute to Wrist Extension

Extensor carpi radialis longusExtensor carpi radialis longus • Origin: Humerus, lower 3Humerus, lower 3rdrd of lateral supracondylar ridge of lateral supracondylar ridge

and lateral epicondyle of humerusand lateral epicondyle of humerus • Insertion: Base of 2nd metacarpal (dorsal surface)

• Nerve supply: Radial Nerve

Extensor carpi radialis BrevisExtensor carpi radialis Brevis

• Origin: Lateral epicondyle of humerus

• Insertion: Base of 3rd metacarpal (dorsal surface)

• Nerve supply: Radial Nerve

Extensor carpi UlnarisExtensor carpi Ulnaris

• Origin: Lateral epicondyle of humerus

• Insertion: Base of 5th metacarpal • Nerve supply: Ulnar Nerve

Note• Range of Motion: • Wrist extension beyond midline; 0 to 70º• Factors Limiting Motion:• Tension of palmar radiocarpal ligament• Fixation:• Weight of arm

Caution!!!!

Normal & Good• Position:

• Sitting with forearm resting on the table and pronated.

• Muscles of fingers and thumb relaxed.

• Stabilization: Stabilize forearm.

• Desired Motion: Patient extends wrist.

Note

• To test Extensor carpi radialis longus and Brevis, resistance is given on dorsal surface of second and third metacarpal bones in direction of flexion and ulnar deviation.

Note

• To test Extensor carpi ulnaris, resistance is given on dorsal surface of fifth metacarpal bone in direction of flexion and radial deviation.

Fair • Position: • Sitting with forearm resting on the table and pronated. • Muscles of fingers and thumb relaxed.• Stabilization: Stabilize forearm.• Desired Motion: Patient extends wrist with radial

deviation or ulnar deviation.

Poor• Position: Sitting, forearm supported, hand resting on medial

border.

• Stabilization: Stabilize forearm.

• Desired Motion:

• Patient extends wrist, sliding hand along table through range of motion.

• Deviation should be observed and muscles graded accordingly

Trace & Zero

• Tendons of wrist extensors may be found on lateral dorsal surface of wrist in line with second and third metacarpal bones and on medial dorsal surface proximal to fifth metacarpal bone.

Joints of Fingers

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Flexion of metacarpophalangeal joints of fingers

LumbricalesLumbricales

Muscles contribute to Flexion of metacarpophalangeal joints of fingers

LumbricalesLumbricales • Origin:

• Four tendons of flexor digitorum profundus.

• Radial 2: radial side only (unipennate).

• Ulnar 2: cleft between tendons ( bipennate)

• Insertion:

• Proximal phalanx of fingers 2-5 radial side

• Action:

• Flexion of MP joints

• Nerve supply

Normal & Good

• Position: • Sitting with hand resting on dorsal surface.• Stabilization: • Stabilize metacarpals.• Desired Motion: • Patient flexes fingers at MCP joints,

keeping IP joints extended. • Resistance:• Is given on palmar surface of proximal

row of phalanges.• Note: Resistance may be given to each

finger separately if Lumbricales are unequal in strength.

Fair & Poor

• Position: • Sitting with hand supported.• Stabilization: • Stabilize metacarpals.• Desired Motion: • Patient flexes fingers at MCP joints

through ROM, keeping IP joints extended.

• Patient flexes MCP joints through full ROM for fair grade and through partial range for poor grade.

Trace & Zero

• Contraction of Lumbricales may be detected by light pressure against palmar surface of proximal phalanges as patient attempts to flex at MCP joints.

Note

• The Flexor digitorum superficialis and Flexor digitorum profundus should not be allowed to substitute for Lumbricales with flexion of fingers.

• These muscles should be kept relaxed as much as possible with motion limited to meta carpophalangeal joint.

• Individual testing of fingers (in all tests) is often desirable as they vary in strength.

Caution!!!!

Flexion of Proximal Interphalangeal Joints of Fingers

Flexor digitorum superficialisFlexor digitorum superficialis

Diseases of the fingers

• Arthritis (rheumatoid arthritis, gout arthritis)

• Diabetes

• Fractures

• Trigger finger

• Tendonitis

• Trauma

Rheumatoid arthritis trigger

Trigger Finger• Definition • Trigger finger is an inflammation of the synovial sheath

that encloses the flexor tendons of the thumb and fingers. Tendons are the cords that connect bones to muscles in the body. Usually, tendons slide easily through the sheath as the finger moves.

• In the case of trigger finger, however, the synovial sheath becomes swollen and the tendon cannot move easily through small pulleys in the finger, causing the finger to remain in a flexed (bent) position.

• In mild cases, the finger may be straightened with a pop, like a trigger being released.

• In severe cases, the finger becomes stuck in the bent position.

• Usually this condition can easily be treated; contact your doctor if you think you may have trigger finger.

Causes

• Often, the cause of trigger finger is unknown. However, many cases of trigger finger are caused by one of the following:

• Overuse of the hand from repetitive motions – Computer operation – Machine operation – Repeated use of hand tools – Playing musical instruments

• Inflammation caused by a disease – Rheumatoid arthritis – Gout – Hypothyroidism

Risk Factors

• The following factors increase your chances of developing trigger finger:

• Age: 40-60 • History of repetitive hand motions for work

or play • Sex: female • History of certain diseases:

– Rheumatoid arthritis – Gout – Hypothyroidism

Symptoms

• If you experience any of these symptoms do not assume it is due to trigger finger. Some of these symptoms may be caused by other health conditions. If you experience any one of them for a period of time, see your physician. – Finger or thumb stiffness – Finger, thumb, or hand pain – Swelling or a lump in the palm – Catching or popping when straightening the

finger or thumb – Finger or thumb stuck in bent position

Diagnosis

• Your doctor will ask about your symptoms and medical history, and perform a physical exam. The physical exam may include:

• Asking you to move the affected finger or thumb

• Feeling the hand and fingers • For severe cases of trigger finger, your

doctor may refer you to a hand specialist.

Treatment

• The goals of treatment for tenosynovitis are:–to reduce swelling and pain –to allow the tendon to move freely with the tendon sheath.

• Treatment options include the following:

• Rest• Stopping movement in the finger or

thumb, sometimes with the help of a brace or splint, is often the best treatment for mild cases of trigger finger.

• Rest may be combined with stretching of the muscle tendon unit involved.

• Medications• Several medications are used to treat tenosynovitis.

These include: • Corticosteroids, given as an injection into the

synovial tendon sheath to reduce swelling of the tendon sheath

• Nonsteroidal anti-inflammatory drugs (NSAIDs) to help reduce inflammation and pain: – Ibuprofen (Advil, Motrin) – Naproxen (Aleve, Naprosyn)

• For severe cases of trigger finger that do not respond to medications, surgery may be used to release the finger from a locked position and to allow the tendon to move freely through the sheath.

• This surgery is usually performed on an outpatient basis and requires only a small incision in the palm of the hand.

Prevention

• The most important action you can take to prevent trigger finger is to avoid overuse of your thumb and fingers.

• If you have a job or hobby that involves repetitive motions of the hand, you can take the following steps: – Adjust your workspace to minimize the strain on

your joints – Alternate activities when possible – Take breaks throughout the day – Exercise regularly

Muscles contribute to Flexion of proximal interphalangeal joints of fingers

Flexor digitorum superficialisFlexor digitorum superficialis • Origin: • Humeral head: common flexor origin of medial epicondyle

humerus, medial ligament of elbow.

• Ulnar head: medial border of coronoid process and fibrous arch.

• Radial head: whole length of anterior oblique line

• Insertion:• Tendons split to insert onto sides of middle phalanges of medial

four fingers

• Action:• Flexion of PIP & DIP joints

• Nerve supply

Normal & Good

• Position: • Sitting with hand resting palm upward on

table and fingers extended.• Stabilization: • Stabilize proximal phalanx of finger. • Desired Motion: • Patient flexes middle phalanx. • Resistance:• Is given on palmar surface of middle

phalanx of finger.

Fair & Poor

• Patient flexes proximal phalanx through full range of motion for fair grade and through partial range for poor grade.

Trace & Zero

• Superficial portion of the Flexor digitorum superficialis may be palpated at the wrist under the Palmaris longus

Caution!!!

Flexion of Distal Interphalangeal Joints of Fingers

Flexor digitorum profundusFlexor digitorum profundus

Muscles contribute to Flexion of distal interphalangeal joints of fingers

Flexor digitorum profundusFlexor digitorum profundus • Origin:

• Medial olecranon, upper three quarters of anterior and medial surface of ulna as far round as subcutaneous border and narrow strip of interosseous membrane

• Insertion:

• Distal phalanges of medial four fingers.

• Tendon to index finger separates early

• Action:

• Flexion of PIP & DIP joints

• Nerve supply

Normal & Good

• Position:

• Sitting with hand resting palm upward on table and fingers extended.

• Stabilization:

• Stabilize middle phalanx of finger.

• Desired Motion:

• Patient flexes distal phalanx.

• Resistance:

• Is given on palmar surface of distal phalanx of finger

Fair & Poor

• Patient flexes distal phalanx through full ROM for fair grade and through partial range for poor grade.

Trace & Zero

• Flexor digitorum profundus may be palpated on the palmar surface of the middle phalanx

Caution!!!!

Extension of metacarpophalangeal joints of

fingers

Extensor digitorum communis Extensor indicis proprius Extensor digiti minimiExtensor digitorum communis Extensor indicis proprius Extensor digiti minimi

Muscles contribute to Extension of metacarpophalangeal joints of fingers

Extensor digitorum communisExtensor digitorum communis • Origin:

• Common extensor origin on anterior aspect of lateral epicondyle of humerus

• Insertion:

• External expansion to middle and distal phalanges by four tendons. Tendons 3 and 4 usually fuse and little finger just receives a slip

• Action:

• Extension of MP joints

• Nerve supply

Muscles contribute to Extension of metacarpophalangeal joints of fingers

Extensor indicis propriusExtensor indicis proprius • Origin:

• Lower posterior shaft of ulna (below extensor pollicis longus) and adjacent interosseous membrane

• Insertion:

• Extensor expansion of index finger (tendon lies on ulnar side of extensor digitorum tendon)

• Action:

• Extension of MP joints

• Nerve supply

Muscles contribute to Extension of metacarpophalangeal joints of fingers

Extensor digiti minimiExtensor digiti minimi• Origin:

• Common extensor origin on anterior aspect of lateral epicondyle of humerus

• Insertion:

• Extensor expansion of little finger-usually two tendons which are joined by a slip from extensor digitorum at metacarpophalangeal joint

• Action:

• Extension of MP joints

• Nerve supply

Normal & Good

• Position: • Arm resting on table, hand

supported, wrist in midposition, fingers flexed.

• Stabilization: • Stabilize metacarpals.• Desired Motion: • Patient extends proximal row of

phalanges with IP joints partially flexed.

• Resistance :• Is given on dorsal surface of

proximal row of phalanges of fingers.

Fair & Poor

• Position:• Sitting with hand supported, fingers

flexed and wrist in midposition. • Stabilization: • Stabilize metacarpals. • Desired Motion:• Patient extends proximal row of

phalanges to end of range, with IP joints partially flexed.

• Patient extends MCP joints through full ROM for grade of fair and through partial range for grade of poor

Trace & Zero

• The tendons of the finger extensors may easily be located on dorsum of hand where they pass over metacarpals.

Finger Abduction

Interossei dorsales Abductor digiti minimiInterossei dorsales Abductor digiti minimi

Muscles contribute to Finger Abduction

Interossei dorsalesInterossei dorsales • Origin:

• Bipennate from inner aspects of shafts of all metacarpals

• Insertion:

• Proximal phalanges and dorsal extensor expansion on radial side of index and middle fingers and ulnar side of middle and ring fingers

• Action:

• Finger Abduction

• Nerve supply

Muscles contribute to Finger Abduction

Abductor digiti minimiAbductor digiti minimi • Origin:

• Pisiform bone, pisohamate ligament and flexor retinaculum

• Insertion:

• Ulnar side of base of proximal phalanx of little finger and extensor expansion

• Action:

• Finger Abduction

• Nerve supply

Normal & Good

►Test for first and third Interossei dorsales• Position: • Sitting with hand supported palm downward,

fingers adducted. • Stabilization: • Stabilize metacarpals.• Desired Motion: • Patient abducts fingers. • Resistance:• Is given on radial side of second and ulnar side

of third finger, (To test individual fingers, resistance is given on first phalanx)

Normal & Good

►Test for second and fourth Interossei dorsales and Abductor digiti minimi

• Position: • Sitting with hand supported palm

downward, fingers adducted. • Stabilization: • Stabilize metacarpals.• Desired Motion:• Patient abducts fingers. • Resistance:• Is given on ulnar side of fourth and fifth

fingers and on radial side of third finger.

Fair & Poor

• Position:

• Sitting with palm resting on table, fingers adducted.

• Desired Motion:

• Patient abducts fingers through ROM. (Third finger must be moved in both directions.)

• Patient abducts fingers through full ROM for fair grade and through partial range for poor grade.

Trace & Zero

• The Interossei dorsales lie deep between the metacarpal bones on the dorsum of the hand.

• (Palpation of first Interosseus dorsales shown in illustration.)

Fingers Adduction

Interossei palmaresInterossei palmares

Muscles contribute to Finger Adduction

Interossei palmaresInterossei palmares • Origin: • Entire length of second, fourth and fifth

metacarpal bones on palmar surface• Insertion:• Side of base of proximal phalanx of

corresponding finger: first into ulnar side of index finger; second and third into radial side of ring and little fingersInto aponeurotic expansion of Extensor digitorum tendon of same finger

• Action:• Finger Adduction• Nerve supply

Normal & Good

• Position :• Sitting with hand supported palm

clown ward, fingers abducted.• Desired Motion:• Patient adducts fingers. • Resistance:• Is given in radial direction on

second finger and in ulnar direction on fourth and fifth fingers.

Fair & Poor

• Position: • Sitting with hand resting palm

downward on table, fingers in abduction.

• Desired Motion:• Patient adducts fingers through full

range of motion for fair grade and through partial range for poor grade

Trace & Zero

• Presence of contraction of the Interossei palmares may be determined by outward pressure on the second, fourth and fifth fingers as the patient attempts to adduct

Flexion of Metacarpophalangeal & Interphalangeal of Thumbs joints

Flexor pollicis Brevis Flexor pollicis LongusFlexor pollicis Brevis Flexor pollicis Longus

Muscles contribute to Flexion of Metacarpophalangeal & Interphalangeal of Thumbs joints

Flexor pollicis BrevisFlexor pollicis Brevis • Origin:

• Flexor retinaculum and tubercle of trapezium

• Insertion:

• Base of proximal phalanx of thumb (via radial sesamoid)

• Action:

• Flexion of MP & IP of the thumb

• Nerve supply

Muscles contribute to Flexion of Metacarpophalangeal & Interphalangeal of Thumbs joints

Flexor pollicis LongusFlexor pollicis Longus

• Origin:

• Anterior surface of radius below anterior oblique line and adjacent interosseous membrane

• Insertion:

• Base of distal phalanx of thumb

• Action:

• Flexion of MP & IP of the thumb

• Nerve supply

Flexion of MCP Joint of Thumb

Normal & Good

• Position: • Sitting with hand resting palm upward on

table.• Stabilization: • Stabilize first metacarpal. • Desired motion: • Patient Flexes first phalanx of thumb. &

distal phalanx remains relaxed. • Resistance: • Is given on palmar surface of proximal

phalanx

Fair & Poor

• Patient flexes first phalanx of thumb through full ROM for fair grade and through partial range for poor grade

Trace & Zero

• Contraction of Flexor pollicis Brevis may be determined by pressure over palmar surface of first metacarpal (medial to Abductor pollicis Brevis) as patient attempts flexion.

Flexion of Interphalangeal Joint of Thumb

Normal & Good

• Position: • Sitting with hand resting palm

upward on table.• Stabilization: • Stabilize first phalanx of thumb. • Desired motion:• Patient flexes distal phalanx

(motion takes place in plane of palm).

• Resistance:• Is given on palmar surface of

distal phalanx of thumb

Fair & Poor

• Patient flexes distal phalanx through full ROM for fair grade and through partial range for poor grade.

Trace & Zero

• The tendon of Flexor pollicis longus may be found on palmar surface of the first phalanx of the thumb

Extension of Metacarpophalangeal & Interphalangeal of Thumbs joints

Extensor pollicis Brevis Extensor pollicis longusExtensor pollicis Brevis Extensor pollicis longus

Muscles contribute to Extension of Metacarpophalangeal & Interphalangeal of Thumbs joints

Extensor pollicis BrevisExtensor pollicis Brevis • Origin:

• Lower third of posterior shaft of radius and adjacent interosseous membrane

• Insertion:

• Over tendons of radial extensors and brachioradialis to base of proximal phalanx of thumb

• Action:

• Extension of MP & IP of the thumb

• Nerve supply

Muscles contribute to Extension of Metacarpophalangeal & Interphalangeal of Thumbs joints

Extensor pollicis longusExtensor pollicis longus • Origin:

• Middle third of posterior ulna (below abductor pollicis longus) and adjacent interosseous membrane

• Insertion:

• Base of distal phalanx of thumb via Lister's tubercle (dorsal tubercle of radius).

• Action:

• Extension of MP & IP of the thumb

• Nerve supply

Extension of Metacarpophalangeal Joint of Thumb

Normal & Good

• Position:

• Sitting with hand resting on table.

• Stabilization:

• Stabilize first metacarpal.

• Desired motion:

• Patient extends first phalanx of thumb.

• Resistance:

• Is given on dorsal surface of proximal phalanx.

Fair & Poor

• Patient extends first phalanx of thumb through full ROM for fair and through partial range for poor

Trace & Zero

• Tendon of Extensor pollicis Brevis may be found at base of metacarpal of thumb

Extension of Interphalangeal Joint of Thumb

Normal & Good

• Position:• Sitting with hand resting on

ulnar border.• Stabilization: • Stabilize first phalanx of

thumb.• Desired motion: • Patient extends distal phalanx

(motion takes place in plane of palm).

• Resistance: • Is given on dorsal surface of

distal phalanx of thumb

Fair & Poor

• Patient extends distal phalanx of thumb through full ROM for fair, and through partial range for poor.

Trace & Zero

• Tendon of Extensor pollicis longus may be palpated on dorsal surface of hand between head of first metacarpal and base of second. It may also be found on dorsal surface of first phalanx

Thumb Abduction

Abductor pollicis Brevis Abductor pollicis longusAbductor pollicis Brevis Abductor pollicis longus

Muscles contribute to Thumb Abduction

Abductor pollicis BrevisAbductor pollicis Brevis • Origin:

• Tubercle of scaphoid & flexor retinaculum

• Insertion:

• Radial sesamoid of proximal phalanx of thumb & tendon of extensor pollicis longus

• Action:

• Thumb Abduction

• Nerve supply

Muscles contribute to Thumb Abduction

Abductor pollicis longusAbductor pollicis longus • Origin:

• Upper posterior surface of ulna and middle third of posterior surface of radius and interosseous membrane between

• Insertion:

• Over tendons of radial extensors and brachioradialis to base of 1st metacarpal and trapezium

• Action:

• Thumb Abduction

• Nerve supply

Normal & Good

• Position:• Sitting with hand supported.• Stabilization: • Stabilize medial four metacarpals

and wrist.• Desired motion:• Patient raises thumb vertically

through range of abduction. • Resistance: • Is given on lateral border of first

phalanx of thumb.

Note

• If Abductor pollicis longus is stronger than the Brevis, thumb will deviate toward radial side of hand.

• If Abductor pollicis Brevis is stronger, deviation will be toward ulnar side

Fair & Poor

• Position:

• Sitting with hand supported.

• Stabilization:

• Stabilize metacarpals and wrist.

• Desired motion:

• Patient abducts thumb through full ROM for fair grade and through partial range for poor grade

Trace & Zero

• The Abductor pollicis Brevis fibers may easily be found on thenar eminence lateral to the Flexor pollicis Brevis. The tendon of the Abductor pollicis longus may be palpated near its insertion

Thumb Adduction

Adductor PollicisAdductor Pollicis

Muscles contribute to Thumb Adduction Adductor pollicisAdductor pollicis

• Origin:

• Oblique head: base of 2nd and 3rd metacarpals, trapezoid and capitate. Transverse head: palmar border and shaft of 3rd metacarpal

• Insertion:

• Ulnar sesamoid then ulnar side of base of proximal phalanx and tendon of extensor pollicis longus

• Action:

• Thumb Adduction

• Nerve supply

Normal & Good

• Position :• Sitting with hand supported.

Stabilize medial four metacarpals.

• Desired motion: • Patient adducts thumb. • Resistance:• Is given on medial border of

first phalanx

Fair & Poor

• Position:• Sitting with hand supported.• Stabilization:• Stabilize metacarpals.• Desired motion: • Patient adducts thumb

through full ROM for fair grade and through partial range for poor grade.

Trace & Zero

• Muscle fibers may be palpated between first Interossei dorsales muscle and first metacarpal bone.

Note

• Flexor pollicis longus and Flexor pollicis Brevis may help pull thumb toward palm. These muscles should remain relaxed during test.

Opposition of Thumb

Opponens pollicis Opponens digiti minimiOpponens pollicis Opponens digiti minimi

Muscles contribute to Opposition of Thumb

Opponens pollicisOpponens pollicis • Origin:

• Flexor retinaculum and tubercle of trapezium

• Insertion:

• Whole of radial border of 1st metacarpal

• Action:

• Thumb Opposition

• Nerve supply

Muscles contribute to Opposition of Thumb

Opponens digiti minimiOpponens digiti minimi • Origin:

• Flexor retinaculum and hook of hamate

• Insertion:

• Ulnar border of shaft of 5th metacarpal

• Action:

• Thumb Opposition

• Nerve supply

Normal & Good• Position: • Sitting with hand resting palm upward

on table.• Desired motion:• Patient brings palmar surfaces of

distal phalanges of thumb and fifth finger together.

• The first and fifth metacarpals rotate toward the midline of the hand. The movement cannot be carried out by muscles other than the two opponents.

• Resistance: • Is given on distal end of first and fifth

metacarpals on palmar surface with derogating pressure. The two muscles are graded separately

Fair & Poor

• Patient moves thumb and fifth finger through full range of opposition for fair grade and through partial range for poor grade. The two muscles are graded separately.

Trace & Zero

• Note:• The two muscles of

opposition cannot be palpated unless the overlying superficial muscles are nonfunctioning.

Trunk Manual Muscle Testing

Trunk Flexion

Rectus abdominisRectus abdominis

Muscles contribute to Trunk Flexion Rectus abdominisRectus abdominis

• Origin:

• Pubic crest and pubic symphysis

• Insertion:

• 5, 6, 7 costal cartilages, medial inferiorcostal margin and posterior aspect of xiphoid

• Action:

• Trunk Flexion

• Nerve supply:

Normal

• Position:

• Supine with hands behind neck.

• Stabilization:

• Stabilize legs firmly.

• Desired Motion:

• Patient flexes thorax on pelvis through ROM

Normal

• Note: • If hip flexor muscles are weak, stabilize pelvis. • A curl up is emphasized and flexion is possible until

scapulae are raised from table. • Tests for neck flexion should precede those for trunk

flexion

Good• Position:

• Backlying with arms at sides.

• Stabilization:

• Stabilize legs firmly.

• Desired Motion:

• Patient flexes thorax on pelvis through range of motion.

• If hip flexor muscles are weak, stabilize pelvis.

• Flexion is possible until scapula are raised from table.

Fair• Position: • Supine with arms at sides.• Stabilization: • Stabilize legs firmly.• Desired Motion: • Patient flexes thorax on pelvis

through partial range of motion. • Head, tips of shoulders and cranial

borders of scapulae should clear table with inferior angle remaining in contact with table.

• If hip flexor muscles are weak, stabilize pelvis

Poor• Position: • Supine with arms at sides• Desired Motion: • Patient flexes cervical spine.• Caudal portion of thorax is

depressed, and pelvis is tilted until the lumbar area of spine is flat on table.

• Palpation will help to determine smoothness of contraction

Trace & Zero

• Position: • Backlying.• A slight contraction may be

determined by palpation over anterior abdominal wall as patient attempts to cough (also during rapid exhalation or as patient attempts to lift head).

• Observe deviation of umbilicus.• Cranial movement indicates

stronger contraction of upper section of muscle, and caudal movement, stronger contraction of lower section (not illustrated.)

Note• Factors Limiting Motion:• 1- Tension of posterior longitudinal ligament, ligamenta flava,

and interspinal and supraspinal ligaments• 2- Tension of spinal extensor muscles• 3-Apposition of caudal lips of vertebra bodies anteriorly with

surfaces of subjacent vertebrae• 4-Compression of ventral part of intervertebral fibrocartilages• 5-Contact of last ribs with abdomen• Fixation:• 1-Reverse action of hip flexor muscles• 2-Weight of legs and pelvis

Trunk Extension

Erector spinae – Spinalis Erector spinae – lliocostalis Erector spinae – LongissimusErector spinae – Spinalis Erector spinae – lliocostalis Erector spinae – Longissimus

Muscles contribute to Trunk Extension Erector spinae – SpinalisErector spinae – Spinalis

• Origin:

• Spinous processes • Insertion:

• Spinous processes six levels above • Action:

• Trunk Extension

• Nerve supply:

• Dorsal rami of spinal nerves

Muscles contribute to Trunk Extension

Erector spinae – lliocostalisErector spinae – lliocostalis • Origin:

• Iliac crest, sacrum, lumbar vertebrae

• Insertion:

• Ribs, cervical transverse processes

• Action:

• Trunk Extension

• Nerve supply:

• Dorsal rami of spinal nerves

Muscles contribute to Trunk Extension Erector spinae – LongissimusErector spinae – Longissimus

• Origin:

• Transverse processes of lumber vertebrae

• Insertion:

• Tip of Transverse processes of all thoracic vertebrae

• Action:

• Trunk Extension

• Nerve supply:

• Dorsal rami of spinal nerves

Normal & Good

• Extension of lumbar spine• Position: Supine.• Stabilization: Stabilize pelvis. • Desired Motion: • Patient extends lumbar spine until caudal part of thorax is

raised from table. • Resistance: Is given on caudal portion of thoracic area.

Normal & Good• Extension of thoracic spine• Position: • Facelying.• Stabilization: • Stabilize pelvis and lower part of

thorax.• Desired Motion: • Patient extends thoracic spine to

horizontal position. • Resistance:• Is given on cranial portion of thorax.• A pad can he placed under caudal

portion of thorax if a greater range of motion is needed.

Fair • Extension of thoracic and lumbar spine• Position: • Facelying. • Stabilization: • Stabilize pelvis.• Desired Motion: • Patient extends thoracic and lumbar spine

through range of motion.

Poor

• Extension of thoracic and lumbar spine• Position: • Facelying. • Stabilization: • Stabilize pelvis.• Desired Motion: • Patients completes partial ROM

Trace & Zero

• Position: • Facelying.• Examiner palpates spinal extensor muscles to

determine presence and degree of contraction as patient attempts to raise trunk

Note

• Factors Limiting Motion:1-Tension of anterior longitudinal ligament of spine2-Tension of anterior abdominal muscles3-Contact of spinous processes4-Contact of caudal articular margins with laminae• Fixation:1-Contraction of Glutens maximums and2-Hamstring muscles3-Weight of pelvis and legs

Trunk Rotation

Obliquus externus abdominis Obliquus internus abdominisObliquus externus abdominis Obliquus internus abdominis

Muscles contribute to Trunk Rotation Obliquus externus abdominisObliquus externus abdominis

• Origin:

• Anterior angles of lower eight ribs • Insertion:

• Outer anterior half of iliac crest, inguinal leg, public tubercle and crest, and aponeurosis of anterior rectus sheath

• Action:

• Trunk Rotation

• Nerve supply:

Muscles contribute to Trunk Rotation Obliquus internus abdominisObliquus internus abdominis

• Origin:

• Lumbar fascia, anterior two thirds of iliac crest and lateral two thirds of inguinal ligament

• Insertion:

• Costal margin, aponeurosis of rectus sheath (anterior and posterior ), conjoint tendon to pubic crest and pectineal line

• Action:

• Trunk Rotation

• Nerve supply:

Normal• Position: • Backlying with hands behind neck.• Stabilization: • Stabilize legs firmly.• Desired Motion: • Patient rotates and flexes thorax to one

side. • Repeat to opposite side.• Note: Test for left Obliquus externus

abdominis and right Obliquns interims abdominis is shown in illustration. Rotation to left is brought about by opposite muscles.

• If hip flexor muscles are weak, stabilize pelvis as in "Fair" test. Upper thorax should be lifted from table with rotation.)

Good

• Position:

• Backlying with arms at sides.

• Stabilization:

• Stabilize legs firmly.

• Desired Motion:

• Patient rotates and flexes thorax to one side.

• Repeat to opposite side.

• If hip flexor muscles are weak, stabilize pelvic as in "Fair" test.

Fair

• Position:

• Backlying with hands on opposite shoulders.

• Stabilization:

• Stabilize pelvis.

• Desired Motion:

• Patient rotates thorax until scapula on side of forward shoulder is raised from table.

• Repeat with rotation to opposite side.

Poor

• Position:

• Sitting with arms relaxed at sides.

• Stabilization:

• Pelvis stabilized.

• Desired Motion:

• Patient rotates thorax.

• Repeat with rotation to opposite side.

Trace & Zero

• Examiner palpates muscles as patient attempts to approximate thorax on left and pelvis on right. Repeat on opposite side.

• Note: Observe deviation of umbilicus, which will move toward strongest quadrant if there is a difference in strength of opposing oblique muscles.

Muscle Testing (Lower extremity)

MUSCLE THAT ACT ON THE ANTERIOR THIGH (FEMUR)

MUSCLE THAT ACT ON THE POSTERIOR THIGH (FEMUR)

Elevation of pelvis

• QUADRATUS LUMBORUM

QUADRATUS LUMBORUM

• ORIGIN: Inferior border of 12th rib • INSERTION

Apices of transverse processes of L1-4, iliolumber ligament and posterior third of iliac crest

• ACTIONFixes 12th rib during respiration and lateral flexes trunk

• NERVEAnterior primary rami (T12-L3)

QUADRATUS LUMBORUM

• Range of Motion:• In standing position pelvis may he raised on

one side until foot is well clear of floor. (Reverse action of Quadratus lumborum.)

• Factors Limiting Motion:• Tension of spinal ligaments on opposite

side• Contact of iliac crest with thorax• Fixation:• Contraction of spinal extensor muscles (o

fix thorax

NORMAL AND GOOD

• Position: Backlying (or Facelying) with lumbar area of spine in moderate extension. Patient grasps edge of table to stabilize thorax. (If-arm and shoulder muscles are weak, an assistant should stabilize thorax.)

• Desired Motion: Patient draws pelvis toward thorax on one side.

• Resistance is given above ankle joint.

FAIR AND POOR

• Position: Backlying with legs straight and with lumbar area of spine in moderate extension.

• Patient may grasp side of table to stabilize thorax (not shown in picture).

• Desired Motion: Patient draws pelvis upward toward thorax.• Slight resistance is given for a fair grade. Completion of range

is graded poor.

FAIR (Alternate)

• Standing position.• Stabilize thorax.• Desired motion: Patient lifts pelvis toward

thorax through ROM

TRACE AND ZERO

• As patient attempts to draw pelvis cranial ward, a contraction of Quadratus lumborum may be determined by deep palpation in lumbar area under lateral edge of Erector spinae.

SartoriusOrigin:  Anterior superior iliac spine

Insertion:  medial surface of the tibia 

Function: Hip flexion, Abduction, and External Rotation with Knee Position

Nerve supply:  • Psoas major: lumbar plexus• Iliacus: lumbar plexus

Normal and GoodPosition: Sitting with thighs supported on the

table and legs dangling off, the patient can place their hands down for support.

Desired Motion: The patient flex, abduct, and externally rotate at the hip, and flex at the knee.

Resistance. • One hand will be placed on the lateral

surface of the knee, and the other will be placed on the medial aspect of the ankle.

• The hand at the knee will resist hip flexion and abduction and the resistance will be given in a down and inward direction.

• The hand at the ankle will be resisting external rotation and knee flexion and the resistance is in an up and outward direction.

• Ask the patient to, “slide your heel up the shin of your other leg, don’t let me move your leg or straighten your knee.”

FAIR AND POOR

Position: Sitting with thighs supported on the table and legs dangling off, the patient can place their hands down for support.

Desired Motion: The patient flex, abduct, and externally rotate at the hip, and flex at the knee.

TRACE AND ZERO• Patient Position:  • Supine, with the therapist supporting the limb. • The heel should be on the shin of the opposite leg.

  • While palpating the sartorius ask the patient to

slide their heel up to their knee. 

Hip Flexion

• Sartorius

• PSOAS MAJOR

• ILIACUS

PSOAS MAJOR

• ORIGIN: Transverse processes of L1-5, bodies of T12-L5 and intervertebral discs below bodies of T12-L4

• INSERTION: Middle surface of lesser trochanter of femur

• ACTION: • Flexes and medially rotates hip• NERVE: • Anterior primary rami of L1,2

ILIACUS

• ORIGIN: Iliac fossa within abdomen • INSERTION: Lowermost surface of lesser

trochanter of femur• ACTION: Flexes medially rotates hip• NERVE: Femoral nerve in abdomen (L2,3)

Hip Flexion

• Range of Motion:

Factors Limiting Motion:• With knee Hexed, contact of thigh on abdomen• With knee extended, tension of hamstring musclesFixation:1.Contraction of anterior abdominal muscle to fix lumber spine and pelvis.1.Weight at trunk

Normal and Good

• Position: Sitting with legs over edge of table. • Stabilization: Stabilize pelvis.• Desired Motion: Patient flexes hip through

last part of range of motion.Resistance is given proximal to knee joint.

Fair

• Sitting with legs over edge of table.• Stabilize pelvis.• Patient flexes hip through last part of ROM.

Poor

• Position: Sidelying with upper leg supported. Trunk pelvis and legs straight.

• Stabilize pelvis.• Patient flexes hip through range of motion Knee is

allowed to flex to prevent hamstring tension.

TRACE AND ZERO

• Supine with leg supported. It may be possible to detect contraction in Psoas major just distal to inguinal ligament on medial side of Sartorius.

Note

• Substitution by Sartorius in hip flexion will cause lateral rotation and abduction of thigh. Muscle may be seen and palpated near its origin during the motion.

• Substitution by Tensor Fasciae Latae in hip flexion causes medial rotation and abduction of the thigh. Muscle may be seen and palpated at its origin.

Hip Extension

• GLUTEUS MAXIMUS

• BICEPS FEMORIS

• SEMIMEMBRANOSUS

• SEMITENDINOSUS

GLUTEUS MAXIMUS

• ORIGINOuter surface of ilium behind posterior gluteal line and posterior third of iliac crest lumbar fascia, lateral mass of sacrum, sacrotuberous ligament and coccyx

• INSERTIONDeepest quarter into gluteal tuberosity of femur, remaining three quarters into iliotibial tract (anterior surface of lateral condyle of tibia)

• ACTIONExtends and laterally rotates hip. Maintains knee extended via iliotibial tract

• NERVE: Inferior gluteal nerve (L5, S1,2)

BICEPS FEMORIS

ORIGINLong head: upper inner quadrant of posterior surface of ischial tuberosity.

• Short head: middle third of linea aspera, lateral supracondylar ridge of femur

INSERTIONStyloid process of head of fibula. lateral collateral ligament and lateral tibial condyle

ACTIONFlexes and laterally rotates knee. Long head extends hip

NERVELong head: tibial portion of sciatic nerve. Short head: common peroneal portion of sciatic nerve (both L5, S1)

SEMIMEMBRANOSUS

• ORIGINUpper outer quadrant of posterior surface of ischial tuberosity

• INSERTION

Medial condyle of tibia below articular margin, fascia over popliteus and oblique popliteal ligament

• ACTIONFlexes and medially rotates knee. Extends hip

• NERVETibial portion of sciatic nerve (L5, S1)

SEMITENDINOSUS

• ORIGINUpper inner quadrant of posterior surface of ischial tuberosity

• INSERTIONUpper medial shaft of tibia below Gracilis

• ACTIONFlexes and medially rotates knee. Extends hip

• NERVETibial portion of sciatic nerve (L5, S1)

Hip Extension

Range of Motion – Extension: 115º – 125º to 0º– Extension beyond midline 0º to 10º - 15º

• Factors Limiting Motion:– Tension of iliofemoml ligament– Tension of hip flexor muscles

• Fixation:– Contraction of Iliocustalis

and Quad rat us lumborum muscles– Weight of trunk

NORMAL AND GOOD

• Prone with legs extended.

• Stabilize pelvis.• Patient extends, hip

through range of motion.

• Resistance is given proximal to knee joint.

NORMAL AND GOOD

Test for isolation of Gluteus Maximus)

• Prone with knee flexed.• Stabilize pelvis.• Patient extends hip, keeping

knee flexed to decrease action of hamstrings.

• Resistance is given proximal to knee joint.

• Range of motion will be more limited than in position above, owing to tension in the Rectus femoris

FAIR

• Position: prone with legs extended.• Stabilization: Stabilize pelvis.• Desired motion: Patient extends leg through range of

motion

POOR

• Position: Sidelying with hip flexed, knee extended and upper leg supported.

• Stabilize pelvis.• Patient extends hip

through range of motion.

• (Knee may be flexed for fair and poor to isolate the action of the Gluteus Maximus.)

TRACE AND ZERO

• Prone.• Contraction of

Gluteus Maximus will result in narrowing of gluteal crease. Lower and upper sections of muscle should be pal pated.

Note

• Patient may lift pelvis and support leg with hamstrings, raising leg from table by extending lumbar spine.

• Examiner must be certain that pelvis is stable and movement takes place in hip joint.

Hip Abduction

• GLUTEUS MEDIUS• SARTORIUS

GLUTEUS MEDIUS

• ORIGINOuter surface of ilium between posterior and middle gluteal lines

• INSERTIONPosterolateral surface of greater trochanter of femur

• ACTIONAbducts and medially rotates hip. Tilts pelvis on walking

• NERVESuperior gluteal nerve (L4,5,S1)

Hip Abduction

• Range of Motion:

Factors Limiting Motion:Tension of distal band of iliofemoral ligament and

pubocapsular ligament.Tension of hip adductor musclesFixation:1.Contraction of lateral abdominal muscles and Latissimus

dorsi2.Weight of trunk

NORMAL AND GOOD

• Position: Sidelying with leg slightly extended beyond midline. Lower knee flexed for balance.

• Stabilization: Stabilize pelvis.• Desired motion: Patient abducts leg through

ROM without lateral rotation of the hip.

FAIR

• Position: Sidelying with leg slightly extended beyond midline. Lower knee flexed for balance.

• Stabilization: Stabilize pelvis. • Desired motion: Patient abducts leg through ROM.

POOR

• Supine with legs extended. • Stabilize pelvis.• Patient abducts leg through ROM without

allowing leg to rotate.

TRACE AND ZERO

• Fibers of the Gluteus medius maybe found on lateral aspect of ilium above greater trochanter of femur.Resistance is given proximal to knee joint.

Note

• Patient may bring pelvis to thorax by strong contraction of lateral trunk muscles, thereby lifting leg through partial abduc tion.

• Examiner must stabilize pelvis to make sure motion takes place in hip joint.

Note

• Lateral rotation at the hip should be eliminated, or hip flexors may substitute for Gluteus medius. Flexion of the hip allows substitution by the Tensor fasciae Latae.

Hip Adduction

1. GRACILIS

2. PECTINEUS

3. ADDUCTOR BREVIS

4. ADDUCTOR LONGUS

5. ADDUCTOR MAGNUS

GRACILIS

• ORIGINOuter surface of ischiopubic ramus

• INSERTIONUpper medial shaft of tibia below sartorius

• ACTIONAdducts hip. Flexes knee and medially rotates flexed knee

• NERVEAnterior division of obturator nerve (L2, 3)

PECTINEUS

• ORIGINPectineal line of pubis and narrow area of superior pubic ramus below it

• INSERTIONA vertical line between spiral line and gluteal crest below lesser trochanter of femur

• ACTIONFlexes, adducts and medially rotates hip

• NERVEAnterior division of femoral nerve (L2, 3). Occasional twig from obturator nerve (anterior division - L2,3)

ADDUCTOR BREVIS

• ORIGINInferior ramus and body of pubis

• INSERTIONUpper third of linea aspera

• ACTION: Adducts hip • NERVE

Anterior division of obturator nerve (L2, 3)

ADDUCTOR LONGUS

• ORIGINBody of pubis inferior and medial to pubic tubercle

• INSERTIONLower two thirds of medial linea aspera

• ACTIONAdducts and medially rotates hip

• NERVEAnterior division of obturator nerve (L2, 3)

ADDUCTOR MAGNUS

• ORIGINAdductor portion: ischiopubic ramus. Hamstring portion: lower outer quadrant of posterior surface of ischial tuberosity

• INSERTIONAdductor portion: lower gluteal line and linea aspera. Hamstring portion: adductor tubercle

• ACTIONAdductor portion: adducts and medially rotates hip. Hamstring portion: extends hip

• NERVEAdductor portion: posterior division of obturator nerve (L2-4). Hamstring portion: tibial portion of sciatic (L4-S3)

Hip Adduction

• Range of Motion:

Factors Limiting Motion:Contact with opposite legWhen hip is flexed, tension of ischiofemoral ligament.Fixation: Weight of trunk.

NORMAL AND GOOD

• Sidelying with leg resting on table and upper leg supported in approximately 25º of abduction.

• Patient adducts leg until it contacts upper• Resistance is given proximal to knee joint.

FAIR• Sidelying with leg resting on table and

upper leg supported in approximately 25º of abduction.

• Patient adducts leg until it contacts upper leg.

POOR

• Supine with leg in 45º of abduction.• Stabilize pelvis.• Patient adducts leg through ROM without

allowing rotation of hip.

TRACE AND ZERO

• Contraction of fibers of adductor muscles may he palpated on medial aspect of thigh.

Hip Lateral Rotation

• SARTORIUS

• GEMELLUS INFERIOR

• GEMELLUS SUPERIOR

• OBTURATOR EXTERNUS

• OBTURATOR INTERNUS

• QUADRATUS FEMORIS

• PIRIFORMIS

GEMELLUS INFERIOR

• ORIGINUpper border of ischial tuberosity

• INSERTIONMiddle part of medial aspect of greater trochanter of femur

• ACTIONlaterally rotates and stabilizes hip

• NERVENerve to quadratus femoris (L4, 5, S1)

GEMELLUS SUPERIOR

• ORIGIN: Spine of ischium • INSERTION

Middle part of medial aspect of greater trochanter of femur

• ACTIONlaterally rotates and stabilizes hip

• NERVENerve to obturator internus (L5, S1, 2)

OBTURATOR EXTERNUS

• ORIGINOuter obturator membrane , rim of pubis and ischium bordering it

• INSERTIONTrochanteric fossa on medial surface of greater trochanter

• ACTIONlaterally rotates hip

• NERVEPosterior division of obturator nerve (L2,3,4)

OBTURATOR INTERNUS

• ORIGINInner surface of obturator membrane and rim of pubis and ischium bordering membrane

• INSERTIONMiddle part of medial aspect of greater trochanter of femur

• ACTIONlaterally rotates and stabilizes hip

• NERVENerve to obturator internus (L5, S1,2)

QUADRATUS FEMORIS

• ORIGINLateral border of ischial tuberosity

• INSERTIONQuadrate tubercle of femur and a vertical line below this to the level of lesser trochanter

• ACTIONlaterally rotates and stabilizes hip

• NERVENerve to quadratus femoris (L4, 5, S1)

PIRIFORMIS

• ORIGIN2, 3, 4 costotransverse bars of anterior sacrum, few fibers from superior border of greater sciatic notch

• INSERTIONAnterior part of medial aspect of greater trochanter of femur

• ACTIONlaterally rotates and stabilizes hip

• NERVEAnterior primary rami of S1, 2

HIP LATERAL ROTATION

• Range of Motion:

0° T

O 4

5°)

less

wit

h h

ip e

xten

ded

Factors Limiting Motion:Tension of lateral hand of iliofemoral ligamentTension of hip medial rotator musclesFixation:Weight of trunk

NORMAL AND GOOD

• Sitting with legs over edge of table.

• Use counter pressure above knee to prevent abduction and flexion of hip. Patient grasps edge of table to stabilize pelvis.

• Patient laterally rotates thigh.

• Resistance is given above ankle joint.

FAIR

• Sitting with legs over edge of table.

• Use eounterpressure above knee.

• Patient laterally rotates thigh through range

• of motion with stabilization of pelvis In

• patient

POOR

• Backlying with leg in internal rotation.

• Stabilize pelvis.• Patient laterally

rotates leg through range of motion.

TRACE AND ZERO

• Presence of contraction in lateral rotators may be determined by deep palpation be hind greater trochanter.

Note: • Resistance should lie given slowly and

carefully in tests for rotation of the hip and shoulder.

• Use of the long lever arm can cause injury to joint structures if not controlled.

Hip Medial Rotation

• GLUTEUS MINIMUS

GLUTEUS MINIMUS

• ORIGINOuter surface of ilium between middle and inferior gluteal lines INSERTIONAnterior surface of greater trochanter of femur

• ACTIONAbducts and medially rotates hip. Tilts pelvis on walking.

• NERVESuperior gluteal nerve (L4, 5, S1)

HIP MEDIAL ROTATION

Range of Motion.

0° TO 45º )LESS WITH HIP EXTENDED(

Factors Limiting Motion:1. When hip is extended, tension of iliofemoral ligament.

2. When hip is flexed, tension of ischiocapsular ligament.3. Tension of hip lateral rotator musclesFixation: Weight of trunk

NORMAL AND GOOD

• Sitting with legs over edge of table.

• Use counterpressure above knee to prevent

• adduction of the hip. (Patient grasps edge of table to stabilize pelvis.)

• Patient medially rotates thigh. Resistance is given above ankle joint.

FAIR

• Sitting with legs over table. Use counter prcssnre above knee.

• Patient medially rotates thigh through range of motion with stabilization of pelvis.

POOR

• Backlying with leg in lateral rotation. Stabilize pelvis.

• Patient medially rotates leg through range of motion.

TRACE AND ZERO

• Tensor fasciae Latae may be palpated near its origin posterior and distal to anterior superior spine of ilium.

• Glutens Minimus fibers lie beneath Gluteus medius and Tensor fasciae Latae.

Note

• If patient lifts pelvis on side being tested to assist in medial rotation, pelvis should be stabilized.

Knee Flexion

• Biceps femoris

• Semitendinosus

• Semimembranosus

Knee Flexion

Factors Limiting Motion:• Tension of the knee extensor muscles,

particularly Rectus femoris if hip is extends

• Contact of calf with posterior thighFixation:• Contraction of Iliocostalis lumborum

and Quadratics lumborum muscles• Weight of thigh and pelvis

NORMAL AND GOOD

(Biceps femoris)• Prone with legs straight.• Stabilize pelvis.• Patient flexes knee. Grasping

above ankle, laterally rotate leg (muscle is placed in better alignment), and resist flexion to test Biceps lemons.

NORMAL AND GOOD

Semitendinosus and Semimembranosus• Prone with legs straight.• Stabilize pelvis.• Patient Hexes knee. Grasping proximal to the ankle,

medially rotate leg and resist flexion to the Semimembranosus and Semitendinosus.

FAIR

• Prone with legs straight.• Stabilize thigh medially and laterally without pressure over

the, muscle group being tested.• Patient flexes knee through ROM. (if Gastrocnemious is

weak, knee may be flexed to 10º for starting position).

POOR

• Sidelying with legs straight and upper leg supported. • Stabilize thigh.• Patient flexes knee through range of motion. Uneven

muscular pull will cause rotation of lower leg as above.

TRACE AND ZERO

• Prone with knee partially flexed and• lower leg supported. Patient attempts to flex knee. • Tendons of knee flexor muscles may he palpated on

back of thigh near knee joint.

Note

• Patient may flex hip in order to start movement with knee partially flexed.

• The Sartorius may be substituted, which causes flexion and lateral rotation of hip.

• Knee flexion in this position is less difficult, since lower leg is not raised vertically against gravity.

• Strong plantar flexion of the toot should not be allowed in order to present substitution by the Gastrocnemious.

Knee extension

• RECTUS FEMORIS• VASTUS INTERMEDIALIS• VASTUS INTERMEDIALIS• VASTUS LATERALIS

RECTUS FEMORIS

• ORIGINStraight head: anterior inferior iliac spine. Reflected head: ilium above acetabulum

• INSERTIONQuadriceps tendon to patella , via ligamentum patellae into tubercle of tibia

• ACTIONExtends leg at knee. Flexes thigh at hip

• NERVEPosterior division of femoral nerve (L3, 4)

VASTUS INTERMEDIALIS

• ORIGINAnterior and lateral shaft of femur INSERTIONQuadriceps tendon to patella, via ligamentum patellae into tubercle of tibia

• ACTION: Extends knee

• NERVEPosterior division of femoral nerve (L3, 4)

VASTUS LATERALIS

• ORIGINUpper intertrochanteric line, base of greater trochanter, lateral linea aspera, lateral supracondylar ridge and lateral intermuscular septum

• INSERTIONLateral quadriceps tendon to patella, via ligamentum patellae into tubercle of tibia

• ACTION: Extends knee• NERVE: Posterior division of femoral nerve

(L3,4)

VASTUS MEDIALIS

• ORIGINLower intertrochanteric line, spiral line, medial linea aspera and medial intermuscular septum

• INSERTIONMedial quadriceps tendon to patella and directly into medial patella, via ligamentum patellae into tubercle of tibia

• ACTIONExtends knee. Stabilizes patella

• NERVEPosterior division of femoral nerve (L3,4)

Knee extension

Range of Motion: I2O°-13O° TO 0°'

Factors Limiting Motion:• Tension of oblique popliteal, cruciate

and collateral ligaments of knee joint• Tension of knee flexor muscles

Fixation:• Contraction of anterior abdominal

muscles to fix origin of Rectus femoris• Weight of thigh and pelvis

NORMAL AND GOOD

• Sitting with legs over edge of table.

• Stabilize pelvis without pressure over Rectus femoris at origin.

• Patient extends knee through range of motion without terminal locking.

• Resistance is given above ankle joint. (Pad should be used under knee.)

FAIR

• Sitting with legs over edge of table.

• Stabilize pelvis.• Patient extends knee through

range of motion without medial or lateral rotation at the hip (rotation allows extension at an angle, not in a vertical line against gravity).

POOR

• Sidelying with upper leg supported. Leg to be tested is flexed.

• Stabilize thigh above knee joint. (Avoid pressure over Quadriceps femoris.)

• Patient extends knee through ROM.

TRACE AND ZERO

• SUPINE with knee flexed and supported.

• Patient attempts to extend knee.• Contraction of Quadriceps

femoris is determined by palpation of tendon between patella and tuberosity of tibia and fibers of muscle. (Latter not illustrated.)