mti university faculty of physical therapy patient's

MTI University

FACULTY OF PHYSICAL THERAPY

Patient's Evaluation 2

(PT 2304)

Ass. Prof. Dr. Amir N Wadee

Dr. Haitham Mo’men Almasry

Department of Physical Therapy for Basic Sciences

Fall 2021

Contents

Topic Page

Number THEORITICAL PART

Introduction………………………………… 1 Special Tests……………………………….. 11

Scapular Manual Muscle Testing…………... 19

Shoulder Manual Muscle Testing…………… 30 Elbow Manual Muscle Testing……………… 47

Forearm Manual Muscle Testing…………… 54

Wrist Manual Muscle Testing………………. 57

Fingers Manual Muscle Testing……………….. 62

MMT for Cervical muscles…………………….. 86

MMT for Trunk & Pelvic muscle 90

Functional Muscle testing… 101

Isokinetic Muscle Performance Testing… 123

PRACTICAL PART

Measurements of Range of Motion of Scapula… 149

Goniometry of Shoulder Joint………………….. 156

Goniometry of Elbow Joint………………….. 170

Goniometry of Radioulnar Joint……………….. 173 Goniometry of Wrist Joint…………………… 177

Scapular Manual Muscle Testing…………...... 184

Shoulder Manual Muscle Testing…………… 197

Elbow Manual Muscle Testing……………… 216

Forearm Manual Muscle Testing…………… 222

Wrist Manual Muscle Testing………………. 228 Fingers Manual Muscle Testing……………….. 235

Goniometry & MMT for Cervical muscles…….. 287

Goniometry MMT for Trunk & Pelvic muscles 301

Functional Muscle testing… 333

DR. HAITHAM MO’MEN ALMASRY 1

INTRODUCTION

Manual Muscle Testing

Definition:

Manual muscle testing (MMT) is a procedure for the evaluation of

the function and strength of individual muscles and muscles group

based on effective performance of a movement in relation to the

forces of gravity and manual resistance through the available range

of motion (ROM).

The purpose of manual muscle test:

1- To provide information that may be of assistance to a number of

health professionals in differential diagnosis, treatment

planning and prognosis, but it has limitations in the treatment of

neurological disorders where there is an alteration in muscle

tone if reflex activity is altered or if there is a loss of cortical

control due to lesions of the central nervous system.

2- To assess muscle strength, the therapist must have a sound

knowledge of anatomy (including joint motions, muscle origin,

insertion and function) and surface anatomy (to know where a

muscle or its tendon is best palpated).

3- Help the therapist in detecting minimal muscle contraction,

movement, and/or muscle wasting and substitutions or trick

movements.

4- To assess accurately a patient's present status, progress, and the

effectiveness, of the treatment program.


TERMINOLOGY

Muscular strength:

The maximal amount of tension or force that a muscle or muscle

group can voluntarily exert in one maximal effort, when type of

muscle contraction, limb velocity and joint angle are specified.

Muscular Endurance:

The ability of a muscle or a muscle group to perform repeated

contractions, against resistance, or maintain the isometric

contraction for a period of time.

Range of muscle work:

The full range in which a muscle work refers to the muscle

changing from a position of full stretch and contracting to a

position of maximal shortening. The full range is divided into parts,

outer, inner, and middle ranges.

1- Outer range:

Is from a position where the muscle is on full stretch to a position

halfway through the full range of motion.

2- Inner range:

Is from a position halfway through the full range to a position where

the muscle is fully shortened.

3- Middle range:

Is the portion of the full range between the mid-point of the outer

range and the midpoint of the inner range.


Isometric (static) contraction:

This is when there is tension developed in the muscle but no

movement occurs, the origin and insertion of the muscle do not

change position, and the muscle length does not change.

Isotonic contraction:

The muscle develops constant tension against a load or resistance.

Concentric contraction:

Tension is developed in the muscle and the origin and insertion of

the muscle move closer together, the muscle shortens.

Eccentric contraction:

Tension is developed in the muscle and the origin and insertion of

the muscle move farther a part, the muscle lengthens.

Functional classification of muscle:

Muscles may be categorized as follows, according to the major

role of the muscles in producing the movement.

1- Prime Mover or agonist:

A muscle or muscle group that makes the major contribution to

movement at the joint.

2- Antagonist:

A muscle or a muscle group that has an opposite action to the prime

movers. The antagonist relaxes as the agonist moves the part

through a ROM.


3- Synergist:

A muscle that contracts and works a long with the agonist to

produce the desired movement. Three types of synergists are

described.

A) Neutralizing or counter acting synergists:

Muscles contracted to prevent unwanted movements produced by

the prime mover. For ex. When the long finger flexors contract to

produce finger flexion the wrist extensors contract to prevent wrist

flexion from occurring.

B) Conjoint synergists:

Two or more muscles that work together to produce the desired

movement. The muscles contracting alone would be unable to

produce the movement. For ex.: Wrist extension is produced by

contraction of extensor carpiradialis longus and brives and extensor

carpiulnaris. If the extensor carpiradialis longus or brevis contract

a lone the wrist extends and radially deviates, if the extensor

carpiulnaris contracts alone the wrist extends and ulnar deviates.

When the muscles contract as a group the deviation actions cancel

out and the common action of wrist results (extension).

C) Stabilizing or Fixating Synergists:

Muscle that prevent movement or control the movement the

movement at joints proximal to the moving joint to provide a fixed

or stable base from which the distal moving segment can

effectively work. For ex.: If the elbow flexors contract to lift an

object off a table anterior to the body, the muscles of the scapula and

glenohumeral joint must contract to either allow slow controlled


movement or no movement to occur at the scapula and

glenohumeral joint to provide the elbow flexors with a fixed origin

from which to pull. If the scapular muscles did not contract the

object could not be lifted as the elbow flexors would act to pull the

shoulder girdle downward toward the table top.

Individual versus group muscle test

Muscles with a common action or actions may be tested as a group

or a muscle may be tested individually. For example, flexor

carpiulnaris and flexor carpiradialis may be tested together as a

group in the action of wrist flexion. Flexor carpiulnaris may be

tested more specifically in the action of wrist flexion with ulnar

deviation.

Factors affecting strength:

1. Age:

A decrease in strength occurs with increasing age due to

deterioration in muscle mass. Muscle fibers decrease in size and

number, there is an increase in connective tissue and fat, and the

respiratory capacity of the muscle decreases.

2. Sex:

Males are generally stronger than females.

3. Type of muscle contraction:

More tension can be developed during an eccentric contraction than

during an isometric contraction. The concentric contraction has the

smallest tension capability.


4. Muscle size:

The larger the cross sectional area of a muscle, the greater the

strength of the muscle. When testing a muscle that is small, the

therapist would expect less tension to be developed than if testing

a large, thick muscle.

5. Speed of muscle contraction:

When a muscle contracts concentricity the force of contraction

decreases as the speed of contraction increases. The patient is

instructed to perform each muscle test movement at a moderate

pace.

6. Previous training effect:

Strength performance depends up on the ability of the nervous

system to activate the muscle mass. Strength may increase as one

becomes familiar with and learns the test situation. The therapist

must instruct the patient well and give the patient an opportunity to

move through or be passively moved through the test movement at

least once before strength is assessed.

7. Joint position (Angle of muscle pull and Length tension

relation):

The tension developed within a muscle depends up on the initial

length of the muscle. Regardless of the type of muscle contraction,

a muscle contracts with more force when it is stretched that when

it is shortened. The greatest amount of tension is developed when

the muscle is stretched to the greatest length possible within the

body, that is if the muscle is in full outer range.

8. Fatigue:

As the patient fatigues, muscle strength decreases. The therapist


determines the strength of muscle using as few repetitions as

possible to avoid fatigue. The patient's level of motivation, level of

pain, body type, occupation, and dominance are other factors that

may affect strength.

Contraindication of MMT

1. Inflammation is present in the region.

2. Pain

- Pain will inhibit muscle contraction and will not give an accurate

indication of muscle strength.

- Testing muscle strength in the presence of pain may cause further

injury

Precautions of MMT:

1- Extra care must be taken where resisted movements might

aggravate the condition: Such as:

A) Patient with a history of or at risk of having cardiovascular

problems

B) Patients who have experienced abdominal surgery or patients

with herniation of the abdominal wall to avoid unsafe level stress

on the abdominal wall.

C) In situations where fatigue may be detrimental to or exacerbate

the patient's condition.

D) Patients with extreme debility or weakness, for example mal

nutrition, malignancy, and sever chronic obstructive pulmonary

disease. These patients do not have the energy to carry out

strenuous testing.


Factors that may cause inaccurate MMT

• The subject becomes distracted during testing.

• The subject experiences pain during testing.

• The subject is positioned improperly.

• The body part being tested is not adequately stabilized.

• Inability of the subject to understand the test

requirements/commands as a result of poor comprehension or

cultural and language barriers.

• The subject does not have the coordination to perform the test

adequately.

• Inadequate understanding of basic anatomy/kinesiology by the

clinician.

• Poor awareness of basic substitution patterns by the clinician.

• Over grading or under grading clinician inexperience.

• Inconsistency in timing, pressure, and positioning by the clinician.

• The use of gloves by the clinician may alter the ability to palpate

a muscle contraction accurately.


SPECIAL TESTS

Hip Joint

1. Trendelenburg Test:

- This procedure is designed to evaluate the strength of the

gluteus medius muscle.

- Stand behind the patient and observe the dimples overlying the

posterior superior iliac spines. Normally, when the patient bears

weight evenly on both legs, these dimples appear level.

- Then ask the patient to stand on one leg. If he stands erect, the

gluteus medius muscle on the supported side should contract as

soon as the leg leaves the ground and should elevate the pelvis

on the unsupported side. This elevation indicates that the

gluteus medius muscle on the supported side is functioning

properly (negative Trendelenburg sign).

- However, if the pelvis on the unsupported side remains in

position or actually descends, the gluteus medius muscle on the

supported side is either weak or nonfunctioning (positive

Trendelenburg sign).


2. Tests for Leg Length Discrepancy:

If, during the inspection portion of your examination, you suspect

that one of your patient's legs might be shorter than the other, the

following procedures will assist you in determining whether the

discrepancy, is true or only apparent.

A. True Leg Length Discrepancy.

- To determine true leg length, first place the patient's legs in

precisely comparable positions and measure the distance from

the anterior superior iliac spines to the medial malleoli of the

ankles (from one fixed bony point to another).

- Begin measurement at the slight concavity just below the

anterior superior iliac spine, for the tape measure may slide if

pressed directly onto the spine.


- Unequal distances between these fixed points verify that one

lower extremity is shorter than the other.

- Quick tests

- To determine in short order where the discrepancy lies (whether

in the tibia or in the femur), ask the patient to lie supine, with

his knees flexed to 90° and his feet flat on the table (crock lying

position).


- If one knee appears higher than the other, the tibia of that

extremity is longer.

- If one knee projects further anteriorly than the other, the femur

of that extremity is longer.

- A true shortening may be the result of poliomyelitis, or of a

fracture that crossed the epiphyseal plate during childhood.


B- Apparent Leg Length Discrepancy:

- Establish that there is no true leg length discrepancy before

testing for an apparent discrepancy, in which there is no true

bone, inequality.

- Apparent shortening may stem from pelvic obliquity or from

adduction or flexion deformity in the hip joint.

- Have the patient lie supine with his legs in as neutral position.

- Take a measurement from the umbilicus (or xiphisternal

juncture) to the medial malleoli of the ankle (from a nonfixed

point to a fixed bony point).

- Unequal distances signify an apparent leg length discrepancy,

particularly if the true leg length measurements are equal.

Measure from a nonfixed point to a fixed point to determine an

apparent leg length discrepancy.


3. Ober Test:

- For Contracture of the iliotibial Band.

- Have the patient lie on his side with his involved leg above.

- Abduct the leg as far as possible and flex the knee to 90° while

keeping the hip joint in the neutral position to relax the

iliotibial tract. Then release the abducted leg.

- If the iliotibial tract is normal, the thigh should drop to the

adducted position (negative test).

- However, if there is a contracture of the fascia lata or iliotibial

band, the thigh remains abducted when the leg is released

(positive test).

- May be caused by poliomyelitis or meningomyelocele.


Negative test

Positive test

4- Thomas Test for Flexion Contracture:

- For hip flexion contracture.

- The patient lies at the edge of the plinth taking with one hand

his hip in complete flex (non affected side).

A- Pure flexion hip: iliopsoas contracture.

B- Flexion hip with abduction, external rotation and flexion knee:

Sartorius contracture.

C- Flexion hip with abduction, internal rotation: Tensor fascia lata

contracture.


D- Flexion hip with extension knee: Rectus femoris contracture.


SCAPULAR MANUAL MUSCLE TESTING

(MMT)

Scapular Motions

1- Elevation.

2- Depression.

3- Adduction (Retraction).

4- Abduction (Protraction).

5- Upward rotation.

6- Downward rotation.


Scapular abduction & upward rotation

- Prime Movers

1) Serratus anterior (strongest abductor of the scapula)

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

- Insertion: Anterior aspect of the medial vertebral border of the

Scapula

- Nerve supply: Long thoracic nerve (C5 –C7).

- Palpation site: Along the mid axillary line

- adjacent to the inferior angle of the scapula.


- Secondary Movers

- Pectoralis minor

- Factors Limiting Motion:

1- Tension of trapezoid ligament

2- Tension of trapezius and Rhomboid major and minor muscles

- Fixation:

- Weight of thorax

- Effect of weakness:

1- Winging of scapula (main weakness)

2- Difficult to flex or abduct the shoulder.

3- Difficulty to raise the arm overhead


Scapular elevation

- Prime Movers

1- Upper fibers of trapezius

- Origin: - External occipital protuberance

- Spinous process of C7

- Insertion: - Lateral 1/3 of clavicle

- Nerve supply: - Accessory nerve (C3 –C4).

- Palpation site :

- Parallel to cervical spine C7 and near the

insertion above the clavicle


2- Levator scapula

- Origin: - Transverse process of 1st four cervical vertebrae

- Insertion: - Medial border of the scapula

- Nerve supply: - Dorsal Scapular Nerve (C5)

- Palpation site:

- Angle formed by the upper trapezius and sternocleidomastoid

muscles.


- Secondary Movers

- Rhomboids major and minor


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 (for tests done in prone position).

- Substitution:

- In patients with weak shoulder elevators, the Rhomboids may

attempt to substitute.

- During unsuccessful attempts to shrug the shoulder the inferior

angle of the scapula will move medially toward the cervical spine

(scapular adduction), and downward motion (rotation) also may

occur.



1- Lateral winging of the scapula, which is most obvious when

attempting to abduct the shoulder.

2- Difficulty when trying to abduct or flex the upper extremity above

shoulder height.


- Prime Movers

Scapular adduction

1- Middle fibers of trapezius

- Origin: - Spinous process of C7 and 1st, 2nd & 3rd thoracic

vertebrae

- Insertion: - Upper border of scapular spine

- Nerve supply: - Accessory nerve (C3 & C4).

- Palpation site:

- Medial border of the scapula near the root

of the spine.

- Secondary Movers

- Rhomboids major and minor.

- Upper & lower fibers of trapezius


1- Tension of conoid ligament

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


- Prime Movers

Scapular depression & adduction

1- Lower fibers of trapezius

- Origin: - Spinous process of 4th – 12th thoracic vertebrae

- Insertion: - Base of scapular spine

- Nerve supply: - Accessory nerve (C2 –C4).

- Palpation site:

- Between 12th thoracic vertebrae and medial

border of scapula

- Secondary Movers: -Pectoralis major

and minor

- Middle fibers of trapezius

- Latissimus dorsi


1- Tension of Trapezius (upper fibers), Levator

scapular and sternocleidomastoid

- Fixation: - Weight of trunk

- Substitution: - The subject may try to extend the trunk to give

the appearance of scapular movement.


Scapular adduction & downward rotation

- Prime Movers

- Rhomboids major & minor

- Origin: - Spinous process of T2 – T7 vertebrae (major)

- Spinous process of C7 – T1 vertebrae (minor)

- Insertion: - Medial border of the scapula

- Nerve supply: - Dorsal Scapular nerve (C5).

- Palpation site:

- With the subject’s hand behind his or her lumbar spine palpate the

angle between the medial border of the scapula and lateral fibers of lower

trapezius


- Secondary Movers

- Middle fibers of trapezius

- Levator scapula


1- Tension of conoid ligament.

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

- Substitution:

- The latissimusdorsi and teres major may cause the shoulder to

adduct and extend the shoulder without scapular rotation.

- The subject may use the wrist extensors to lift the upper extremity

off the lower back without scapular movement.


SHOULDER MANUAL MUSCLE TESTING (MMT)

Shoulder flexion

- Range of motion (ROM):

0 – 180 degree

- Prime Movers

1- Anterior deltoid

- Origin: - Anterior lateral third of the clavicle

- Insertion: - Deltoid tuberosity on the lateral humerus

- Nerve supply: - Axillary nerve c5-c6

- Palpation site:

- Inferior to lateral third of clavicle.


2- Coracobrachialis

- Origin: - Coracoid process of the scapula

- Insertion: - Middle 1/3 of the medial surface of the humerus.

- Nerve supply: - Musculotendinous nerve c5-c7

- Palpation site:

- In the axilla, under the inferior border of the pectoralis major muscle.


- Secondary Movers

- Middle deltoid

- Pectoralis major

- Biceps brachii


1- Stiffness of shoulder joint

2- Tension of latissimus dorsi, posterior deltoid and teres major

- Fixation:

1- Contraction Trapezius & Serratus anterior muscles.

2- Serratus anterior and upper fibers of Trapezius assist in upward

rotation of scapula as well as in fixation

- Substitution:

1- Scapular elevation (upper trapezius)

2- Horizontal adduction (Pectoralis major)

3- Lateral rotation (biceps brachii)


Shoulder extension


0 – 180 degree

- 0 to 40/60 degrees (from neutral)

- Prime Movers

1- Latissimus dorsi

- Origin: - Spinous process of T7-T12

- Iliac crest and sacrum

- Inferior angle of scapula

- Insertion: - Intertubercle groove of humerus

- Nerve supply: - Thoracodorsal nerve C6-C8

- Palpation site:

- Along the midaxillary line on the trunk.


2- Posterior deltoid

- Origin: - Posterior border of scapular spine

- Insertion: - Deltoid tuberosity on the

lateral humerus


- Palpation site:

- Inferior and lateral to the spine of the scapula.

3- Teres major

- Origin: - Lower 1/3 of the axillary border of the scapula

- Insertion: - Medial lip of intertubercular groove of humerus

- Nerve supply: - Subscapular nerve C5-C6.

- Palpation site:

- Lateral to the inferior angle of the scapula.


- Secondary Movers

- Long head of the triceps brachii


1- Tension of (Anterior deltoid & Coracobrachialis)

2- Contact of greater tubercle of humerus with acromion

posteriorly.

- Fixation:

1- Contraction of Rhomboids major and minor and Trapezius

muscles.

Weight of head (for tests done in prone position).

2- Weight of trunk

- Substitution:

- The subject may attempt to lift and rotate the trunk.

- During unsuccessful attempts to shrug the shoulder the inferior

angle of the scapula will move medially toward the cervical spine

(scapular adduction), and downward motion (rotation) also may

occur.



1- Latissimus dorsi: decreased strength of shoulder extension and

lateral trunk flexion (side bending)

2- Posterior deltoid: decreased strength of shoulder extension and

internal rotation.

3- Teres major: decreased strength of shoulder extension

- The latissimusdorsi is a powerful shoulder extensor

- Is important in some movements as climbing, walking with

crutches and walking between parallel bars

- Active during forceful activities such as swimming,

rowing/paddling, or chopping movements.

- Act as an accessory muscle of respiration

- The teres major is occasionally known as the “little latissimus”, it

pulls the shoulder downward to help stabilize the head of the

humerus during abduction.

N.B:


Shoulder abduction


0 – 180 degree

- Prime Movers

1- Middle deltoid

- Origin: - Acromion process

- Insertion: - Deltoid tuberosity on the lateral humerus


- Palpation site:

- Lateral/inferior to the acromion process.

2- Supraspinatous

- Origin: - Supraspinatus fossa

- Insertion: - Greater tubercle

- Nerve supply: - Suprascapular nerve C5-C6


N.B:

- Secondary Movers

- Anterior & Posterior deltoid


1- Stiffness of shoulder joint.

2- Tension of latissimus dorsi and teres major

- Fixation:

1- Contraction Trapezius & Serratus anterior muscles.

2- Serratus anterior and upper fibers of Trapezius assist in upward

rotation of scapula as well as in fixation

- Substitution:

1- Shoulder elevation

2- Lateral flexion (side bend) the trunk

- Although the deltoid is a strong abductor, it is the supraspinatus,

not the deltoid, that initiates the movement


Shoulder horizontal abduction


- 0 – 45 degree (from neutral)

- 0 – 135 degree (from complete horizontal abduction to complete

horizontal adduction)

- Prime Movers

1- Posterior deltoid


- Insertion: - Deltoid tuberosity on the

lateral humerus


- Palpation site:

- Inferior and lateral to the spine of the scapula.

- Secondary Movers

- Long head of the triceps brachii


1- Tension of anterior fibers of capsule of glenohumeral joint Tension

of trapezius and Rhomboid major and minor muscles

2- Tension of Pectoralis major

- Substitution: 1- Elbow extension (triceps)

2- Trunk rotation


Shoulder horizontal adduction


- 0 – 90 degree (from neutral)

- 0 – 135 degree (from complete horizontal

- abduction to complete horizontal adduction)

- Prime Movers

1- Pectoralis major

- Origin:

- Upper fibers (clavicular portion): Medial half of anterior surface of

clavicle

- Lower fibers (sternal portion): Anterior surface of sternum

- Insertion: - Intertubercle groove of humerus

- Nerve supply: - Lateral & medial Pectoral nerve

- Palpation site:

- Upper fibers (clavicular portion):

inferior to the medial end of clavicle

- Lower fibers (sternal portion):

anterior axillary fold


N.B:

- Secondary Movers

- Anterior deltoid, coracobarchialis and biceps


1- Tension of latissimus dorsi, posterior deltoid and teres major

2- Tension of latissimus dorsi and teres major

3- Contact of arm with chest

- Fixation:

- In forceful horizontal adduction, contraction of obliquus externus

muscle on same side.

- Substitution:

- Trunk rotation

- When testing the upper fibers (clavicular portion): Put the arm

below 90 degree.

- When testing the Lower fibers (sternal portion): Put the arm above

90 degree



1- Upper fibers (clavicular portion):

- Difficulty to bring the arm to opposite shoulder

- Decrease strength of shoulder flexion and medial rotation

2- Lower fibers (sternal portion) :

- Difficulty to bring the arm to opposite hip

- From a supine position, if the subject’s arm is placed diagonally

overhead, he will find it difficult to lift the arm from the table.

- He will also have difficulty holding any large or heavy object in

both hands at or near waist level.


Shoulder external rotation


0 – 90 degree

- Prime Movers

1- Infraspinatus

- Origin: - Infraspinatus fossa of scapula

- Insertion: - Greater tubercle of humerus

- Nerve supply: - Suprascapular Nerve:

C4, C5, C6.

- Palpation site:

- Inferior to the spine of the scapula (body of scapula)

2- Teres minor

- Origin: - Lateral border of the scapula

- Insertion: - Greater tubercle of humerus

- Nerve supply: - Axillary Nerve: C5, C6.

- Palpation site:

- Lateral border of the scapula superior to

the inferior angle of the scapula


Secondary Movers

- Posterior deltoid


1- Tension of superior portion of capsular ligament and coracohumeral

ligament.

2- Tension of (subscapularis, pectoralis major, teres major and latissimus

dorsi)

- Fixation:

- Weight of arm


Difficulty in some activities as:

1- Using a screwdriver

2- Installing a lightbulb into a socket on the ceiling.


Shoulder internal rotation


0 – 90 degree

- Prime Movers

1- Subscapularis (the only pure Internal rotators)

2- Origin: - Subscapular fossa

- Insertion: - Lesser tubercle of the humerus

- Nerve supply: - Suprascapular Nerve: C4, C5, C6.

- Palpation site:

- Deep in the axilla


- Secondary Movers

- Pectoralis major

- Teres major

- Latissimus dorsi


1- Tension of capsular ligament

2- Tension of infraspinatus and teres minor

3- Fixation:

Weight of arm


- Difficulty when lifting the hand away from the back as:

1- Tucking a shirt into a pair of pants (in males)

2- Hooking a bra (in females)


ELBOW MANUAL MUSCLE TESTING (MMT)

Elbow flexion


0 – 145 degree

- Prime Movers

1- Biceps brachii

- Origin: - Short Head: Apex of coracoid process of scapula.

- Long Head: Supraglenoid tubercle of scapula.

- Insertion: - Radial tuberosity

- Nerve supply: - Musculocutaneous nerve C5 C6

- Palpation site:

- With the forearm supinated, the belly of the muscle is palpated

anteriorly or in the cubital fossa


2- Brachialis (strongest elbow fexors)


- Insertion: - lateral supracondylar ridge of

humerus.

- Nerve supply: - Radial nerve C5 C6.

- Palpation site:

- With the forearm pronated, palpate just

proximal to the cubital fossa.

3- Brachioradialis

- Origin: - Lateral supracondylar ridge of humerus.

- Insertion: - Base of radial styloid process of

- Nerve supply: - Radial nerve C5 C6

- Palpation site:

- With the forearm midway between pronation and supination, palpate

just lateral to the biceps tendon


- Secondary Movers

- Pronator teres

- Flexor carpi radialis

- Flexor carpi ulnaris


1- Contact of the forearm muscles with the arm

2- Tension of triceps.


- Difficulties in some activities as:

1- Picking up an object.

2- Bringing food to mouth

- Substitution:

1- Shoulder extension

2- Wrist flexion


N.B:

- The best position for testing biceps : supination

- The best position for testing brachialis: pronation

- The best position for testing brachioradialis : midway (between

supination & pronation)

- Lifting heavy objects too suddenly may cause injury or damage

this muscle

- When the muscle is chronically tight / shortened: Flexion

deformity of elbow occur (elbow cannot be fully straightened).


Elbow extension


- 145 – 0 degree

- Prime Movers

1- Triceps Brachii

- Origin: - Long Head: Infra glenoid tubercle of scapula.

- Short Head: Lateral and posterior surfaces of body of

humerus.

- Medial Head: below the radial groove.

- Insertion: - Posterior surface of olecranon process

- Nerve supply: - Radial Nerve: C6 C7 C8 Tl

- Palpation site:

- On the posterior aspect of the arm just proximal to the olecranon


2- Anconeus

- Origin: - Lateral epicondyle of humerus

- Insertion: - Lateral side of olecranon process.

- Nerve supply: - Redial Nerve: C7, C8

- Palpation site:

- Between the lateral epicondyle and olecranon

process of the ulna.

- Secondary Movers

- Extensor carpi ulnaris, Extensor carpi radialis longus and brevis


1- Contact of the olecranon process with the olecranon fossa

2- Tension of biceps, brachialis and brachioradialis

- Effect of weakness: - Difficulties in some activities as:

1- Reaching upward toward a high shelf.

2- Throw objects or push with the extended elbow.

3- Using crutches or cane (handicapped patients)

- Substitution:

1- Shoulder external rotation


- Grades 3- 4 and 5" may be performed in the supine lying position

or prone lying position. The difference between the two may be

explained as follow:

- When the shoulder is horizontally abducted (as in prone) the long

head of triceps is shortened over both the shoulder and the elbow

joints.

- When the shoulder is flexed (as in supine) the long head of triceps

is shortened over the elbow joint while elongated over the shoulder

joint.

- Because of this two joints action of the long head, it is made less

effective in the prone position by being shortened fully over both

joints.

- Throwing with excessive force may cause injury or damage this

muscle

- When the muscle is chronically tight / shortened: Extension

deformity of elbow occur (elbow cannot be fully flexed).

N.B:


RADIOULNAR MANUAL MUSCLE TESTING (MMT)

Forearm supination


0 – 90 degree

- Prime Movers 1- Supinator

- Origin: - Lateral epicondyle of humerus

- Insertion: - Dorsal and lateral surfaces of

upper third of radius

- Nerve supply: - Radial Nerve: CS C6 (C7)

- Palpation site: - Distal & medial to lateral epicondyle

2- Biceps brachii

- Secondary Movers - Brachioradialis


1- Tension of pronator teres and pronator quadratus


- Feeding oneself - Turning a doorknob

- Substitution: - Shoulder external rotation

- Shoulder adduction - Wrist extension


Forearm pronation


0 – 90 degree

- Prime Movers

1- Pronator teres

- Origin: - Humeral Head: Immediately

above medial condyle of humerus

- Ulnar Head: Medial side of coronoid process of ulna.

- Insertion: - Middle of lateral surface of radius.

- Nerve supply: - Median Nerve C6 C7.

- Palpation site:

- Medial & inferior to cubital fossa


2- Pronator quadratus

- Origin: - Medial side of ulna

- Insertion: - Lateral side of radius

- Nerve supply: - Median Nerve

- Palpation site: - Not palpable

- Secondary Movers

- - Flexor carpi radialis


- Tension of biceps and supinator


1- Pouring liquid from a container

2- Using a knife to cut meats

3- Swinging a racquet

- Substitution:

1- Shoulder internal rotation

2- Shoulder abduction

3- Wrist flexion


WRIST MANUAL MUSCLE TESTING (MMT)

Wrist flexion


0 – 90 degrees

- Prime Movers

1- Flexor carpi radialis

- Origin: Medial epicondyle of humerus.

- Insertion: - Base of second metacarpal bone.

- Nerve supply: - Median Nerve: C6, C7, C8

- Palpation site:

- Lateral to the midline of the wrist as the

subject attempts to flex and radially deviate the wrist

2- Flexor carpi ulnaris

- Origin: Medial epicondyle of humerus.

- Insertion: - Pisiform bone

- Nerve supply: - Ulnar Nerve: C7, C8, T1

- Palpation site:

- Proximal to the pisiform as the subject

attempts to flex and ulnar deviate the wrist.


N.B:

- Secondary Movers - Palmaris longus


- Tension of Extensor carpi ulnaris, Extensor carpi radialis longus

and brevis


1- Pulling rope in towards you.

2- Wielding an axe or hammer.

- Substitution:

1- Finger flexion

- For testing flexor carpi radialis: put the forearm in slightly less than

full supination and resistance is given against thenar eminence

- For testing flexor carpi ulnaris: put the forearm in full supination

and resistance is given against hypothenar eminence


Wrist extension


0 – 70 degrees (hyperextension)

- Prime Movers

1- Extensor carpi radialis longus

- Origin: - Lateral supracondylar ridge of humerus.

- Insertion: - Base of second metacarpal bone.

- Nerve supply: - Radial Nerve: C5, C6, C7, C8.

- Palpation site:

- Proximal to the second metacarpal bone.


2- Extensor carpi radialis brevis

- Origin: - lateral epicondyle of humerus.

- Insertion: - Base of third metacarpal

bone.

- Nerve supply: - Radial Nerve: C5, C6,

C7, C8.

- Palpation site:

- Over the capitate bone.

3- Extensor carpi ulnaris

- Origin: - lateral epicondyle of humerus.

- Insertion: - Base of fifth metacarpal bone.

- Nerve supply: - Radial Nerve: C6,

C7, C8.

- Palpation site:

- Distal to the styloid process

of the ulna and proximal to the

fifth metacarpal.


N.B:

- Secondary Movers - Extensor digitorum, Extensor

digitiminimi and Extensor indicis


- Tension of flexsor carpi ulnaris and flexor carpi radialis


1- Piking a cup to mouth 2- Cleaning windows

- Substitution:

3- Finger extension

- For testing extensor carpi radialis longus and brevis: put the forearm

in slightly less than full pronation and resistance is given against the

second metacarpal bone

- For testing extensor carpi ulnaris: put the forearm in full pronation

and resistance is given against the fifth metacarpal bone.

ASS. PROF. DR. AMIR N WADEE 62

FINGERS II TO V

Note: Because gravity is not a significant factor during testing

of the fingers/thumb, the format used for grading muscle

strength deviates from the

standard grading system applied to other muscle groups; half

grades are not

assigned.

Metacarpophalangeal Flexion

Active Range of Motion

• 0 to 90 degrees

Prime Movers

• Lumbricales

□ Origin: Originate off of the tendons of the flexor digitorum

profundus. Lumbricales #1 and #2: radial sides and plamar

surfaces of tendons of digits II and III; #3 is adjacent to

sides of digits III and IV; #4 is adjacent to sides of the

tendons of digits IV and V.

□ Insertion: Tendinous expansion of the extensor digitorum,

with each muscle running distally to the radial side of the

corresponding digit and attaching to the dorsal digital

expansion.


□ Innervation: Lumbricales #1 and #2; median nerve (C8 to

T1) and #3 and #4; ulnar nerve (C8 to T1).

□ Other actions: Extension of the fingers at the proximal

interphalangeal (PIP) and distal interphalangeal (DIP)

joints.

□ Palpation site: Not palpable.

Secondary Movers

• Dorsal/palmar interossei

• Flexor digitorum superficialis

• Flexor digitorum profundus

• Flexor digiti minimi

• Opponens digiti minimi

• GRADES 5/5 (NORMAL), 4/5 (GOOD), AND 3/5 (FAIR)

Subject position: Sitting or supine with the forearm in

supination and the wrist in neutral. The metacarpophalangeal

(MCP) joints should be extended with the PIP and DIP joints

flexed.

Stabilization: The clinician stabilizes the metacarpal bones

against the tabletop.

SUBJECT DIRECTIVE: “Straighten out your fingers as you

bend your hand at the knuckles and hold it. Do not let me push


your fingers down.”

*The clinician may have to demonstrate the motion first.

Subject position: Sitting or supine with the forearm and wrist

in neutral with the hand resting on the ulnar border. The MCP

joints should be maximally extended with the PIP and DIP joints

in flexion.

Stabilization: The clinician stabilizes the wrist and hand.

Substitutions: The long finger flexors may cause the PIP and

DIP joints to flex as the subject attempts to flex the MCP joints.

PIP Flexion


• 0 to 120 degrees

*The lumbricales are too deep to palpate. A grade of 1/5 or trace

is given if any movement is observed and 0/5 is assigned in the

absence of movement.

Prime Movers


□ Origin: Humero-ulnar head: Medial epicondyle of the

humerus and medial aspect of the coronoid process.


□ Radial head: Oblique line of the radius.

□ Insertion: Four tendons insert into each side of the middle

phalanx of digits II to V.

□ Innervation: Median nerve (C8 to T1).

□ Other actions: Assists with flexion of the wrist.

Palpation site: The tendons are palpated where they cross the

palmar surface of each proximal phalanx

GRADES 5/5 (NORMAL), 4/5 (GOOD), AND 3/5 (FAIR)

Subject position: Sitting or supine with the hand resting on the

dorsal side with the wrist in neutral. The tested digit should be

slightly flexed at the MCP joint.

Stabilization: All joints of the non-tested fingers are held in

extension.

GRADES 2/5 (POOR), 1/5 (TRACE), AND 0/5 (ZERO)

Subject position: Sitting or supine with the forearm in neutral

and the ulnar border of the hand resting on a tabletop.

Stabilization: The clinician stabilizes the forearm and holds the

non-tested digits in extension.

Substitutions: The flexor digitorum profundus may cause

flexion of the DIP joints as the subject attempts to flex the PIP

joint.

DIP Flexion



• 0 to 80 degrees

Prime Movers


□ Origin: Anterior and medial surfaces of the proximal three

quarters of the ulna

□ Insertion: Four tendons insert into the base of each distal

phalanx of digits II to V.

□ Ulnar nerve, digits IV and V (C8 to T1).

□ Innervation: Median nerve, digits II and III (C8 to T1).

□ Other actions: MCP and PIP flexion of fingers II to V.

Assists with flexion of the wrist.

□ Palpation site: The tendons are palpated where they cross

the palmar surface of each middle phalanx of digits II to

V.


Subject position: Sitting or supine with the hand resting on the

dorsal surface with the wrist in neutral. The proximal PIP should

be in extension.

Stabilization: The clinician stabilizes the middle phalanx and

PIP joint of the tested digit.

SUBJECT DIRECTIVE: “Bend the tip of your finger and hold


it. Do not let me straighten it out.”





middle phalanx of the tested digit in extension

Substitutions: The wrist must be kept in a neutral position to

prevent

tenodesis from occurring from wrist extension.

MCP Extension


• 90 to 0 degrees (extension from maximal flexion)

• 0 to 30 degrees (hyperextension)

Prime Movers

• Extensor digitorum

□ Origin: Lateral epicondyle of the humerus.

□ Insertion: Via 4 tendons to digits II to V through the

extensor hood to the base of the distal phalanx.

□ Innervation: Radial nerve (C7 to C8).


□ Other actions: Extends the PIP joints of fingers II to V.

Assists in abduction of fingers I, IV, and V. Assists in the

extension and abduction of the wrist.

□ Palpation site: Over the dorsal aspect of the hand as the

tendons pass down each finger.

• Extensor indicis

□ Origin: Dorsal surface of the shaft of the ulna below the

origin of the extensor pollicis longus.

□ Insertion: Second digit extensor hood via the tendon of the

extensor digitorum.


□ Other actions: Extends the PIP joint of the index finger.

Assists in adduction of the index finger and in extension of

the wrist.

□ Palpation site: Over the dorsal/ulnar aspect of the second

metacarpal, close to the hand.

• Extensor digitiminimi

Origin: Lateral epicondyle via the common extensor tendon

□ Insertion: Extensor hood of the fifth finger with the

extensor digitorum.


□ Other actions: Extends the PIP joint of the little finger and

assists with abduction of the little finger. Assists with


extension of the wrist.

□ Palpation site: Over the dorsal aspect of the fifth

metacarpal, close to the head of the ulna.



pronation and the

wrist in neutral with the palmar aspect of the hand resting on a

tabletop and

the MCP joints flexed to 90 degrees off the edge of the table.

Stabilization: The clinician stabilizes the hand and wrist.

*To test the extensor indicis and extensor digiti minimi, the

subject extends the MCP joint of the second digit and fifth

digit, respectively.

SUBJECT DIRECTIVE: “Bend your knuckles up and hold it.

Do not let me push them down.” *The clinician may have to

demonstrate the motion first.

GRADES 2/5 (POOR), 1/5

(TRACE), AND 0/5 (ZERO)

Subject position: Sitting or

supine with the forearm and

wrist in neutral with the hand


resting on the ulnar border on a tabletop.

Substitution: Flexion of the wrist may cause interphalangeal

(IP) extension via tenodesis. Substitution by the lumbricals may

also cause extension of the IP joints.

Finger Abduction


• 0 to 20 degrees

Prime Movers

• Dorsal interossei

□ Origin: Between each metacarpal bone on adjacent sides.

□ Insertion:

o First/second: Radial side of the extensor expansion of

the second and third digits.

o Third/fourth: Ulnar side of the extensor expansion of the

third and fourth digits.

□ Innervation: Ulnar nerve (C8 to T1).

□ Other actions: Assists the lumbricals in MCP flexion and

PIP/DIP extension of fingers II to V.


□ Palpation site: First dorsal interossei-radial side of the

second metacarpal; second dorsal interossei-radial side of

the proximal phalanx of the third digit; third dorsal

interossei-ulnar side of the proximal phalanx of the third

digit; fourth dorsal interossei-ulnar side of the proximal

phalanx of the fourth digit.

• Abductor digiti minimi

□ Origin: Pisiform bone and tendon of the flexor carpi ulnaris

muscle.

□ Insertion: Base of the proximal phalanx of the fifth digit

(ulnar side) and dorsal expansion of the extensor digiti

minimi.

□ Innervation: Ulnar side (C8 to T1).

□ Other actions: Assists with extension of the wrist.

□ Palpation site: Along the ulnar border of the fifth

metacarpal.

Secondary Movers


• Extensor digiti minimi


Subject position: Sitting or supine with the forearm pronated,

wrist in neutral, and the palmar aspect of the hand resting on the


tabletop. The fingers should be in extension.

Stabilization: The clinician stabilizes the hand and nontested

fingers.

SUBJECT DIRECTIVE: “Spread your fingers apart and hold

it. Do not let me push them together.”

*Because the third digit has 2 dorsal interossei, it is important

that it is tested as it moves away from the midline in both

directions (ulnarly and radially).



wrist in neutral, and the palmar aspect of the hand resting on the

table. The fingers should be in extension.

Stabilization: The clinician stabilizes the hand (and non-tested

fingers when testing fingers individually.)

*The most readily palpable dorsal interossei muscle is the first,

which is located at the base of the proximal phalanx. The

abductor digiti minimi is palpated on the ulnar border of the

hand as the subject abducts the fifth digit.

Substitutions: The subject may try to extend the MCP joints as

he or she attempts to abduct the fingers.

Finger Adduction



• 0 to 20 degrees

Prime Movers

• Palmar interossei

□ Origin

o First: Length of the ulnar side of the second

metacarpal. o Second: Length of the radial side of

the fourth metacarpal. o Third: Length of the radial

side of the fifth metacarpal.

□ Insertion

o First: Proximal phalanx, ulnar side of the second

digit. o Second: Proximal phalanx, radial side of

the fourth digit. o Third: Proximal phalanx, radial

side of the fifth digit.

□ Innervation: Ulnar nerve (C8 to T1),

□ Other actions: Assists the lumbricals in MCP flexion and

PIP/DIP extension of fingers II to V.

□ Palpation site: First palmar interossei-ulnar side of the

proximal phalanx of the second digit; second palmar

interossei-radial side of the proximal phalanx of the fourth

digit; third palmar interossei-radial side of the proximal

phalanx of the fifth digit.


Secondary Movers




wrist in neutral, and the palmar aspect of the hand resting on a


Stabilization: The clinician stabilizes the hand and non-tested

fingers.

SUBJECT DIRECTIVE: “Keep your fingers together and do

not let me pull them apart.”*The third digit has no palmar

interosseus and is not tested in adduction.




tabletop. The fingers should be in extension and abducted.

Substitutions: The subject might flex the fingers while

attempting to move them into adduction


THUMB

MCP Flexion


• 0 to 50 degrees (MCP flexion)

Prime Movers

• Flexor pollicis brevis

□ Origin: Distal ridge of the trapezium, the trapezoid,

capitate, and flexor retinaculum.

□ Insertion: Base of the proximal phalanx of the thumb on

the radial side.


□ Other actions: None.

□ Palpation site: The ulnar side of the first metacarpal.



supination, the wrist in neutral, and the hand resting on the

dorsal surface on a tabletop. The thumb is in an adducted

position.

Stabilization: The clinician stabilizes the first metacarpal.

SUBJECT DIRECTIVE: “Bend the base of your thumb and hold

it. Do not let me straighten it out.” *For a grade of 3/5, the


subject flexes the MCP through the maximal range of motion

with slight resistance.

Substitutions: The flexor pollicis longus may be activated to

flex the MCP joint. The DIP of the thumb should remain in

extension during testing of MCP flexion to avoid this

substitution.

IP Flexion


• 0 to 90 degrees

Prime Movers

• Flexor pollicis longus

□ Origin: Anterior surface of the middle half of the shaft of

the radius and coronoid process of the ulna.

□ Insertion: Base of the distal phalanx of the thumb.



□ Palpation site: Palpate where the tendon crosses the

palmar surface of the proximal phalanx of the thumb.






position.

Stabilization: The clinician stabilizes the proximal phalanx.

SUBJECT DIRECTIVE: “Bend the tip of your thumb and hold

it. Do not let me straighten it out.”*For a grade of 3/5, the

subject flexes the IP joint through the maximal range of

motion with slight resistance.

MCP Extension


• 50 to 0 degrees (MCP extension)

Prime Movers

• Extensor pollicis brevis

□ Origin: Dorsal surface of the distal radius.


□ Insertion: Base of the first proximal phalanx of the thumb.


□ Other actions: Assists with wrist radial deviation.

□ Palpation site: Palpate the tendon of the extensor pollicis

brevis as it crosses the lateral aspect of the base of the first

MCP.



in neutral and the hand resting on the ulnar border on a tabletop.


*For a grade of 3/5, the subject extends the MCP joint through

the maximal range of motion with slight resistance.





Substitutions: If the extensor pollicis longus comes into play

while the subject is attempting to extend the first MCP joint,

the clinician may observe the IP joint of the thumb extend as

the carpometacarpal (CMC) joint adducts.

IP Extension



• 90 to 0 degrees

Prime Movers

• Extensor pollicis longus

□ Origin: Lateral aspect of the middle third of the dorsal

surface of the ulna.

□ Insertion: Base of the first proximal phalanx of the thumb.


□ Other actions: Assists with radial deviation.

□ Palpation site: Palpate the tendon of the extensor pollicis

longus as it crosses the dorsal aspect at the base of the

first MCP.





SUBJECT DIRECTIVE: “Straighten the tip of your thumb out

and hold it. Do not let me bend it down.”

*For a grade of 3/5, the subject extends the IP joint through

the maximal range of motion with slight resistance.





Stabilization: The clinician stabilizes the proximal phalanx and

metacarpal.

Substitutions: The muscles of the thenar eminence may be

activated to flex the CMC joint, resulting in IP joint extension

via extensor tenodesis.

Thumb Abduction


• 0 to 60 degrees

• Abductor pollicis brevis

□ Origin: Flexor retinaculum, scaphoid, and trapezium

tubercles.

□ Insertion: Base of the first proximal phalanx, radial

aspect.

Innervation: Median nerve (C8 to T1).



□ Palpation site: Along the anterior surface of the shaft of

the first metacarpal.

• Abductor pollicis longus

□ Origin: Lateral aspect of the dorsal surface of the shaft of

the ulna.

□ Insertion: Base of the first metacarpal, radial aspect.


□ Other actions: Assists with wrist radial deviation.

□ Palpation site: The most anterior of the 3 tendons at the

base of the CMC joint; palpate immediately proximal to

the CMC joint.

Secondary Movers

• Palmaris longus

• Extensor pollicisbrevis

• Opponenspollicis


Subject position: Sitting or supine with the forearm supinated

and wrist in neutral with the hand resting on the dorsal surface;

thumb relaxed into adduction. The MCP and IP joints should be

flexed when testing the abductor pollicis longus to decrease


thumb extension.

Stabilization: The clinician stabilizes the palm of the hand and

wrist.

SUBJECT DIRECTIVE: Move your thumb away from your

palm toward the ceiling and hold it. Do not let me push it

down.”



and wrist in neutral with the hand resting on the ulnar border,

thumb relaxed into adduction.

Stabilization: The clinician stabilizes the palm of the hand and

wrist

Substitution: If the thumb deviates toward the dorsal surface of

the forearm, the extensor pollicis brevis is being called in to

substitute for the abductor pollicis longus.

*The thumb will deviate radially if the abductor pollicis longus

is stronger than the brevis and ulnarly if the abductor pollicis

brevis is stronger than the longus.

Thumb Adduction


• 60 to 0 degrees


Prime Movers

• Adductor pollicis

□ Origin: Capitate bone and bases of the second and third

metacarpal bones and palmar surface of the distal two

thirds of the third metacarpal bone.

□ Insertion: Ulnar aspect of the base of the proximal phalanx

of the thumb.

□ Innervation: Ulnar nerve (C8 to T1).


□ Palpation site: Deep in the first web space between the first

dorsal interossei and the first metacarpal bone.

Secondary Movers

• First dorsal interosseus



pronation and the hand hanging over the edge of a table,

supported by the clinician’s hand. The wrist is in neutral with

the thumb positioned loosely in abduction.

Stabilization: The clinician stabilizes the palm of the hand

SUBJECT DIRECTIVE: Move your thumb in toward your index

finger and hold it. Do not let me move it out.”


GRADES 2/5 (POOR), 1/5 (GOOD), AND 0/5 (ZERO)


in neutral with the ulnar border of the hand resting on the

tabletop with the thumb in abduction.

Stabilization: The clinician stabilizes the wrist and hand on the

tabletop.

Substitutions: The CMC joint will extend if the extensor

pollicis longus is activated while the subject attempts to adduct

the thumb and flexor pollicisbrevis and longus may flex the

thumb as the thumb is adducted.

Thumb Opposition


• Variable; “normal” range of motion allows for complete

motion until the tips of the thumb and fifth digit meet from

an open palm position.

Primary Movers

• Opponenspollicis

□ Origin: Tuberosity of the trapezium and flexor

retinaculum.

□ Insertion: Entire lateral aspect of the shaft of the first

metacarpal bone.




□ Palpation site: Deep to the abductor pollicis brevis along

the lateral shaft of the first metacarpal.


□ Origin: Hook of the hamate and flexor retinaculum.

□ Insertion: The entire ulnar margin of the shaft of the fifth

metacarpal.

Innervation: (C8 to T1).


□ Palpation site: Along the shaft of the fifth metacarpal deep

to the abductor digiti minimi.

Secondary Movers





supination with the wrist in neutral, thumb adducted, and the

MCP and IP joints in flexion.

Stabilization: The clinician stabilizes the hand and wrist

against the tabletop if necessary.


SUBJECT DIRECTIVE: “Put the pads of your thumb and little

finger together so they meet in the shape of an ‘O’ and do not

let me pull them apart.”



supination with the wrist in neutral, thumb adducted and the



against the tabletop if necessary. Grade 2/5: Not pictured. The

two opponens muscles move through the range of motion, but

are evaluated individually.

Substitutions: If the thumb moves parallel to the surface of the

palm toward the little finger and touches the tips, not the pads

of the fingers, the flexor pollicis longus and brevis have been

activated. This is not considered opposition of the thumb.

ASS.PROF. DR. AMIR N WADEE 86

MMT for Cervical Muscles

NECK Flexion


• 0 to 45 degrees with a goniometer

• 1.0 to 4.3 inch with a tape measure

Prime Movers

• Sternocleidomastoid (SCM)

□ Origin

o Sternal head: Cranial aspect of the ventral surface of the

manubrium.

O Clavicular head: Superior border and anterior surface of

the medial one third of the clavicle.

□ Insertion: Lateral surface of the mastoid process and lateral

half of the superior nuchal line of the occipital bone.

□ Innervation: Spinal accessory nerve (C2 and C3 anterior

rami).

□ Other actions: Lateral flexion (to the same side) and rotation

(to the opposite side) of the neck/head.

□ Palpation site: Anterolateral aspect of the neck.

Secondary Movers

• Rectus capitits anterior

• Rectus capitis lateralis

• Suprahyoid


• Infrahyoid

• Platysma

• Scalenes

• Longus capitis

• Longus colli

Anti-Gravity

• Subject position: Supine on a table.

• Stabilization: Weight of the trunk and clinician’s hand on the

thorax.

Gravity Minimized

• Subject position: Sidelying with the head supported on a

smooth surface. Stabilization: The clinician stabilizes the lower

thorax.

Substitutions: The corners of the subject’s mouth may be pulled

down if the platysma contracts.

Points of interest: Torticollis may result if the sternocleidomastoid

becomes dystonic.

Neck Extension


• 0 to 45 degrees

Prime Movers

• Splenius capitis


□ Origin: Caudal half of the ligamentum nuchae and spinous

processes of C7 and T1 to T4 vertebrae.

□ Insertion: Occipital bone just inferior to the lateral one third

of the superior nuchal line into the mastoid process of the

temporal bone.

□ Innervation: Lateral branches of the dorsal primary cervical

nerves.

□ Other actions: Slight rotation and lateral flexion of the head.

□ Palpation site: Under the lateral borders of the upper

trapezius.

• Semi spinalis capitis

□ Origin: Tips of the transverse processes of the C7 and T1 to

T7 vertebrae.

□ Insertion: Between the superior and inferior nuchal lines of

the occipital bone.

□ Innervation: Dorsal primary divisions of the cervical nerves.

□ Other actions: Unilaterally: Rotation of the spine to the

opposite side.


trapezius.

• Cervicis muscles

□ Origin: Spinous processes of the T3 to T6 vertebrae.

□ Insertion: Posterior tubercles of C1 to C3.


□ Innervation: Dorsal primary branch of the spinal nerves.

□ Other actions: Unilaterally: Lateral flexion and rotation of

the head.


trapezius.

Secondary Movers

• Upper trapezius

Anti-Gravity

Subject position: Prone on a table.

Stabilization: Weight of the trunk and the clinician’s hand on the

upper thoracic area and scapulae.

Gravity Minimized

Subject position: Sidelying with the head supported on a smooth

surface. Stabilization: Weight of the trunk on the table.

Substitutions: The subject may try to use the back muscles to lift

the upper trunk from the table.

Points of interest: Tasks such as reaching overhead into a high

cabinet, the top shelf in a closet, or drinking out of a cup require

the contraction of the cervical extensors at the end of the range of

motion.


MMT for Thoracic and lumbar

Spine TRUNK FLEXION

Prime Movers

• Rectus abdominus

□ Origin: Pubic crest and symphysis.

□ Insertion: Costal cartilage of ribs 5 to 7 and the xiphoid process

of the sternum.

□ Innervation: Ventral primary rami (T5 to L1).


□ Palpation sites: Upper rectus: both sides of the midline

between the umbilicus and xiphoid process. Lower rectus:

both sides of the midline between the umbilicus and symphysis

pubis.

• External oblique

□ Origin: Lateral surface of ribs 5 to 12.

□ Insertion: Linea alba, inguinal ligament, anterior superior iliac

spine, pubic tubercle, and anterior half of the iliac crest.


□ Other actions: Trunk rotation.

□ Palpation site: Opposite side of direction of rotation just below

the ribs and lateral to the rectus abdominus.


• Internal oblique

□ Origin: Inguinal ligament, iliac crest, and the thoracolumbar

fascia.

□ Insertion: Pubic crest, linea alba, and ribs 10 to 12.



□ Palpation site: Just medial to the anterior superior iliac spine

along the lateral aspect of the abdomen.

Secondary Movers

• Psoas major

• Psoas minor

Anti-Gravity

• Upper rectus abdominus

Subject position: Supine on a table with both lower extremities

in extension.

Stabilization: No stabilization of the pelvis is provided if the hip

flexors are strong. If weak hip flexors are noted, the clinician

stabilizes the pelvis against the table.

SUBJECT DIRECTIVE: “Curl your head, shoulders, and torso up

until your shoulder blades are off the table.”

Substitutions: The subject may rise up rapidly to use momentum

to lift the trunk or use his arms to push off the tabletop. If the

subject inhales deeply, it may cause depression of the lower


thorax. The umbilicus may deviate to the stronger side.

Gravity Minimized

• Upper rectus abdominis

Subject position: Supine on a table with the knees flexed.

Stabilization: The clinician stabilizes the subject’s pelvis against

the table.

Anti-Gravity

• Lower rectus abdominus

Subject position: Supine on a table with both knees flexed

Stabilization: The weight of the pelvis and lower extremities

provide the necessary stabilization.

SUBJECT DIRECTIVE: “Lift both your knees toward your chest

and lift your buttocks off the table.”

Substitutions: The subject may use the arms to push up or use

momentum to lift up the sacrum. The umbilicus may deviate to the

stronger side.

Points of interest: The rectus abdominis and internal and external

obliques act together to stabilize the pelvis and contribute to proper

postural alignment. Weakness of the abdominal obliques may

decrease respiratory efficiency and reduce support of the

abdominal viscera.


TRUNLK ROTATION

Prime Movers


□ Origin: Lateral surface of ribs 5 to 12.

□ Insertion: Linea alba, inguinal ligament, anterior superior

iliac spine, pubic tubercle, and anterior half of the iliac crest.

□ Innervation: Ventral primary rami of T7 to L1.

□ Other actions: Trunk flexion.

□ Palpation site: Below the ribs and costal cartilages of the

lowest ribs in the midclavicular line.


□ Origin: Inguinal ligament, iliac crest, and the thoracolumbar

fascia.

□ Insertion: Pubic crest, lineaalba, and ribs 10 to 12.

□ Innervation: Ventral primary rami of T7 to L1.

□ Other actions: Trunk flexion.

□ Palpation site: Immediately medial to the anterior superior

iliac spine along the midclavicular line.

Anti-Gravity

Subject position: Supine on a table with the lower extremities

extended.

Stabilization: The clinician stabilizes the pelvis against the table.


The scapula corresponding to the external oblique must clear the

table for a grade of 5/5.

SUBJECT DIRECTIVE: “Lift your head and shoulders off the

table and turn to your left elbow toward your right knee.”

*Instruct the subject to turn the right elbow toward the left knee

to test the opposite side/musculature. When moving the right

elbow toward the left knee, the right external and left internal

obliques are tested.

Substitutions: The pectoralis major may cause the shoulders to

shrug or slightly lift the shoulder off the table.

Gravity Minimized

Subject position: Supine on the table with the lower extremities

extended.


*The umbilicus will move toward the strongest quadrant when

there is unequal strength in the opposing obliques.

Note: The direction of the muscle fibers of the internal obliques can

be mimicked by crossing the arms over the abdomen and placing

the fingertips on each anterior superior iliac spine. The fingers will

parallel the muscle fibers(up and in). The direction of the muscle

fibers of the external obliques can be mimicked by positioning the

hands into the pants pockets (down and in).


TRUNK EXTENSION

Prime Movers

Note: Palpation sites are not listed as the individual muscles

cannot be isolated.

• Iliocostalis thoracis

□ Origin: Angles of ribs 7 to 12.

□ Insertion: Angles of ribs 6 to 1 and the transverse process of

C7.

□ Innervation: Dorsal primary rami of the thoracic spinal nerves.

□ Other actions: Trunk lateral flexion.

• Longissimus thoracis

□ Origin: Lumbar transverse processes (L1 to L5) and

thoracolumbar fascia.

□ Insertion: Transverse processes of T1 to T12 and ribs 2 to 12

between the angles and tubercles.



• Semispinalis thoracis

□ Origin: Transverse processes of T6 to T10.

□ Insertion: Spinous processes of C6 to T4.


□ Other actions: Contralateral trunk flexion.

• Multifidi

□ Origin: Articular processes of C4 to C7, transverse processes


of T1 to T12, mamillary processes of L1 to L5, sacroiliac

ligaments, posterior superior iliac spine, and sacrum.

□ Insertion: Spinous process of higher vertebrae (2 to 4 and

above).

□ Innervation: Dorsal primary rami of the thoracic and lumbar

spinal nerves.

□ Other actions: Trunk lateral flexion and trunk rotation.

• Rotatores thoracis and lumborum

□ Origin: Transverse processes of the thoracic and lumbar

vertebrae.

□ Insertion: Lamina of the next highest vertebrae.


spinal nerves.


• Interspinalis thoracis and lumborum

□ Origin/Insertion

O Thoracis: Three pairs between the spinous processes of T1

to T2, T2 to T3, and T11 to T12.

o Lumbar: Four pairs between the spinous processes of all 5

lumbar vertebrae.


spinal nerves.


• Inter transversarii thoracis and lumborum


□ Origin/Insertion

O Thoracis: Eleven pairs between spinous processes of T1 to

T12.

o Lumbar: Four pairs between spinous processes of L1 to L5.


spinal nerves.

□ Other actions: Trunk lateral flexion.

• Quadratus lumborum

□ Origin: Iliolumbar ligaments. Iliac crest and superior borders

of the transverse processes of L2 to L5.

□ Insertion: Inferior border of the twelfth rib and transverse

processes of L1 to L4.

□ Innervation: Ventral primary rami of L1 to L3.

□ Other actions: Pelvic elevation and trunk lateral flexion.

Secondary Movers

• Gluteus maximus

Anti-Gravity

• Lumbar

Subject position: Prone with the hands clasped behind the head.

^Alternate position: Prone with pillows under the subject’s hips

and the hands clasped on the buttocks.

Stabilization: The clinician stabilizes the pelvis and hips.

SUBJECT DIRECTIVE: "Lift your head and chest up toward the


ceiling as high as possible and hold it.”

Gravity Minimized

• Lumbar

Subject position: Sitting backwards on a chair or on a stool with

the hands resting on a tabletop.

Stabilization: Achieved by the weight of the subject on the chair

and subject compliance.

Anti-Gravity

• Thoracic

Subject position: Prone with the head and upper trunk draped at

chest level off the edge of a table with the hands clasped behind

the head.

^Alternate position: Prone with pillows under the abdomen and

with the hands clasped on the buttocks.

Stabilization: The clinician stabilizes the pelvis and lumbar

vertebrae.

SUBJECT DIRECTIVE: "Lift your head, shoulders, and chest up

toward the ceiling as high as possible and hold it.”

Gravity Minimized

• Thoracic

Subject position: Sitting backwards on a chair with the thoracic

spine relaxed and the hands resting on the back of the chair.


Stabilization: Weight of the subject on the chair and subject

compliance.

Substitutions: The subject may use momentum by forcefully

pushing the shoulders backwards.

Points of interest: The longissimus is the predominant muscle that

is active during all motions of the trunk.

PELVIC ELEVATION

Prime Movers


□ Origin: Superior borders of the transverse processes of L2 to

L5.

□ Insertion: Inferior border of the twelfth rib and transverse

processes of L1 to L4.

□ Innervation: Ventral primary rami of L1 to L3.

□ Other actions: Lateral trunk flexion to the same side.

Stabilizes the twelfth rib during inspiration.

□ Palpation site: Too deep to be palpated.

Secondary Movers

• Latissimusdorsi

• Iliocostalislumborum

Anti-Gravity

Subject position: Standing on a stool or step with the clinician


supporting the subject for balance, the test limb hanging free.

Stabilization: The clinician stabilizes the pelvis on the opposite

side.

SUBJECT DIRECTIVE: “Hike your hip up toward your ribs and

hold it.

Substitution: The subject may laterally flex the trunk away from

the tested side.

Gravity Minimized

Subject position: Supine or prone on a table with the lower

extremities in extension.

Stabilization: The subject may hold onto the sides of the table for

resistance.


Functional Muscle Testing of Facial

Muscles MUSCLES OF THE FACE

Muscle Tested:

a. Frontalis (Frontal belly)

1) Origin:

Aponeurosis midway between coronal suture and

orbital arch.

2) Insertion:

Fibers are continuous medially with those of procerus;

intermediate fibers blend with corrugator and orbicularis

oculi.

3) Nerve Supply:

Temporal branches of facial nerve.


b. Corrugator supercilii

1) Origin:

Medial end of superciliary arch

2) Insertion:

Deep surface of skin above middle of orbital arch

3) Nerve Supply:

Temporal and zygomatic branches of facial

c. Procerus

1) Origin:

Fascia covering lower part of nasal bone and upper part

of lateral nasal cartilage

2) Insertion:

Skin over lower forehead, between eyebrows.

3) Nerve Supply:

Buccal branches of facial nerve.

d. Nasalis

1) Origin:

Transverse part: (compressor) Maxilla, above and lateral

to incisive fossa.

Alar part: (dilator) Greater alar cartilage

2) Insertion:


Thin aponeurosis continuous with muscle of opposite

side.

Integument at point of nose

3) Nerve Supply:

Buccal branches of facial nerve.

Test Procedures:

In the testing of the face muscles, positioning is not a

factor, and, with the exception of the muscles of mastication,

only very fine movements are involved. Grades which may

be used are: zero, if no contraction can be elicited; trace, for

minimal muscle contraction; fair, for performance of the

movement with difficulty; and normal, for completion of the

movement with case and control. Resistance may be given

in the tests for the muscles of mastication.

Occipitofrontalis (frontal belly):

Command: raise eyebrows, forming horizontal wrinkles

in forehead (expression of surprise) ----- Relax.

Corrugator Supercilii:

Command: draws eyebrows medially and downward,

forming vertical wrinkles between brows (frowning) ---

-- Relax.


Procerus:

Command: Lift lateral borders of nostrils, forming

diagonal wrinkles along bridge of nose (expression of

distaste).

Nasalis:

Command: Dilate nostrils alar part of nasalis followed

by compression (transverse portion) ------ Relax.


MUSCLES OF THE EYE

Muscle Tested:

a. Orbicularis oculi

1) Origin:

Orbital part:

a. Nasal part of frontal bone

b. Frontal process of maxilla in front oflacrimal groove

c. Anterior surface and borders of medial palpebral

ligament

Palpebral part:

Bifurcation of medial palpebral ligament

Lacrimal part (tensor tarsi):

Posterior crest and adjacent part of lacrimal

bone

2) Insertion:

- (Fibers form a complete ellipse without interruption,

surrounding circumference of orbit and spreading over

temple and downward on cheek)

- Lateral palpebral raphe

- Divides into two slips which insert into superior and

inferior tarsi medial to punctala crimalia

3) Nerve Supply: Temporal and zygomatic branches of

facial nerve.


b. Levator palpebrae superioris

1) Origin:

Inferior surface of small wing of sphenoid, above and in

front of optic foramen

2) Insertion:

Forms broad aponeurosis which splits into 3 lamellae:

superficial blends with upper part of orbital septum and

is prolonged forward above superior tarsus to deep

surface of skin of upper eyelid; middle into upper margin

of superior tarsus; deepest into superior fornix of

conjunctiva

3) Nerve Supply: Oculomotor nerve.

c. Rectus superior:

1) Origin:

Upper part of fibrous ring surrounding optic foramen on

upper, medial and lower margins

2) Insertion:

Into sclera about 6 mm behind cornea, on superior aspect

of eyeball

3) Nerve Supply: Oculomotor nerve


d. Rectus inferior

1) Origin:

Lower part of fibrous ring surrounding optic foramen on


2) Insertion:

Into sclera about 6 mm behind cornea, on inferior aspect of

eyeball


e. Rectus medialis:

1) Origin:

Medial part of fibrous ring surrounding optic foramen on


2) Insertion:

Into sclera on medial aspect of eyeball, farther forward

than recti superior and inferior.


f. Rectus lateralis:

1) Origin:

Two heads from lateral parts of bands surrounding optic

foramen and adjoining part of orbital fissure

2) Insertion:

Into sclera on lateral aspect of eyeball, farther forward

than recti superior and inferior.


3) Nerve Supply: Abducent nerve.

g. Superior oblique:

1) Origin:

Above margin of optic foramen, from body of

sphenoid.

2) Insertion:

Passes forward, ending in tendon which plays in

fibrocartilaginous pulley attached to trochlear fovea of

frontal bone; tendon passes backward, lateralward, and

downward to lateral aspect of eyeball, inserting into sclera

behind the equator of the eyeball; thus muscle pulls in a

forward, upward and medial direction.

3) Nerve Supply: Trochlear nerve

h. Inferior oblique:

l) Origin: Orbital surface of maxilla, lateral to lacrimal

groove.

2) Insertion:

Passes lateralward, backward and upward to insert into

lateral part of sclera somewhat behind insertion of

obliquus superior.



Test Procedures:

Orbicularis oculi

Command: Close your eyes tightly ------ Relax.

Levator palpebrae superioris

Command: Lift your upper eyelids completely as eyes

are turned upward ------ Relax.

Inferior oblique (right) and superior rectus (left)

Command: move your eyes in a direction upward and

to the right ------ Relax

Superior oblique (left) and inferior rectus (right)

Command: move your eyes in a direction downward

and to the left ------- Relax.

The rectus medialis and rectus lateralis may be tested by

movement of the eyes horizontally to the right and left.

(Not illustrated. )


MUSCLES OF THE MOUTH

Muscle Tested:

a. Orbicularis oris:

1) Origin:

a. Fibers derived from other facial muscles, principally

Buccinator, Levator anguli oris, and Depressor

anguli oris.

b. Proper fibers of lips, from under surface of skin

c. Fibers attached to maxilla and septum of nose above

and to mandible below.

2) Insertion:

a. Intermingling of transverse and oblique fibers


comprising muscle

b. Mucous membrane lining mouth cavity

c. Decussation of some fibers of Buccinator at corner

of mouth; Levator anguli oris fibers pass below, and

Depressor anguli oris fibers pass, above mouth

3) Nerve Supply: Buccal branches of facial nerve.

b. Zygomaticus minor:

1) Origin:

Malar surface of zygomatic bone posterior to

zygomaticomaxillary suture

2) Insertion:

- Upper lip between angular head and Levator anguli

oris

- Upper lip at corner of mouth


c. Levator anguli oris:

1) Origin:

Canine fossa, immediately below infraorbital foramen

2) Insertion:

Angle of mouth, intermingling with zygomaticus,

depressor anguli oris and orbicularis



d. Zygomaticus major:

1) Origin:

Zygomatic bone anterior to zygomaticotemporal

suture.

2) Insertion:

Angle of mouth, intermingling with levator and

depressor anguli oris and orbicularis oris


e. Risorius:

1) Origin:

Fascia over Masseter; muscle passes laterally superficial to

Platysma

2) Insertion:

Skin at angle of mouth

3) Nerve Supply: Mandibular and buccal branches of

facial

f. Buccinator

1) Origin:

a. Outer surfaces of alveolar processes of maxilla

above and mandible below, alongside the 3 molar

teeth.


b. Pterygomandibular raphe

2) Insertion:

Fibers blend with deeper stratum of fibers in lips.

3) Nerve Supply: Buccal branches of facial

g. Depressor anguli oris

1) Origin: Oblique line of mandible.

2) Insertion: Angle of mouth

3) Nerve Supply: Mandible and buccal branches of facial

nerve.

h. Depressor labii inferioris:

1) Origin:

Oblique line of mandible, between symphysis and

mental foramen

2) Insertion:

Skin of lower lip, blending with orbicularis oris and

opposite depressor labii inferioris


i. Mentalis

1) Origin: Incisive fossa of mandible

2) Insertion: Integument of chin

3) Nerve Supply: Mandibular and buccal branches of

facial nerve.


j. Platysma

1) Origin:

Fascia over superior pectoralis major and deltoideus

muscles

2) Insertion:

a. Anterior fibers interlace with opposite muscle

inferior and posterior to symphysis menti

b. Posterior fibers insert into mandible below oblique

line or blend with muscles near angle of mouth.

3) Nerve Supply: Cervical branch of facial nerve.

Test Procedure:

Orbicularis Oris

Command: Approximate and compress your lips -----

Relax.

Zygomaticus Minor

Command: Protrude your upper lip------- Relax.

Levator Anguli Oris:

Command: Lift your upper border of lip on one side

without raising lateral angle of mouth (sneering) ------

Relax.


Zygomaticus Major:

Command: Raise your lateral angle of mouth upward

and lateralward (smiling)------ Relax.

Risorius:

Command: Approximate your lips and draw your

corners of mouth lateralward (grimacing) ----- Relax.

Buccinator

Command: Approximate your lips and compress your

cheeks(blowing) ------ Relax.

Depressor Labii Inferior:

Command: Protrude your lower lip (pouting) -----

Relax.

Depressor Anguli Oris and Platysma:

Command: Draw your corners of mouth downward

strongly ------ Relax.

Mentalis

Command: Draw your tip of chin upward ------ Relax


MUSCLES OF MASTICATION

Muscle Tested:

Temporalis:

1) Origin:

a. Temporal fossa

b. Deep surface of temporal fascia

2) Insertion:

a. Medial surface, apex, and anterior border of


coronoid process of mandible

b. Anterior border of ramus of mandible nearly as far

forward as last molar tooth

3) Nerve Supply:

Deep temporal nerves from mandibular division of

facial nerve.

Masseter:

1) Origin:

Superficial portion:

a. Zygomatic process of maxilla

b. Anterior two thirds of lower border of zygomatic

arch

Deep portion:

a. Posterior third of lower border of zygomatic arch

b. Whole medial surface of zygomatic arch

2) Insertion:

Angle and lower half of lateral surface of ramus of

mandible

a. Lateral surface of upper half of ramus of mandible

b. Lateral surface of coronoid process

3) Nerve Supply:

Masseteric nerve from mandibular division of

trigeminal.


Pterygoid externus:

1) Origin:

Upper head:

a. Lower part of lateral surface of great wing of sphenoid

b. Infratemporal crest

Lower head:

Lateral surface of lateral pterygoid plate

2) Insertion:

a. Depression in front of neck of condyle of mandible

b. Front of articular disk of temporomandibular

articulation

3) Nerve Supply:

External pterygoid nerve from mandibular division of

trigeminal.

Pterygoid internus:

1) Origin:

a. Medial surface of lateral pterygoid plate

b. Pyramidal process of palatine bone (second slip is

external to pterygoid externus)

2) Insertion:

Lower and posterior parts of medial surface of ramus

and angle


of mandible as high as mandibular foramen

3) Nerve Supply:

Internal pterygoid nerve from mandibular division of

trigeminal

Mylohyoid:

1) Origin:

Whole length of mylohyoid line of mandible, from

symphysis in front to last molar tooth

2) Insertion: Body of hyoid bone

3) Nerve Supply: Trigeminal nerve.

Geniohyoid:

1) Origin:

Inferior mental spine on back of symphysis menti

2) Insertion:

Anterior surface of body of hyoid bone

3) Nerve Supply: (C1) via hypoglossal

Digastricus:

1) Origin:

- Posterior belly: Mastoid notch of temporal bone

- Anterior belly: Depression on inner side of lower

border of mandible

2) Insertion:


The two portions are united by an intermediate rounded

tendon which perforates the stylohyoid muscle.

3) Nerve Supply:

Posterior belly, trigeminal; anterior belly, facial

Stylohyoid:

1) Origin:

Styloid process near its base

2) Insertion:

Body of hyoid bone at junction with greater cornu,

just above

omohyoid muscle

3) Nerve Supply: Facial nerve.

Sternohyoid:

1) Origin:

a. Posterior surface of medial end of clavicle

b. Posterior and upper part of manubrium

2) Insertion:

Lower border of body of hyoid bone

3) Nerve Supply: (Cl, 2, 3) via ansa hypoglossi.

Styreohyoid:

1) Origin:

Oblique line on lamina of thyroid cartilage

2) Insertion:


Lower border of greater cornu of hyoid bone

3) Nerve Supply: (C1, 2) via hypoglossal

Sternothyroid:

1) Origin:

Posterior surface of manubrium below sternohyoid, from

edge of cartilage of first and sometimes second rib

2) Insertion:

Oblique line on lamina of thyroid cartilage

3) Nerve Supply: (Cl, 2, 3) via ansa hypoglossi.

Omohyoid:

1) Origin:

Inferior belly: upper border of scapula, near superior

transverse ligament

Superior belly: lower border of hyoid bone

2) Insertion:

The two portions are united by a central tendon held in

position by a sheath of deep cervical fascia which is

anchored to the clavicle and first rib.

3) Nerve Supply: (Cl, 2, 3) via ansa hypoglossi

Test Procedures:

Temporalis, Masseter and Pterygoid internus

Command: Close your jaws tightly ------ Relax.


Pterygoid externus and internus (left)

Command: Move your mandible laterally and forward

to the right ----- Relax.

Digastric and suprahyoid muscles;

(hyoid bond is fixed by Infrahyoid muscles)

Command: Depress your mandible ------ Relax.


ISOKINETIC MUSCLE PERFORMANCE

TESTING

Isokinetic is a Latin word means “same movement”. It is the

dynamic movement at a preset constant controlled velocity.

Isokinetic dynamometry, originally described by Hislop & Perrine

(1967), is a relatively recent tool used in physiotherapy

departments in measurements and training.

Cybex, Lido and Biodex are isokinetic dynamometers which

enable the measurement of static and dynamic muscle strength.

The dynamometer is capable of providing objective and

quantifiable muscle performance in static (isometric) situations,

and it also has the advantage of providing similar information for

dynamic muscle contraction. It measures muscle force, moment,

work, power ..ect. A velocity up to 500 o/s allowed.

The early dynamometers were known as passive systems,

i.e. they were only capable of measuring the torque or force

generated during a concentric (shortening) and an isometric (static)

contraction.

Active isokinetic dynamometer systems operate passively,

and are now able to quantify eccentric muscle contraction. This

ability has focused much attention on the investigation of delayed

onset of muscle soreness.


The Isokinetic Dynamometer

An isokinetic dynamometer is consisted of a chair and

dynamometer which are both capable of rotating about 360° in the

transverse plane. Additionally, the dynamometer is also able to

rotate vertically. This latter feature enables the patient to be

positioned in a number of ways. For example, it is possible, with

practice, to set the patient up to allow exercise of the shoulder joint

complex in one of the two functional diagonal patterns of

movement, namely that of flexion, abduction and lateral rotation.

Principle of Isokinetic Systems

The dynamometer is consisted of a fixed axis with a rotating

lever arm attached to a moveable head (Fig. 199).


Fig. (1): Head assembly and motions: A; rotation. B; swiveling

(seven stops). C; up/down (tilt, not shown).

The lever arm is driven either hydraulically or electrically, and

accommodates the movement generated by the patient contracting

muscles in such a way that the distal limb segment moves through

a predetermined joint range at a constant angular velocity.

However, this does not take place until the patient's limb exceeds

the preset angular velocity which has been programmed into the

machine by the physiotherapist.

Basic components of the dynamometer:

1. The force acceptance unit is the interface between the user and


the dynamometer. It consists of a metallic attachment on the

lever-arm, with or without foam padding, which connects to the

lever-arm via the “load cell”. The location of the unit along the

lever-arm is individually adjusted.

2. The load cell converts the force signal into an electric signal.

3. The lever-arm provides the base for the force acceptance unit

and moves radially about a fixed single axis.

4. The head assembly (Fig. 199) houses the motor responsible for

the motion of the lever-arm. It could be oriented as follows:

a. tilt, for movement in planes other than the vertical, e.g.

rotations of the humerus or subtalar motions.

b. swivelling for applications such as testing of shoulder

elevators.

The head may be moved up or down using an electric motor,

for the purpose of alignment. The head may be positioned

between two seats for bilateral test. In other system design the

head can move around the subject.

5. The seat, or plinth is used to position the subject in a vertical or

horizontal (forward/backward) alignment options (Fig. 200).

The control unit is the personal computer and its associated peripheral

equipment. The isokinetic mode and various parameters are fed

into the computer using the keyboard. The same computer is also

responsible for the real-time data processing.

7. Attachments used for different applications of the isokinetic


dynamometer.

Modes of Operation in The Isokinetic Dynamometer

Modern machines are capable of testing and exercising

muscles in a wide range of exercise modes: passive, isometric,

isotonic and isokinetic. These can be combined to provide a tailor-

made test or exercise regimen to suit the individual.

Passive Mode

When operating in the passive mode, the velocity remains

constant and no voluntary force is required by the patient to initiate

the movement. it is a useful mode in which to start to familiarise

the patient with the machine. The motion obtained in this mode

can be similar to that achieved using a continuous passive motion

(CPM) machine to maintain postoperative range of movement, e.g.

after, a total knee replacement. Additionally, it is a useful mode to

begin motor relearning, as required, e.g., after an anterior cruciate

ligament repair. When progression is necessary, active assisted

movement can be incorporated into the passive mode.

Isometric Mode

During isometric exercise, the muscle contracts without

shortening or lengthening. As the force of contraction increases,

there is an increase in the tension generated by the muscle, but there

is no change in muscle length and there is no visible joint


movement. Isometric exercise is also called “static” exercise.

The isometric mode on the dynamometer allows the

physiotherapist to programme a series of isometric hold angles

throughout the patient's available range of motion. For example,

the quadriceps muscle may be weak towards the inner range.

Strength here is essential for a normal gait. It may also be weak at

90° of knee flexion. Strength here is important to assist with rising

from sitting. These two areas of weakness should be tested. So, a

program is specifically designed for the patient.

The physiotherapist is able to test the quadriceps at these

specific angles by presetting these as hold angles before starting

the test. The machine passively moves the patient's limb to the first

preset angle (90°) of knee flexion and instructs the patient, via a

screen prompt, to contract the quadriceps isometrically for a

predetermined time, e.g. 5 seconds. The machine then instructs the

patient to relax, and the limb is allowed to reposition or is moved

passively to the next hold angle in inner range and the process

repeated. Force is displayed on a print out.

Isokinetic Mode

The concept of isokinetic exercise involves training or testing

muscle strength under conditions of constant angular velocity. The

isokinetic dynamometer can be programmed to fix the speed of

movement of the exercising muscle throughout its exercising range


of movement. In this mode, the angular velocity of the lever arm will

remain constant, unlike during isotonic test or exercise, where it is

variable and controlled by the patient. The external load applied to

the moving segment remains consistent with the maximum capacity

of the muscle throughout the range of either concentric or eccentric

contraction.

Isotonic Mode

The term “isotonic” (iso = same, tonic = tension) is

somewhat of a misnomer, and is therefore best regarded only as a

“working definition”, because muscle tension never remains

constant throughout range as implied.

During functional activity, the tension varies as the muscle

alters its length through the available range, and the muscle

develops its maximum tension at only one point in range. This

point is usually identified in the habitual functional range for that

specific muscle. Most muscles tend to develop maximal tension

when approaching mid to inner range, since it is in this range that

they tend to function in normal daily activities.

During the isotonic mode on the dynamometer, the patient

selects the exercise velocity and thus it may vary across the range.

The muscle tension may also vary through the available joint range

and will be weakest at the extremes of range and greatest in mid

range.


Fig. (2): Basic elements of isokinetic dynamometer: A, rotates seat right and

left; B, adjusts scat forward/backward; C, seat up/down control switch; D,

dynamometer head up/down; E, seatbelt; F, forward/backward lock; G, Force

acceptance unit and load cell; H, hook to hold thigh straps; I, mechanical stops

of lever-arm; J, table extension pad receiving tube.

Isokinetic measurements:

The basic measurement record by isokinetic dynamometery

is a sequence of numbers which represent magnitude of the force

exerted by the moving distal body segment against the force sensor.

This record is displayed in a graphical form on the computer

display. The output parameters depend on a set of control (input)


parameters and other variables. These variables, notably the

angular velocity, determines the general framework of the test.

I. Control (input) parameters of strength testing

The objective is to produce a moment-angular position (MAP)

curve for the muscle group, from which various performance

parameters are derived. The control, or input, parameters which must

be specified in advance, fall into two groups, the joint-dependent and

joint-independent parameters.

A) Joint-Dependent Input

The joint-dependent parameters vary according to which

joint is being tested.

1. Range of motion

The range of motion (ROM) describes the allowable angular

displacement of the lever arm ( in degrees).

* The isokinetic range of motion (IROM)

The specified ROM of the angular sector in which the joint

motion is isokinetic. The isokinetic ROM (IROM) is always

smaller than the ROM, as each contraction cycle starts and

terminates at a static position. An inverse relationship normally

exists between the test velocity and the IROM: an increase in the


preset velocity implies a smaller IROM.

The dynamometer may have a preload system that allow the

limb to be preaccelerated to its isokinetic velocity and is introduced

before active muscle takes place.

* Magnitude of the ROM

The ROM has a direct effect on the isokinetic performance.

Knee extensors in concentric contractions was found to be

significantly greater in peak moment for 90° compared with 120°

test. i.e. a greater ROM has a positive effect on some performance

parameters as peak moment.

2. Angular velocity

Angular velocity is measured in degrees per second (°/s) up

to 500°/sec. The test angular velocity is of the lever arm not of the

distal segment. The preset velocity does not indicate any simple

relationship to muscle linear contraction velocity, and this

relationship is different for each muscle because of differing

anatomical configurations.

The preset angular velocity is reached only after a certain

sector of motion has been covered, and the greater the preset value,

the longer it takes to attain it. Examiners should inspect the velocity

trace (if one exists) on the screen to ascertain that isokinetic took

place. Some new attachments/ systems allow linear rather than


angular patterns to be tested as in lifting or leg press. In this case

the unit of measurement is the centimeter per second (cm/s) or inch

per second (in/s).

B) Joint-Independent Control Parameters

1. Damp setting

The angular sectors of the acceleration and deceleration

phases, the so-called 'moment signal transients', are directly

proportional to the angular velocity.

The damping effect is illustrated in two MAP curves depicted in

Fig. (3). The conspicuous spike which occur at the beginning of the

contraction in Fig. (3a) under undamping condition is significantly

attenuated (Fig. 3b), with maximally damped test. The spike has been

termed interchangeably as impact artefact, torque overshoot, or

moment overshoot or simply overshoot. To overcome the overshoot

phenomenon ramping was used in which acceleration of the segment

to the preset velocity is allowed, the computer-controlled

acceleration. It provide an “absorber” for the excess force resulting in

an overshoot-free, smooth transition from 0°/s to the preset velocity.

* Variation of the damp setting

Damp settings was be low, medium or high, which

corresponded to a long, medium and short delay in reaching the

preset angular velocity (PAV). The choice of the damp setting

affects either the peak or average moments.


Fig. (3): Damp settings and moment overshoot phenomena:

A, undamped signal; B, damped signal.

2. Isometric preactivation (IPA)

It is the static contraction which is generated in the tested

muscle/s before movement of the lever-arm and segment. It has

restraining effect on the initial moment oscillation. There are three

approaches to setting the IPA: absolute force, absolute moment and

relative %MVIC (maximal voluntary isometric contraction)

values. Isometric preactivation of 25% MVIC induces only

marginal variations and hence higher values may be used. It would

be erroneous to compare muscle performances which are not based

on the same isometric preactivation.


3. Lower isometric basis (LIP) and upper moment limit

(UML)

The LIB is the minimal magnitude of moment that has to be

maintained in order to ensure a smooth progression of isokinetic

motion. Thus serves as a complement to isometric pre activation

(IPA).

In upper moment limit may be incorporated for the purpose of

ensuring the safety of potentially vulnerable structure. The use of LIB

together with UML may be beneficial in nonmaximal efforts (e.g.

post-ACL reconstruction), or for the purpose of fine motor

performance analysis.

4. Feedback

Isokinetic test may be affected by the provision of the

following feedback characteristics:

1. Form: auditory (verbal), visual, or a combination

2. Amount: how much information is given to the subject.

3. Delay: the period of time between the performance and the

provision of the information, or between the presentation of the

information and the next response.

4. Content: the parameter of performance to which the feedback

refers, for instance peak or average moment.

Isometric quadriceps test was significantly improved (by about

10%) by combined visual and auditory feedback but not by either of


them separately. The use of visual feedback may be limited to

strength testing at low angular velocities. Aggressive verbal

commands and encouragement results in earlier occurrence of

fatigue. If encouragement is given, it should be consistent and

moderate in intensity.

II. Performance (output) parameters of strength testing

Moment-angular position (MAP) curve is the force,

expressed in Newtons (N), which is the most basic mechanical

parameter, all isokinetic findings relate to its rotational effect,

namely the moment.

1. Moment and torque

Torque like moment is associated with a force which acts at a

distance from an axis but the mechanical connotation of the two is

different. When a torque acts on a body it imparts torsional stresses

and may in addition impart axial rotation (winding) as in internal

and external rotations. When a moment acts on a body it exerts

bending stresses and may in addition exerts rotation as in flexion

and abduction. The unit of measurement of moment is the

Newton-meter (Nm) represents the strength of the tested muscles

at that point (Fig. 4).

2. Peak moment

The maximal value of the MAP curve is termed the peak

moment (PM) or maximal strength.

3. Moment/force threshold value:


If the maximum amount of moment or force, the dynamometer

is capable to provide, is exceeded an error message appears or

alarm is activated.

4. Angle-based moment:

It is the value of the moment at a predetermined angular

position.

5. Angle of peak moment

The angle at which the peak moment occurs (60° in fig. 4) is

called the angle of peak moment (APM). A higher test velocity

results in a delay in reaching the peak moment and hence a

greater APM. In addition, the APM varies widely among

subjects, particularly in the case of the shoulder.

6. Average moment

The average moment (AM), also expressed as Newton-

meters. Clearly the average moment is measured over the isokinetic

range of movement (IROM). To test heavy body segments (e.g.

trunk hip region muscles), the use of average rather than peak

moment is strongly recommended.


Fig. (4): Peak moment (force) of an isokinetic strength curve. The

dotted line shows highest point and maximum force value on the

MAP curve (623 N). Multiplication of this force value by the length

of the lever arm give the peak moment.

Relationship of peak and average moments

The average and peak moments are strongly correlated, in

concentric and eccentric contractions alike.

Average and peak moments cannot be used interchangeably

because of their different magnitudes, and their probably different

relationships to angular velocity.

Both the peak and average moments are commonly

measured in Nm units. Although the preferred unit is Nm/kilogram

of body-weight (Nm/kgbw).


7. Contractional work

Unit of measurement of the contractional work (CW) is the

joule (J). It is a measure of the work done, or energy expended, by the

muscle/s under test. It is equal to the area under the MAP curve or

alternatively to the average moment times the angular displacement

(A).

W = M average A

A normally refers to the angular displacement in the truly

isokinetic sector of the MAP curve, as with the calculation of the

average moment, described earlier.

8. Contractional power

Contractional power (CP), is measured in watts. It is an

important performance, parameter which relates to the average

time rate of work namely:

Power = Work

= M average

A = M

Time taken T average

where cv is the test angular velocity.

The importance of this parameter derives from the fact that it

reflects aspects other than strength although it bears a close

relationship to the latter.

9. Contractional impulse

The contractional impulse (CI) is the product of the

moment multiplied by the time for which it acts:

I = M average T


where I is the value of the impulse namely

Impulse is measured in Nms has a special significance.

Using knee extension performance, the contractional impulse at

180°/s is the best discriminator between the sprinters and cross

country skiers, while the peak moment at 30°/s revealed no

differences. In patients suffering from patellofemoral pain

syndrome, the contractional impulse was highly correlated with the

subjective pain ratings whereas the average moment was not.

Specification of parameters

All of the above parameters must be used with reference to test

angular velocity and mode of contraction. Since it is the concentric

strength that is most commonly referred to, the latter should be used

as a default. The following is suggested as a convenient way of

quoting isokinetic parameters: parameter, angular velocity,

contraction mode (only if eccentric). Examples are PM-120, AM-30

or CI-60 (PM, peak moment; AM, average moment; CI, contractional

impulse).

Fatigue (F) and Endurance (E) Testing

Isokinetic of fatigue and endurance test is based on a series

of repetitive contractions, performed at predetermined angular

velocity and contraction modes. Additional/ alternative criteria are

involved.

Control Parameters in F And E Testing


Number of repetitions

There is no rule governing the number of contractions (NOC)

required in a fully fledged, fatigue and endurance test. The reported

NOC in a single testing session ranges typically from 10 to 150.

Measurement of PM, CW and CP are commonly used. Two phases

were identified, the first, termed the “fatigue” phase, was

characterized by a steep decrease in the mechanical output. The

second, or “endurance” phase showed a steady state performance.

When a relatively high NOC is involved, one does not attain the

endurance phase without first passing through the fatigue phase.

Performance Parameters in Measured Fatigue and Endurance

Testing

Performance parameters measured in strength analysis is

generally valid for fatigue and endurance. Instead of considering the

performance within the framework of a single contraction, the basis

is an ensemble of contractions. The following performance

parameters have been used in analysing fatigue and endurance in

isokinetic situations.

1. Reductions in peak moment (PM) contractional work (CW)

and contractional power (CP)

Reduction in peak moment (PM) is probably the most

commonly used performance measure. It is based on the percentage


ratio, of the last and first contractions. There are some variations.

Comparing the average peak moment of the first five contractions

with that of the last five, or the three highest peak moment values

from the five initial and five final contractions.

Reductions in contractional work and contractional power are

used as performance measures in a way comparable to peak

moment. A variant of contraction work reduction was used in

fatigue and endurance test. Instead of dividing the final by the

initial peak moment, the initial and final contractional work values

were used.

2. Time to 50% of peak moment

It is the period of time in which a subject can maintain a

repetitive peak moment level of 50% or above the peak moment

obtained at the initial contraction. It is therefore a time-based rather

than an NOC-based indicator. The exact number of contractions can

not be predicted. A single contraction with a peak moment value of

50% that of the initial peak moment should be sufficient or not to

terminate the test requires investigation.

The Measurement Level and Isokinetic Ratios

Isokinetic measurements is classified as interval and not ratio

scales. Isokinetic moment measurements must be considered to be


interval scaled. The zero level on the moment curve does not

represent a true absence of muscularity generated moment. The

moment curve actually represents the resistive moment generated by

the machine to keep a limb segment from accelerating. The moment

generated by the muscle to move the limb segment 5 up to the

dynamometer speed is not registered. Ratios, or percentages, thus

cannot be formed from interval-scaled data. Zero moment levels

(which in this case are equivalent to grade 3 in manual muscle testing)

are never compared. We can not say that the muscle which generates

a PM of 80 N m is twice as strong as another muscle which generates

40 N m.

Specificity in MAP curves

Not all isokinetic curves have the same typical inverted U shape.

There is a certain degree of specificity associated with these curves i.e.

testing in the sitting position, the quadriceps curve starts and normally

ends at near zero moment, the hamstring is characterized by a

monotonously increasing curve which peaks near or at the end of the

ROM.

Also, the phenomenon of “break” or “dip’ in the curve, which has

been associated with pain in the knee joint. These breaks disappeared

following surgical intervention, a finding which correlated well with

the alleviation of pain in the joint. On the other hand the

reproducibility of this phenomenon in terms of both magnitude and


location has not been confirmed. It does not mean that this is an

invalid criterion as the source of pain, e.g. tissue stretching, may vary

its responsivity even within the same testing session. Nevertheless the

shape may vary quite considerably and thus few inferences may be

drawn from it.

Programme Facilities of Isokientic Dynamometer

In addition to providing the contraction modes described above,

dynamometers allow the physiotherapist to select several other

parameters such as the velocity at which the exercise should take

place, the range of movement in which it should be performed, the

number of repetitions required, and the moment/force threshold

values and damp setting and other parameters mentioned before as

input parameters.

Velocity

The exercise velocity is measured in degrees per second.

Current dynamometer velocities range from 1° to 500° per second.

Although a velocity of 300° per second seems very fast when

exercising on a dynamometer, it is in fact much slower than the

velocities generated in many sporting events. For example,

velocities of 6180° per second have been recorded in top-flight

baseball pitchers. Also, an isokinetic velocity is not functionally

normal, since no muscle contracts through range at constant

velocity; rather, it varies according to the task in hand. For


example, when reaching to pick up a glass, the triceps extends the

elbow initially relatively quickly before the biceps provides the

braking force as the glass is approached.

Angular velocities on current machines are classified into three

categories: slow (1° to 60° per second), intermediate (60° to 240°

per second) and fast (over 240° per second).

Force generation at these different velocities varies

substantially. In a concentric contraction, greatest force is

generated at the slowest angular velocities, and least force at the

fastest velocities. But this pattern is not repeatable for an eccentric

contraction, where force generation in the lower limb has been

shown to decrease, increase or remain constant when the velocity

is increased.

Range of Movement

The exercising range of movement can be controlled by

programming the desired start and stop angles into the

dynamometer computer. Mechanical stops positioned slightly

beyond these programmed values are also an additional safety

feature on some machines. All systems, however, do have a patient-

controlled cut-out switch which can be operated immediately

should the software control mechanism fail or the patient for some


other reason, perhaps because of pain, need to stop testing.

Repetition of program movement

The number of repetitions can easily be programmed to the

intended test requirements.

Moment/force Threshold Values

All dynamometers have torque limits, i.e. the maximum

amount of resistance that they can provide. If exceeded, an error

message and/or alarm is activated.

Factors affecting isokinetic measurement:

A number of factors will influence how this is carried out,

such as:

* Diagnosis.

* Age of patient.

* Muscle group(s) to be tested.

* System calibration.

* Acceleration.

* Gravity effect.

* Optimal biological-mechanical alignment.

* Stabilization.

* Test protocol.


Isokinetic Lower Limb Measurement Procedure:

The following steps are to be followed:

1. Assess the patient by both subjective and objective

examination.

2. Familiarise the patient with the isokinetic dynamometer.

3. Explain the test aims.

4. Ensure that the patient warms up without the dynamometer, e.g.

stretches, cycle ergometer.

5. Position and stabilise the patient accurately on the

dynamometer.

6. Test the contralateral limb first.

7. Align the joint and dynamometer axes of rotation as closely as

possible.

8. Use gravity correction if testing in a gravity-dependent

position.

9. Select the test type, e.g. concentric/eccentric for knee

extensors.

10. Select the test velocity, e.g. 30° per second.

11. Warm up on the dynamometer using the “warm up” mode.

12. Perform the maximal test at the chosen velocity, e.g. perform

three concentric/eccentric repetitions with overlay facility, with

a 30-second or 1-minute rest between repetitions.

13. Record test details to ensure replication on retest following the

same protocol of test


14. Retest at the same time of day as the original measurement is

performed.


MEASUREMENT OF RANGE OF MOTION OF SCAPULA

Scapular Upward Rotation

- Planes/axis of movement:

- Motion occurs in the frontal plane around an anterior/posterior axis.

- Range of motion:

- Normal range of motion is determined by comparing the motion of

one scapula to the other.

- The measurement is recorded in inches or centimeters between the

anatomical starting and ending positions.

- Preferred starting position:

- The subject should sit with the shoulder in anatomical position (may be in standing

or prone position)

- The upper extremity should be in a neutral position

- End position:

- The shoulder is maximally abducted or flexed to allow for full

scapular upward rotation.

- Measurement of motion:

- The distance between the inferior angle of the scapula and the

spinous process of the seventh thoracic vertebra T7 is measured.

- The subject fully abducts the shoulder and a second measurement is

taken.

- The difference between the two measurements is the amount of

scapular upward rotation present.


- Stabilization:

- Thoracic stabilization is achieved through subject compliance.

- Substitutions:

- The subject may attempt to laterally flex or extend the trunk to gain

more shoulder motion.

Scapular Downward Rotation



- Range of motion:

- Normal range of motion is determined by comparing the motion of one

scapula to the other.


anatomical starting position and ending position.



- The subject should sit with the shoulder in anatomical position (may

be in standing or prone position)

- The upper extremity should be in a neutral position

- End position:

- The subject is asked to maximally extend and adduct his/her arm

across his/her back.


- The distance between the inferior angle of the scapula and the

spinous process of T7 is measured.

- The subject fully adducts the upper limb across the posterior trunk

and a second measurement is taken.


scapular downward rotation present.

- Stabilization:


- Substitutions:

- The subject may try to retract the scapula to gain more motion.


Scapular Abduction


- Motion occurs in the frontal plane and is translatory.

- Range of motion:






- The subject should be sitting with the shoulder in 90 degrees of

abduction (may be in standing or prone position).

- The elbow should be flexed to 90 degrees; the forearm and wrist

should be in neutral positions.


- End position:

- The subject is asked to horizontally adduct his/her arm maximally

across his/her chest.


- The distance between the origin of the spine of the scapula and the

thoracic vertebrae is measured.

- The subject fully horizontally adducts the shoulder across the anterior

trunk and a second measurement is taken.


scapular abduction present.

- Stabilization:


- Substitutions:

- The examiner must be aware of the individual trying to rotate the

shoulder joint or laterally flex the trunk

to gain more motion or avoid pain during the motion.


Scapular Adduction


- Motion occurs in the frontal plane and is translatory.

- Range of motion:






- The subject should be sitting with the shoulder in 90 degrees of

abduction (may be in standing or prone position).

- The elbow should be flexed to 90 degrees; the forearm and wrist

should be in neutral positions.

- End position:

- The subject is asked to horizontally abduct his/her arm maximally

across his/her chest.


- The distance between the origin of the spine of the scapula and the

thoracic vertebrae is measured.

- The subject fully horizontally abducts the shoulder across the anterior

trunk and a second measurement is taken.



scapular abduction present.

- Stabilization:


- Substitutions:

- The examiner must be aware of the individual trying to rotate the

shoulder joint or rotate the trunk to gain more motion or avoid pain

during the motion.


GONIOMETRY OF SHOULDER JOINT

Shoulder Flexion


- Motion occurs in the sagittal plane around a transverse axis through

the head of the humerus.

- Range of motion: 0 degrees to 180 degrees.


- The subject is positioned in supine with the knees flexed to stabilize

the lumbar spine.

- The elbow is extended and the forearm is in mid position between

supination and pronation.

- End position:

- The shoulder should be in a position of maximal flexion at the end of

the movement.

- The elbow should be in extension and the forearm should be in a

neutral position.

- Goniometric alignment:

• Axis: Near the acromion process, through the humeral head

• Stationary arm: Align with the midaxillary line of the trunk

• Moving arm: Align with the lateral midline of the humerus siting the

lateral epicondyle of the humerus.


- Stabilization:

- The scapula must be stabilized against a supporting surface by the

weight of the trunk to prevent elevation, upward rotation, and

posterior tilting.

- Substitutions:

- Common substitutions in an attempt to gain more shoulder flexion

may include scapular elevation, shoulder horizontal adduction, or

lateral rotation.

- These substitutions may occur because of limitations at the

glenohumeral joint or as a result of pain during testing. The subject

may be placed in sitting.

The subject may be also in sitting position


Shoulder Extension/ Hyperextension


- Motion occurs in the sagittal plane around a transverse axis through

the head of the humerus.

- Range of motion:

- 180 degrees to 0 degrees of extension (from full flexion)

- 0 degrees to 40 to 60 degrees of hyperextension.


- The subject is placed in the prone position with the forearm in mid

position between supination and pronation.

- The head should not be supported by a pillow and the elbow should

be slightly flexed.

- End position:

- The shoulder should be in a position of maximal extension/

hyperextension at the end of the movement.

- The elbow should be in extension with the forearm in a pronated

position


• Axis: Near the acromion process, through the humeral head

• Stationary arm: Align with the midaxillary line of the trunk

• Moving arm: Align with the lateral midline of the


humerus siting the lateral epicondyle of the humerus.

- Stabilization:

- The scapula should be stabilized against a supporting surface by the

weight of the trunk to prevent anterior tilting and elevation.

- Substitutions:

- The subject may try to extend the trunk or abduct the shoulder to

complete the motion or avoid pain during testing.

- N.B:

- The subject may be placed in the supine position with the arm resting

over the side of the table or in sitting


Shoulder Abduction



Range of motion:

- 0 degrees to 180 degrees.


- The subject should be placed in the supine position.

- The shoulder should be in mid position between flexion and

extension.

- The forearm should be in mid position between supination and

pronation with the elbow in full extension.

- End position:

- The shoulder should be in a position of maximal abduction at the end

of the movement (Allow the shoulder to externally rotate during

testing).


• Axis: Close to the anterior aspect of the acromion process through

the center of the humeral head

• Stationary arm: Align parallel to the midline of the sternum along

the lateral aspect of the trunk

• Moving arm: Align along the medial midline of the humerus siting

the medial epicondyle of the humerus.


- Stabilization:

- The scapula must be stabilized against a supporting surface by the

weight of the trunk.

- Substitutions:

- The examiner should not allow the subject to elevate the scapula or

laterally flex the trunk to the contralateral side during testing in an

attempt to gain more range of motion.

- Alternate position (sitting):

• Axis: Posterior aspect of the acromion process, through the center

of the humeral head

• Stationary arm: Align parallel to

the spinous process of the vertebral

column

• Moving arm: Align on the posterior

aspect of the humeral shaft, siting

the olecranon process of the ulna.


Shoulder Adduction


- Movement occurs in the frontal plane around an anterior/posterior

axis.

- Range of motion:

- 180 degrees to 0 degrees (from full abduction).


- Subject lies supine with the shoulder in a maximally abducted and

externally rotated position.

- End position:

- The upper extremity should come to rest at the maximum range of

shoulder adduction.


• Axis: Anterior aspect of the acromion process, through the center of

the humeral head

• Stationary arm: Align along the lateral aspect of the anterior surface

of the trunk in parallel with the midline of the sternum

• Moving arm: Align with the midline of the humerus siting the

medial epicondyle of the humerus


- Stabilization:

- Stabilize the thorax against a supporting surface and encourage

subject compliance to prevent ipsilateral flexion.

- Substitutions:

- The subject may try to laterally flex the trunk toward the tested side to

gain more motion or avoid pain during testing.

Shoulder Horizontal Abduction


- Movement occurs in the transverse plane around a vertical axis.

- Range of motion:

- 0 degrees to 45 degrees from neutral

- 0 degrees to 135 degrees from a fully horizontally adducted position.


- The subject should be sitting with the shoulder in neutral rotation.


- The shoulder should be abducted to 90 degrees with the elbow in 90

degrees of flexion.

- End position:

- The shoulder should be in a position of maximal horizontal abduction

with the scapula fully adducted.


• Axis: The superior aspect of the acromion process through the head

of the humerus

• Stationary arm: Align along the midline of the shoulder siting the

base of the neck

• Moving arm: Align along the midline of the humeral shaft, siting

the lateral epicondyle of the humerus.

- Stabilization:

- The thorax must be stabilized against the back of a chair to prevent

trunk rotation.

- Substitutions:

- The subject may attempt to rotate the trunk to gain more movement.

- Elbow extension and scapular elevation


Shoulder Horizontal Adduction


- Movement occurs in the transverse plane around a vertical axis.

- Range of motion:


- 0 degrees to 135 degrees from a fully horizontally abducted position.


- The subject should be sitting with the shoulder in neutral

rotation.

- The shoulder joint is flexed to 90 degrees and the elbow is flexed to

90 degrees.

- End position:

- The shoulder should be in a position of maximal horizontal adduction

at the end of the movement.


-Axis: The superior aspect of the acromion process of the scapula,

through the head of the humerus

• Stationary arm: Align along the midline of the shoulder siting the

base of the neck.

• Moving arm: Align along the midline of the humeral shaft, siting

the lateral epicondyle of the humerus.


- Stabilization:

- The thorax must be stabilized against the back of a chair or

supporting surface to prevent rotation.

- Substitutions:

- The subject may try to rotate the trunk to obtain more motion during

testing.

Shoulder Internal (Medial) Rotation


- Movement occurs in the transverse plane around a longitudinal axis

- Range of motion:



- The subject should be in supine, with the shoulder joint positioned in

90 degrees of abduction.

- The forearm is placed in mid position between supination and

pronation and the elbow is flexed in 90 degrees.


- The humerus is placed level with the acromion process by placing a

pad under the upper arm.

- End position:

- The shoulder should be in maximal internal rotation at the end of the

movement.


• Axis: Over the olecranon process of the ulna

• Stationary arm: Align perpendicular to the floor

• Moving arm: Align with the shaft of the ulna, siting the styloid


- Stabilization:

- Make sure the distal end of the humeral shaft is stabilized against a

supporting surface and the trunk does not rise during the movement.

- Substitutions:

- The trunk or anterior shoulder may elevate to accommodate a

restricted joint capsule.

- The subject may also adduct or extend either the shoulder or elbow to

avoid internally rotating the shoulder


- N.B:

- The subject may be placed in the prone position with the shoulder in

90 degrees abduction and the elbow flexed to 90 degrees over the

edge of the table.

Shoulder External (Lateral) Rotation


- Motion occurs in the transverse plane around a longitudinal axis.

- Range of motion:



- The subject should be in supine, with the shoulder joint positioned in

90 degrees of abduction.

- The forearm is placed in mid position between supination and

pronation and the elbow is flexed in 90 degrees.

- The humerus is placed level with the acromion process by placing a

pad under the upper arm.

- End position:

- The shoulder should be in maximal external rotation at the end of the


movement.


• Axis: Over the olecranon process of the ulna


• Moving arm: Align with the shaft of the ulna, siting the styloid


- Stabilization:

Make sure the distal end of the humerus is stabilized against a

supporting surface and the trunk does not rise during movement.

- Substitutions:

- Extension the trunk or shoulder abduction out of 90 degrees.

- Elbow extension to avoid shoulder external rotation.

N.B: (Alternate position)

- The subject is in the prone position with the shoulder abducted to

90 degrees and the elbow flexed to 90 degrees over the edge of the

table


GONIOMETRY OF ELBOW JOINT

Elbow Flexion


- Motion occurs in the sagittal plane around a coronal axis.

- Range of motion:



- The subject lies supine with the upper arm close to the body.

The shoulder should be in neutral position.

- The forearm should be in supination.

- A pad should be placed at the distal end of the humerus to

allow for full motion.

- End position:

- The elbow should be in maximal flexion at the end of the movement.


• Axis: Over the lateral epicondyle of the humerus

• Stationary arm: Align along the lateral midline of the humerus, siting

the acromion process

• Moving arm: Align along the lateral midline of the radius, siting the

radial styloid


- Stabilization:

- The distal end of the humerus should be stabilized against a

supporting surface to prevent shoulder flexion.

Elbow Extension


Movement occurs in the sagittal plane around a coronal axis.

- Range of motion:



- The subject is placed in a supine position with the upper arm

alongside the trunk with.

- The forearm in full supination and with the elbow maximally flexed.

- A pad should be placed at the distal end of the humerus to allow for

full motion.

- End position:

- The elbow should be in maximal extension at the end of the

movement.



• Axis: On the lateral epicondyle of the humerus

• Stationary arm: Align along the lateral midline of the humerus, siting

the acromion process

• Moving arm: Align along the lateral midline of the radius, siting the

radial styloid

- Stabilization:

- The proximal humerus should be stabilized anteriorly by the

clinician’s hand to prevent scapular protraction and trunk extension.


GONIOMETRY OF RADIOULNAR JOINT

Type of joint: The proximal radioulnar joint may be considered alone

as a uniaxial pivot joint with one degree of freedom.

Forearm Pronation


- Motion occurs in the transverse plane around a longitudinal axis in

the anatomical position.

- Range of motion:



- The subject is sitting with the shoulder in 0 degrees of abduction,

flexion, and extension and with the elbow flexed to 90 degrees.

- The forearm should be in mid position between pronation and

supination resting on a tabletop.

- The subject grip a pencil or pen vertically in his/her hand.

- End position:

- The forearm should be in a position of maximal pronation at the end

of the movement.


• Axis: The third metacarpal head, siting through the third metacarpal

shaft


• Stationary arm: Align perpendicular to the table surface

• Moving arm: Align parallel to the midline of the pencil.

- Stabilization:

- The distal end of the humerus must be stabilized on a supporting

surface to prevent internal rotation and abduction at the shoulder

joint.

- The subject may use the non- tested hand to keep the humeral shaft

against the thorax.

- Substitutions:

- The subject may try to abduct/internally rotate the shoulder to

increase the amount of range of motion.


Forearm Supination


- Movement occurs in the transverse plane around a longitudinal axis

in the anatomical position.

- Range of motion:



- The subject is sitting with the shoulder in 0 degrees of abduction,

flexion, and extension and with the elbow flexed to 90 degrees.

- The forearm should be in mid position between pronation and

supination resting on a tabletop.

- The subject grip a pencil or pen vertically in his/her hand.

- End position:

- The forearm should be in a position of maximal supination at the end

of the movement.


• Axis: The third metacarpal head, siting through the third metacarpal

shaft

• Stationary arm: Align perpendicular to the table surface

• Moving arm: Align parallel to the midline of the pencil.


- Stabilization:

- The humerus must be stabilized on a supporting surface to prevent

external rotation of the shoulder.

- The subject may use the no tested hand to keep the humeral shaft

against the thorax.

- Substitutions:

- The subject may try to use shoulder external rotation to avoid a

painful movement.


GONIOMETRY OF WRIST JOINT

Wrist Flexion


- Motion occurs in the sagittal plane around a coronal axis primarily at

the radiocarpal joint.

- Flexion also occurs at the midcarpal joint to a lesser degree, while

the proximal row of carpal bones glide posteriorly on the distal end

of the radius.

- Range of motion:

- 0 degrees to 50 degrees (at the radiocarpal joint)

- 0 degrees to 35 degrees (at the midcarpal joint)

- 0 degrees to 90 degrees (from the anatomical position).


- The subject should be sitting with the forearm resting on a table with

the palm facing down.

- The shoulder should be abducted to 90 degrees with the elbow flexed

to 90 degrees and the fingers should be loosely in extension.

- End position:

- The wrist should be in a position of maximal flexion at the end of the

movement.


• Axis: Center over the lateral aspect of the wrist, just distal to the

styloid process of the ulna


• Stationary arm: Align with the lateral midline of the ulna, siting the

olecranon process

• Moving arm: Align with the lateral midline of the fifth metacarpal

bone

- Stabilization:

- The forearm should be stabilized on a supporting surface.

- Substitutions:

- Fingers flexion

- The examiner must watch to make sure the forearm stays down on

the table and the wrist does not drift into ulnar/radial deviation to

avoid pain or gain more flexion.


Wrist Extension


- Motion occurs in the sagittal plane around a coronal axis at both the

radiocarpal and midcarpal joint, with extension occurring more

extensively at the latter.

- Range of motion:

- 90 degrees to 0 degrees (from full flexion)

- 0 degrees to 70 degrees (hyperextension).


- The subject should be sitting with the forearm resting on a table with

the palm facing down.

- The shoulder should be abducted to 90 degrees with the elbow flexed

to 90 degrees.

- The fingers should be loosely in flexion.

- End position:

- The wrist should be in a position of maximal extension at the end of

the movement.


• Axis: Center over the lateral aspect of the wrist, just distal to the

styloid process of the ulna

• Stationary arm: Align with the lateral midline of the ulna, siting the

olecranon process


• Moving arm: Align with the lateral midline of the fifth metacarpal

bone

- Stabilization:

- The forearm should be stabilized on a supporting surface.

- Substitutions:

- Fingers extension

- The examiner should watch to make sure the forearm does not rise off

the table or the wrist does not drift into ulnar/radial deviation to avoid

a painful movement or to gain more extension.

Wrist Radial Deviation (Abduction)


- Motion occurs in the frontal/coronal plane in the anatomic position

around an anterior/posterior axis.

- Range of motion:



- The subject is sitting with the shoulder abducted to 90


degrees and the elbow flexed to 90 degrees.

- The forearm rests on a supporting surface with the palm down.

- The wrist should be neutrally positioned between radial and ulnar

deviation.

- End position:

- The wrist should be in a position of maximal radial deviation at the

end of the movement.


• Axis: Align over the middle of the dorsal surface of the wrist, over

the capitate

• Stationary arm: Align with the dorsal midline of the forearm, siting

the lateral epicondyle of the humerus

• Moving arm: Align with the midline of the dorsal surface of the

third metacarpal

- Stabilization:

- The distal ends of the radius and ulna must be stabilized against a

supporting surface.

- Substitutions:

- The subject may try to flex or extend the wrist or move the forearm

into supination to avoid pain or gain more radial deviation.


Wrist Ulnar Deviation (Adduction)


- Motion occurs in the frontal/coronal plane in the anatomic position


- Range of motion:



- The subject is sitting with the shoulder abducted to 90 degrees and

the elbow flexed to 90 degrees.

- The forearm rests on a supporting surface with the palm down.

- The wrist should be neutrally positioned between radial and ulnar

deviation.

- End position:

- The wrist should be in a position of maximal ulnar


deviation at the end of the movement.


• Axis: Align over the middle of the dorsal surface of the wrist, over

the capitate

• Stationary arm: Align with the dorsal midline of the forearm, siting

the lateral epicondyle of the humerus

• Moving arm: Align with the midline of the dorsal surface of the

third metacarpal

- Stabilization:

- The distal ends of the radius and ulna must be stabilized against a

supporting surface.

- Substitutions:

- The subject may try to flex or extend the wrist or move the forearm

into pronation to avoid pain or gain more radial deviation.


MANUAL MUSCLE TEST OF SCAPULA (MMT)

SCAPULAR ABDUCTION AND UPWARD ROTATION

- Prime Movers: - Serratus anterior

- Palpation site: Along the midaxillary line adjacent to the inferior angle

of the scapula.

- Secondary Movers: - Pectoralis minor

- Anti-Gravity:

- Subject position:

- Supine with the shoulder flexed to 90 degrees and elbow in extension.

- Stabilization:

- Weight of the trunk against the table.

- Grades 5/5 to +3/5

- Resistance is given in a downward/inward direction by grasping the

forearm and elbow.

- Subject directive: “Punch up toward the ceiling and resist as I push

down.”


- Grades 3/5 to + 2/5:

- The subject moves the arm upward from a resting position on the table

without resistance.

- Gravity minimized

- Subject position:

- Sitting with the upper arm resting on a table in 90 degrees of shoulder

flexion and with the elbow extended.

- Stabilization:

- Clinician stabilizes the thorax to prevent rotation or forward

movement.

- Grades 2/5 to −2/5

- The subject moves the arm

forward 2 to 3 inches by abducting the

scapula through the maximal range of motion.


-Grades 1/5 to 0/5

- The serratus anterior is palpated along the mid axillary line adjacent to

the inferior angle of the scapula as the subject attempts to abduct the

scapula against light resistance.

SCAPULAR ELEVATION

- Prime Movers: 1- Upper fibers of trapezius

- Palpation site: Parallel to cervical spine C7 and near the insertion

above the clavicle

1- Levator scapula

- Palpation site: Deep to the upper trapezius in the angle formed by the

upper trapezius and sternocleidomastoid muscles.

- Secondary Movers: - Pectoralis major and minor

- Anti-Gravity:

- Subject position:

- Sitting in a chair or on a table with the arms hanging by the sides.


- Stabilization:

- Achieved through subject compliance.

-Grades 5/5 to +3/5

- Resistance is applied symmetrically in a downward direction on top of

the shoulders.

- Subject directive: “Raise your shoulders as high as possible toward

the ceiling and hold while I try to push them down.”

- Grades 3/5 to + 2/5:

- The subject elevates the shoulders through the maximal range of

motion without resistance.


- Gravity minimized

- Subject position:

- Supine or prone on a table with the arms by the sides.

- Stabilization:

- Weight of the trunk on the table.


- As the clinician supports the shoulders, the subject elevates the

shoulders toward the ears

- Grades 1/5 to 0/5

- The upper trapezius is palpated parallel to cervical spine C7 and near

the insertion above the clavicle


SCAPULAR ADDUCTION

- Prime Movers: 1- Middle fibers of trapezius

- Palpation site: Medial border of the scapula near the root of the spine.

1- Pectoralis major and minor

- Palpation site: With the subject’s hand behind his or her lumbar spine,

palpate under and along the medial border of the scapula.

- Secondary Movers: - Upper and lower trapezius

- Anti-Gravity:

- Subject position:

- Prone on a table with the shoulder in 90 degrees of abduction and with

the elbow flexed to 90 degrees.

- The forearm hanging freely over the edge of a table.

- Stabilization:


- The clinician stabilizes the contralateral thorax.


- Resistance is applied just proximal to the elbow toward the floor as

the subject horizontally abducts the shoulder and adducts the scapula.

- Subject directive:

- “Squeeze your shoulder blades together and push your arm up into my

hand and hold it. Do not let me push your arm down.”


- Grades 3/5 to + 2/5:

- The subject raises his arm toward the ceiling while adducting the

scapula through the available range of motion without resistance.

- Gravity minimized

- Subject position:

- Sitting with the arm resting on a table with the shoulder abducted to

90 degrees and the elbow flexed to 90 degrees.

- Stabilization:



- The subject horizontally abducts the shoulder and adducts the scapula

through the

available range of motion.


- Grades 1/5 to 0/5

- The middle trapezius is palpated along the medial border of the

scapula between thoracic vertebrae T1 to T5 and near the root of the

spine of the scapula as the subject attempts to horizontally

abduct the shoulder.


SCAPULAR DEPRESSION/ADDUCTION

- Prime Movers: - Lower fibers of trapezius

- Palpation site: Between 12th thoracic vertebrae and medial

border of scapula

- Secondary Movers: - Pectoralis major and minor, middle fibers of

trapezius and latissimus dorsi

- Anti-Gravity:

- Subject position:

- Prone with the head rotated to the same side and tested

shoulder in approximately 130 degrees of abduction and with the

elbow in extension.

- Stabilization:



- Resistance is applied just proximal to the elbow joint directed down

toward the floor.

- Subject directive: “Raise your arm up off the table as far as you can

and hold it. Do not let me push it down.”


- Grades 3/5 to + 2/5:

- The subject lifts the limb off the table without resistance. -

-

Gravity minimized

- Subject position:

- Prone with the head rotated to the same side as the tested shoulder in

approximately 130 degrees of abduction.

- Stabilization:


- Grades 2/5

- The subject is able to achieve full scapular movement with the tested

limb supported.


- Grades 1/5 to 0/5

- The lower trapezius is palpated medial to the root of the spine and

medial border of the scapula (between 12th thoracic vertebrae and

medial border of scapula) as the subject attempts to lift the arm off the

table.

SCAPULAR ADDUCTION/DOWNWARD ROTATION

- Prime Movers: - Rhomboid major and minor

- Palpation site: With the subject’s hand behind his or her lumbar spine,

palpate under and along the medial border of the scapula.

- Secondary Movers: - Middle trapezius and levator scapula

- Anti-Gravity:

- Subject position:

Prone with the tested upper extremity behind the back with the hand

resting on the lumbar spine. The head is rotated to the opposite side.

- Stabilization:

- The clinician stabilizes the thorax on the opposite side.



- As the subject lifts his hand off the back, resistance is applied above

the elbow in a down and out direction, pushing the scapula into

abduction and upward rotation.

Subject directive: “Lift your hand up toward the ceiling and do not let

me push your arm down.”

- Grades 3/5

- The subject lifts his hand off the back as the scapula is adducted

through the maximal range of motion.


- Gravity minimized

- Subject position:

- Sitting with the tested arm internally rotated and adducted behind the

lumbar spine.

- Stabilization:

- The clinician stabilizes the anterior/posterior trunk, if necessary, to

prevent flexion or rotation.


- The subject attempts to

adduct the scapula through the range of

motion.

- Grades 1/5 to 0/5

- With the subject’s hand behind his or her lumbar spine the rhomboids

may be palpated at the angle between the medial border of the scapula

and lateral fibers of lower trapezius


MANUAL MUSCLE TEST OF SHOULDER (MMT)

SHOULDER FLEXION

- R.O.M: - 0 – 180 degrees

- Prime Movers: 1- Anterior deltoid

- Palpation site: Inferior to the lateral third of the clavicle.

- 2- Coracobrachialis

- Palpation site: In the axilla, under the inferior border of the pectoralis

major muscle.

- Secondary Movers: - Middle deltoid, Pectoralis major and Biceps

brachii

- Anti-Gravity:

- Subject position:

- Sitting with the shoulder flexed to 90 degrees, palm facing down.

- Stabilization:

- The clinician stabilizes the opposite scapula.


- Resistance is applied in a downward direction just proximal to the

elbow joint.

- Subject directive: “Hold your arm up and do not let me push it

down.”


- Grades 3/5:

- The subject flexes the shoulder to at least 90 degrees without resistance.

- Gravity minimized

- Subject position:

- Side lying with the upper extremity supported on a smooth surface

and in neutral rotation with the elbow in flexion.

- Stabilization:

- The opposite shoulder is stabilized by the weight of the body

against the table.



- The subject flexes the shoulder through the maximal range of motion.

- Grades 1/5 to 0/5

- The anterior deltoid is palpated inferiorly to the lateral third of the

clavicle. The coracobrachialis is palpated in the axilla along the

inferior border of the pectoralis major muscle. (Shown: Palpating the

anterior deltoid.)

SHOULDER EXTENSION

- R.O.M: - 180 to 0 degrees - 0 to 40/60 degrees (from

neutral)

- Prime Movers: 1- Latissimus dorsi

- Palpation site: Along the midaxillary line on the trunk.


- 2- Posterior deltoid

- Palpation site: Inferior and lateral to the spine of the scapula.

- 3- Teres major:

- Palpation site: Lateral to the inferior angle of the scapula.

- Secondary Movers: - Long head of the triceps brachii

- Anti-Gravity:

- Subject position:

- The subject should be prone with the arms at the sides and with the

palm facing up toward the ceiling.

- Stabilization:

- The weight of the thorax against the table.


- Resistance is applied at the elbow in a downward direction toward

the floor

- Subject directive: “Lift your arm as high as youcan toward the

ceiling and hold it. Do not let me push it down.”


- Grades 3/5:

- The subject lifts the arm up toward the ceiling through the maximal

range of motion without resistance.

- Gravity minimized

- Subject position:

- Side lying with the upper extremity supported on a smooth surface

and in neutral rotation with the elbow in flexion.

- Stabilization:

- The opposite shoulder is stabilized by the weight of the body against

the table.


- The subject extends the shoulder through the maximal range of

motion.


-Grades 1/5 to 0/5

The latissimus dorsi is palpated (along the midaxillary line on the

trunk) inferiorly and lateral to the inferior angle of the scapula on the

side of the thoracic wall as the subject attempts to extend the shoulder.

The teres major palpated lateral to the inferior angle of the scapula and

the posterior deltoid palpated inferior and lateral to the spine of the

scapula. (Shown: palpating the latissimus dorsi).

SHOULDER ABDUCTION

- R.O.M: - 0 – 180 degrees

- Prime Movers: - Middle deltoid

- Palpation site: Lateral/inferior to the acromion process.

- Secondary Movers: - Suprspinatous

- Anti-Gravity:

- Subject position:

- Sitting with the shoulder abducted to 90 degrees, palm down.


- Stabilization:

- The clinician stabilizes the opposite shoulder.


- Resistance is applied just proximal to the elbow in a downward

direction toward the floor.

- Subject directive: “Hold your arm up and do not let me push it

down.”

- Grades 3/5:

- The subject abducts the shoulder to at least 90 degrees without resistance.


Gravity minimized

-Subject Position

- Supine with the tested limb supported on a table.

- Stabilization:



- The subject abducts the shoulder through the maximal range of

motion.

- Grades 1/5 to 0/5

- The middle deltoid is palpated lateral to the acromion process on the

superior aspect of the shoulder as the subject attempts to abduct the

shoulde


SHOULDER HORIZONTAL ABDUCTION

- R.O.M:


- 0 degrees to 135 degrees from a fully horizontally adducted position.

- Prime Movers: - Posterior deltoid

- Palpation site: Inferior and lateral to the spine of the scapula.

- Secondary Movers: - Long head of triceps brachii

- Anti-Gravity:

- Subject position:

- Prone with the shoulder in 90 degrees of abduction and with the

forearm off the edge of the table with the elbow in flexion

- Stabilization:



- Resistance is applied just proximal to the elbow toward the floor.

- Subject directive: “Lift your elbow up

toward the ceiling and hold it. Do not let

me push it down.”

-


- Grades 3/5 to +2/5:

- The subject horizontally abducts the shoulder through the range of

motion without

resistance.

- Gravity minimized

- Subject position:

- Sitting with the arm supported on a table in 90 degrees of shoulder

abduction and with the elbow in flexion.

- Stabilization:

- The clinician stabilizes the scapula on the tested side.


- The subject horizontally abducts the shoulder through the range of

motion


- Grades 1/5 to 0/5

- The posterior deltoid is palpated just below and lateral to the spine of the

scapula as the subject attempts to horizontally abduct the shoulder.

SHOULDER HORIZONTAL ADDUCTION

- R.O.M:


- 0 degrees to 135 degrees from a fully horizontally abducted position.

- Prime Movers: - Pectoralis major

- Palpation site: Inferior to medial end of clavicle or anterior axillary

fold.

- Secondary Movers: - Anterior deltoid, Coracobrachialis and Biceps

brachii

- Anti-Gravity:

- Subject position:

- Supine with the shoulder in 90 degrees abduction and neutral

rotation, elbow flexed to 90 degrees.


- Stabilization:

- Weight of the trunk against the table.


- Resistance is applied to the anterior medial aspect of the arm just

proximal to the elbow.

- Subject directive: “Move your arm across your chest and do not

let me pull it back.”

- Grades 3/5 to +2/5:

- The subject horizontally adducts the shoulder through the maximal


-

Gravity minimized

- Subject position:


- Sitting with the shoulder supported on a table, abducted to 90

degrees, and in neutral rotation with the elbow flexed to 90 degrees.

- Stabilization:

- The clinician stabilizes the contralateral shoulder.


- The subject horizontally adducts the shoulder through the range of

motion.

- Grades 1/5 to 0/5

- (A) The clavicular portion of the pectoralis major is palpated inferior

to the medial end of the clavicle. (B) The sternal portion is palpated

near the anterior axillary fold as the subject attempts to horizon-

tally adduct and extend the shoulder.


SHOULDER INTERNAL ROTATION

- R.O.M:

- 0 degrees to 90 degrees

- Prime Movers: - Subscapularis

- Palpation site: Deep in the axilla.

- Secondary Movers: - Pectoralis major, Teres major and Latissimus

dorsi

- Anti-Gravity:

- Subject position:

- Prone with the shoulder abducted to 90 degrees and the elbow flexed

90 over the edge of the table. The head should be rotated to the tested

side.

- Stabilization:

- The clinician stabilizes the humerus and thorax.


- Resistance is applied to the flexor surface of the forearm just

proximal to the wrist.

- Subject directive: “Move your arm and hand up toward the

ceiling and hold it. Do not let me push it down.”


- Grades 3/5 to +2/5:

- The subject internally rotates the shoulder through the maximal range

of motion without resistance.

- Gravity minimized

- Subject position:

- Prone with the tested arm hanging freely over the edge of the table

with the palm facing the table (externally rotated). The head should

be rotated to the tested side.

- Stabilization:

- The weight of the trunk on the table.


The subject internally rotates the shoulder so that the palm faces

away from the table.


-Grades 1/5 to 0/5

- The subscapularis is palpated deep in the axilla

SHOULDER EXTERNAL ROTATION

- R.O.M:

- 0 degrees to 90 degrees

- Prime Movers: 1- Infraspinatous

- Palpation site: Inferior to the spine of the scapula (body of scapula)

- 2- Teres minor

- Palpation site: Lateral border of the scapula superior to the inferior

angle of the scapula.


- Secondary Movers: - Posterior deltoid

- Anti-Gravity:

- Subject position:

Prone with the shoulder abducted to 90 degrees and the elbow

flexed 90 over the edge of the table. The head should be rotated to the

tested side.

- Stabilization:

- The clinician stabilizes the humerus and thorax.


- Resistance is applied to the extensor surface of the forearm just

proximal to the wrist.

- Subject directive: “Move your arm and the back of your hand up

toward the ceiling and hold it. Do not let me push it down.”

- Grades 3/5 to +2/5:

- The subject externally rotates the shoulder through the maximal range

of motion without resistance.


- Gravity minimized

- Subject position:

- Prone with the tested arm hanging freely over the edge of the table

with the palm facing the table (internally rotated). The head should be

rotated to the tested side.

- Stabilization:

- The weight of the trunk on the table.


- The subject externally rotates the shoulder so that the palm faces

away from the table.


- Grades 1/5 to 0/5

- The infraspinatus is palpated inferiorly to the spine of the scapula and

the teres minor is palpated along the lateral border of the scapula

superior to the inferior angle of the scapula as the subject attempts to

externally rotate the shoulder. (Shown: Palpating the teres minor.)


MANUAL MUSCLE TEST OF ELBOW (MMT)

ELBOW FLEXION

- R.O.M:

0 degrees to 90 degrees

Prime Movers: 1- Biceps brachii

Palpation site: With the forearm supinated, the belly of the muscle is

palpated anteriorly or in the cubital fossa

2- Brachialis

Palpation site: With the forearm pronated, palpate just proximal to the

cubital fossa

3- Brachioradialis

Palpation site: With the forearm midway between pronation and

supination, palpate just lateral to the biceps tendon

Secondary Movers: - Pronator teres, Flexor carpi radialis and Flexor

carpi ulnaris

- Anti-Gravity:

Subject position:

Sitting, with the elbow flexed to 90 degrees and the forearm supinated

(biceps brachii), pronated (brachialis), or in neutral (brachioradialis),

depending on which muscle is being tested. General elbow flexion is

tested with the forearm in supination.


Stabilization:

The clinician stabilizes the upper arm against the trunk.


Resistance is applied on the anterior forearm just proximal to the

wrist.

Subject directive: “Bend your elbow up. Do not let me pull your arm

down.”

- Grades 3/5 to +2/5:

The subject flexes the elbow through the maximal available range of



- Gravity minimized

Subject position:

Sitting, with the upper extremity resting on a smooth surface. The

shoulder should be in 90 degrees of abduction with the elbow in

maximal extension and the forearm in neutral rotation.

Stabilization:

The clinician stabilizes the upper arm against the testing surface.


The subject flexes the elbow through the maximal available range of

motion.

-Grades 1/5 to 0/5

- The elbow flexors are palpated on the anterior aspect of the arm

just proximal to the joint as the subject attempts to flex the elbow.


ELBOW EXTENSION

R.O.M:


Prime Movers: 1- Triceps brachii

Palpation site: On the posterior aspect of the arm just proximal to the

olecranon

2- Anconeus

Palpation site: Between the lateral epicondyle and olecranon process of

the ulna.

Secondary Movers: -Extensor carpi ulnaris, Extensor carpi radialis

longus and brevis

- Anti-Gravity:

Subject position:

Supine on a table with the shoulder flexed to 90 degrees and the elbow in

maximal flexion.

Stabilization:

The clinician stabilizes the upper arm.


The subject extends the elbow as resistance is applied just proximal to

the wrist on the proximal forearm.

Subject directive: “Push your arm up toward the ceiling and hold it.


Do not let me push it down.”

- Grades 3/5 to +2/5:

The subject extends the elbow through the maximal available range of



- Gravity minimized

Subject position:

Sitting with the upper extremity resting on a smooth surface. The

shoulder should be in 90 degrees of abduction and internally rotated

with the elbow in maximal flexion and forearm in neutral or pronated.

Stabilization:

The clinician stabilizes the upper arm.


The subject extends the elbow through maximal range of motion

without resistance.

-Grades 1/5 to 0/5

The elbow extensors are palpated on the posterior aspect of the arm just

proximal to the olecranon.


MANUAL MUSCLE TEST OF FOREARM (MMT)

FOREARM SUPINATION

R.O.M:


Prime Movers: 1- Supinator

Palpation site: Distal & medial to lateral epicondyle

2- Biceps brachii

Palpation site: With the forearm supinated, the belly of the muscle is

palpated anteriorly or in the cubital fossa

Secondary Movers: -Brachioradialis

- Anti-Gravity:

Subject position:

Sitting with the arm at the subject’s side, elbow flexed to 90 degrees, and

the forearm in pronation. The fingers should be relaxed.

Stabilization:



Resistance is applied to the wrist just proximal to the joint line into

pronation.


Subject directive: “Turn your palm up and hold it. Do not let me push

it down.”

-Grades 3/5 to +2/5:

The subject supinates the forearm through the available range of


- Gravity minimized

Subject position:


Sitting with the shoulder in approximately 45 degrees of flexion, the

elbow flexed, and the forearm in neutral. The clinician supports the arm

at the elbow.

Stabilization:



The subject supinates the forearm throughout the maximal range of

motion.

- Grades 1/5 to 0/5

The supinator is just palpated distal & medial to lateral epicondyle.


FOREARM PRONATION

R.O.M:


Prime Movers: 1- Pronator teres

Palpation site: Medial & inferior to cubital fossa

2- Pronator quadratus

Palpation site: Not palpable.

Secondary Movers: - Flexor carpi radialis

- Anti-Gravity:

Subject position:

Sitting with the arm at the subject’s side, elbow flexed to 90 degrees, and

the forearm in supination. The fingers should remain relaxed.

Stabilization:



Resistance is applied to the wrist just proximal to the joint line into

supination.

Subject directive: “Turn your palm down and hold it. Do not

let me push it up.”


- Grades 3/5 to +2/5:

The subject pronates the forearm through the available range of motion

without resistance.

-Gravity minimized

Subject position:

Sitting with the shoulder in approximately 45 degrees of flexion, the

elbow flexed, and forearm in neutral. The clinician supports the arm at

the elbow.

Stabilization:



-Grades 2/5 to −2/5

The subject pronates the forearm throughout the maximal range of

motion.

-Grades 1/5 to 0/5

The supinator is just palpated medial & inferior to cubital fossa.


MANUAL MUSCLE TEST OF WRIST (MMT)

WRIST FLEXION

R.O.M:


Prime Movers: 1- Flexor carpi radialis

Palpation site: Lateral to the midline of the wrist as the as the subject

attempts to flex and radially deviate the wrist

2- Flexor carpi ulnaris

Palpation site: Immediately proximal to the pisiform as the subject

attempts to flex and ulnary deviate the wrist

Secondary Movers: -Palmaris longus

-Anti-Gravity:

Subject position:

Sitting or supine with the forearm supinated and the dorsal surface

resting on a tabletop. The wrist should be in neutral with the fingers

relaxed.

Stabilization:

The clinician stabilizes the forearm against the tabletop.


N.B:

The flexor carpi radialis and flexor carpi ulnaris may be tested

separately by resisting wrist flexion with radial deviation and ulnar

deviation, respectively.

-Grades 5/5 to +3/5

Resistance is applied to the palm of the hand into wrist extension.

Subject directive: “Move your hand up and hold it. Do not let me push

it down.”


The subject flexes the wrist straight up without deviation through the

maximal available range of motion without resistance.


-Gravity minimized

Subject position:

Sitting or supine with the forearm in neutral and the ulnar border of the

hand resting on a tabletop with the wrist in neutral. The fingers should

be relaxed.

Stabilization:



The subject flexes the wrist through the maximal range of motion.

-Grades 1/5 to 0/5

The flexor carpi radialis is palpated slightly lateral to the midline of the

wrist as the subject attempts to flex and radially deviate the wrist.

The flexor carpi ulnaris is palpated immediately proximal to the pisiform

as the subject attempts to flex and ulnarly deviate the wrist. (Shown:

Palpating the flexor carpi radialis.)


WRIST EXTENSION

R.O.M:

0 degrees to 90 degrees (from anatomical position)

0 – 70 digress (hyperextension)

Prime Movers: 1- Extensor carpi radialis longus

Palpation site: Proximal to the second metacarpal.

2- Extensor carpi radialis brevis

Palpation site: Over the capitate bone

3- Extensor carpi ulnaris

Palpation site: Distal to the styloid process of the ulna and proximal to

the fifth metacarpal.

Secondary Movers: - Extensor digitorum, Extensor digiti minimi and

Extensor indicis

-Anti-Gravity:


Subject position:

Sitting with the forearm pronated and supported on a tabletop. The

wrist should be in neutral and the fingers should be relaxed.

Stabilization:


N.B:

The extensor carpi radialis longus, extensor carpi radialis brevis, and

extensor carpi ulnaris may be tested separately by resisting wrist

extension with radial deviation and ulnar deviation, respectively.

-Grades 5/5 to +3/5

Resistance is applied to the dorsum of the hand into wrist flexion

Subject directive: Move the back of your hand up toward the ceiling

and hold it. Do not let me push it down.”


The subject extends the wrist straight up without deviation through the

maximal available range of motion without resistance.


-Gravity minimized

Subject position:

Sitting or supine with the forearm in neutral and the ulnar border of the

hand resting on a tabletop with the wrist in neutral. The fingers should

be relaxed.

Stabilization:



The subject extends the wrist through the maximal available range of

motion.


-Grades 1/5 to 0/5

The extensor carpi radialis longus is palpated on the dorsum of the wrist in

line with the second metacarpal, the extensor carpi radialis brevis is

palpated on the dorsum of the wrist over the capitate bone as the subject

attempts to extend and radially deviate the wrist

The extensor carpi ulnaris is palpated on the dorsum of the wrist proximal

to the fifth metacarpal just distal to the ulnar styloid process as the subject

attempts to extend and ulnarly deviate the wrist. (Shown: Palpating the

extensor carpi radialis longus.)


FINGERS II TO V

Note: Because gravity is not a significant factor during testing

of the fingers/thumb, the format used for grading muscle

strength deviates from the

standard grading system applied to other muscle groups; half

grades are not

assigned.

Metacarpophalangeal Flexion


• 0 to 90 degrees

Prime Movers

• Lumbricales

□ Palpation site: Not palpable.

Secondary Movers

• Dorsal/palmar interossei



• Flexor digiti minimi

Opponens digiti minimi

• GRADES 5/5 (NORMAL), 4/5 (GOOD), AND 3/5 (FAIR)



supination and the wrist in neutral. The metacarpophalangeal

(MCP) joints should be extended with the PIP and DIP joints

flexed.

Stabilization: The clinician stabilizes the metacarpal bones

against the tabletop.

• Grades 5/5 to 4/5: See Figure 87-3.

Figure 87-3. Resistance is applied to the palmar surface of the

proximal row of the phalanges into metacarpophalangeal

extension.

SUBJECT DIRECTIVE: “Straighten out your fingers as you

bend your hand at the knuckles and hold it. Do not let me push

your fingers down.”

• Grade 3/5: See Figure 88-3.


Figure 88-3 The subject flexes the metacarpophalangeal

joints while simultaneously extending the proximal and

distal interphalangeal joints

Grades 2/5 (poor), 1/5 (Trace), and 0/5 (Zero)


in neutral with the hand resting on the ulnar border. The MCP

joints should be maximally extended with the PIP and DIP joints

in flexion.

Stabilization: The clinician stabilizes the wrist and hand



Figure 89-3. The subject attempts to flex the meta-

carpophalangeal joints while simultaneously extending the

proximal interphalangeal and distal interphalangeal joints.

*The lumbricales are too deep to palpate. A grade of 1/5 or trace

is given if any movement is observed and 0/5 is assigned in the

absence of movement.

Substitutions: The long finger flexors may cause the PIP and

DIP joints to flex as the subject attempts to flex the MCP

joints.


PIP Flexion


• 0 to 120 degrees

Prime Movers


Palpation site: The tendons are palpated where they cross the

palmar surface of each proximal phalanx.


Subject position: Sitting or supine with the hand resting on

the dorsal side with the wrist in neutral. The tested digit should

be slightly flexed at the MCP joint.

Stabilization: All joints of the non-tested fingers are held in

extension.



middle phalanx of the tested digit into extension.


SUBJECT DIRECTIVE: “Bend your finger and hold it. Do not

let me straighten it out. Keep all your fingers relaxed.”


Figure 91-3. The subject flexes the proximal interphalangeal

of the tested digit through the maximal available range of






non-tested digits in extension.



Figure 92-3. The subject flexes the proximal interphalangeal

joint of the tested digit through the available range of motion


Figure 93-3. The flexor digitorum superficialis is palpated on

the palmar aspect of the wrist between the palmaris longus and

flexor carpi ulnaris.


Substitutions: The flexor digitorum profundus may cause

flexion of the DIP joints as the subject attempts to flex the PIP

joint.

DIP Flexion


• 0 to 80 degrees

Prime Movers

• Flexor digitorump rofundus

□ Palpation site: The tendons are palpated where they cross

the palmar surface of each middle phalanx of digits II to

V.


Subject position: Sitting or supine with the hand resting on

the dorsal surface with the wrist in neutral. The proximal PIP

should be in extension.

Stabilization: The clinician stabilizes the middle phalanx and

PIP joint of the tested digit.




distal phalanx into extension

SUBJECT DIRECTIVE: “Bend the tip of your finger and hold

it. Do not let me straighten it out.”

Figure 95-3. The subject flexes the distal interphalangeal of

the tested digit through the maximal available range of motion

without resistance






middle phalanx of the tested digit in extension.


Figure 96-3. The subject flexes the distal interphalangeal

joint of the tested digit through the maximal available range of

motion



Figure 97-3. The flexor digitorum profundus tendons can be

palpated on the palmar surfaces of the middle phalanx of digits

II to V.

Substitutions: The wrist must be kept in a neutral position to

prevent

tenodesis from occurring from wrist extension.


MCP Extension


• 90 to 0 degrees (extension from maximal flexion)

• 0 to 30 degrees (hyperextension)

Prime Movers


□ Palpation site: Over the dorsal aspect of the hand as the

tendons pass down each finger.


□ Palpation site: Over the dorsal/ulnar aspect of the second

metacarpal, close to the hand.


□ Palpation site: Over the dorsal aspect of the fifth

metacarpal, close to the head of the ulna.



pronation and the

wrist in neutral with the palmar aspect of the hand resting on a

tabletop and

the MCP joints flexed to 90 degrees off the edge of the table.

Stabilization: The clinician stabilizes the hand and wrist.



Figure 98-3. Resistance is applied to the distal end of the

proximal phalanx (dorsally) as the subject extends the MCP

joints with the PIP joints in flexion.

*To test the extensor indicis and extensor digit iminimi, the

subject extends the MCP joint of the second digit and fifth

digit, respectively.

SUBJECT DIRECTIVE: “Bend your knuckles up and hold it.

Do not let me push them down.” *The clinician may have to

demonstrate the motion first.



Figure 99-3. The subject extends the tested

metacarpophalangeal joints through the maximal range of

motion without resistance




in neutral with the hand resting on the ulnar border on a

tabletop.

• Grade 2/5: See Figure 100-

Figure 100-3. The subject extends the metacarpophalangeal

joint of the tested digits through the maximal range of motion.



Figure 101-3. The tendons of the extensor digitorum, extensor

indicis, and extensor digiti minimi are readily palpable on the


dorsal surface of the hand as the subject attempts to extend the

corresponding metacarpophalangeal joints.

(Shown: palpating the tendons of the extensor digitorum.)

Substitution: Flexion of the wrist may cause interphalangeal

(IP) extension via tenodesis. Substitution by the lumbricals

may also cause extension of the IP joints.


Finger Abduction


• 0 to 20 degrees

Prime Movers

• Dorsal interossei

□ Palpation site: First dorsal interossei-radial side of the

second metacarpal; second dorsal interossei-radial side of

the proximal phalanx of the third digit; third dorsal

interossei-ulnar side of the proximal phalanx of the third

digit; fourth dorsal interossei-ulnar side of the proximal

phalanx of the fourth digit.

• Abductor digiti minimi

Palpation site: Along the ulnar border of the fifth metacarpal

Secondary Movers





wrist in neutral, and the palmar aspect of the hand resting on

the tabletop. The fingers should be in extension.


fingers.



Figure 102-3. Resistance is applied to the radial side of one

finger and ulnar side of the adjacent finger on the distal end of

the proximal phalanx into finger adduction

SUBJECT DIRECTIVE: “Spread your fingers apart and hold

it. Do not let me push them together.” • Grade 3/5: See Figure

103-3.


Figure 103-3. The subject abducts the tested fingers through

the maximal range of motion without resistance


*Because the third digit has 2 dorsal interossei, it is

important that it is tested as it moves away from the midline

in both directions (ulnarly and radially).



wrist in neutral, and the palmar aspect of the hand resting on

the table. The fingers should be in extension.

Stabilization: The clinician stabilizes the hand (and non-tested

fingers when testing fingers individually.)



Figure 104-3. The subject is able to abduct the tested fingers

through partial range of motion


Figure 105-3. The dorsal interossei are palpated for the

corresponding digit as the subject attempts to abduct the

finger. (A) Palpating the first dorsal interossei and (B)

palpating the abductor digiti minimi.

*The most readily palpable dorsal interossei muscle is the

first, which is located at the base of the proximal phalanx.

The abductor digit iminimi is palpated on the ulnar border of

the hand as the subject abducts the fifth digit.

Substitutions: The subject may try to extend the MCP joints

as he or she attempts to abduct the fingers.

Finger Adduction


• 0 to 20 degrees


Prime Movers

• Palmar interossei

□ Palpation site: First palmar interossei-ulnar side of the

proximal phalanx of the second digit; second palmar

interossei-radial side of the proximal phalanx of the fourth

digit; third palmar interossei-radial side of the proximal

phalanx of the fifth digit.

Secondary Movers







fingers.



Figure 106-3. Resistance is applied to the middle phalanx of

each of the 2 adjoining fingers, “pulling” them into abduction

SUBJECT DIRECTIVE: “Keep your fingers together and do

not let me pull them apart.”*The third digit has no palmar

interosseus and is not tested in adduction.



Figure 107-3. The subject is able to adduct the fingers toward

the middle finger but is unable to hold them against resistance




tabletop. The fingers should be in extension and abducted.



Figure 108-3. The subject is able to adduct the tested finger

through partial range of motion.



Figure 109-3. The palmar interossei are difficult to palpate,

but the clinician might be able to detect a slight contraction by

placing a finger against the side of the finger to be tested.

Substitutions: The subject might flex the fingers while

attempting to move them into adduction


THUMB

MCP Flexion


• 0 to 50 degrees (MCP flexion)

Prime Movers


□ Palpation site: The ulnar side of the first metacarpal.





position.


Figure 110-3. Resistance is applied to the proximal phalanx

into extension


SUBJECT DIRECTIVE: “Bend the base of your thumb and hold

it. Do not let me straighten it out.” *For a grade of 3/5, the

subject flexes the MCP through the maximal range of motion

with slight resistance.

Grade 2/5: See Figure 111-3.

Figure 111-3.The subject flexes both the metacarpophalangeal

joint of the thumb through maximal range of motion without

resistance.



Figure 112-3.The flexor pollicis brevis is palpated on the ulnar

side of the first metacarpal as the subject attempts to flex the

metacarpophalangeal joint

Substitutions: The flexor pollicis longus may be activated to

flex the MCP joint. The DIP of the thumb should remain in

extension during testing of MCP flexion to avoid this

substitution.


Figure 113-3.Resistance is applied to the distal phalanx into

IP Flexion


• 0 to 90 degrees

Prime Movers

• Flexor pollicis longus

□ Palpation site: Palpate where the tendon crosses the palmar

surface of the proximal phalanx of the thumb.





position.

Stabilization: The clinician stabilizes the proximal phalanx

extension.


SUBJECT DIRECTIVE: “Bend the tip of your thumb and

hold it. Do not let me straighten it out.”*For a grade of 3/5, the

subject flexes the IP joint through the maximal range of

motion with slight resistance.


• 50 to 0 degrees (MCP extension)

Grade 2/5: See Figure 114-3.

Figure 114-3.The subject flexes the interphalangeal joint

through the maximal range of motion without resistance.



Figure 115-3.The tendon of the flexor pollicis longus is

palpated where it crosses the palmar surface of the proximal

phalanx of the thumb as the subject attempts to flex the

interphalangeal joint.

MCP Extension

Prime Movers

• Extensor pollicisbrevis

□ Palpation site: Palpate the tendon of the extensor

pollicisbrevis as it crosses the lateral aspect of the base of

the first MCP.




in neutral and the hand resting on the ulnar border on a

tabletop.


Grades 5/5 to 4/5: See Figure 116-3

Figure 116-3. Resistance is applied to the dorsal surface of the

proximal phalanx.

SUBJECT DIRECTIVE: “Straighten your thumb out and hold

it. Do not let me push it down.”

*For a grade of 3/5, the subject extends the MCP joint

through the maximal range of motion with slight resistance.







Figure 117-3.The subject extends the metacarpophalangeal

joint of the thumb through maximal range of motion without

resistance.



Figure 118-3.The extensor pollicis brevis is palpated at the

base of the first metacarpal between the tendons of the

abductor pollicis and extensor pollicis longus as the subject

attempts to extend the first metacarpophalangeal joint.

(Shown: Palpating the extensor pollicis brevis.)

Substitutions: If the extensor pollicis longus comes into play

while the subject is attempting to extend the first MCP joint, the

clinician may observe the IP joint of the thumb extend as the

carpometacarpal (CMC) joint adducts

IP Extension



• 90 to 0 degrees

Prime Movers

• Extensor pollicislongus

□ Palpation site: Palpate the tendon of the extensor

pollicislongus as it crosses the dorsal aspect at the base of

the first MCP.




tabletop.


Grades 5/5 to 4/5: See Figure 119-3.

Figure 119-3.Resistance is applied to the dorsal surface of the

distal phalanx.

SUBJECT DIRECTIVE: “Straighten the tip of your thumb out


and hold it. Do not let me bend it down.”

*For a grade of 3/5, the subject extends the IP joint through

the maximal range of motion with slight resistance




tabletop.

Stabilization: The clinician stabilizes the proximal phalanx and

metacarpal


Figure 120-3.The subject extends the interphalangeal joint

through the range of motion without resistance


Figure 121-3.The extensor pollicis longus is palpated on the

ulnar aspect of the “anatomical snuff box” on the dorsal

surface at the base of the first metacarpal as the subject

attempts to extend the first interphalangeal joint.

Substitutions: The muscles of the thenar eminence may be

activated to flex the CMC joint, resulting in IP joint extension

via extensor tenodesis.

Thumb Abduction


• 0 to 60 degrees

Prime Movers

• Abductor pollicisbrevis


□ Palpation site: Along the anterior surface of the shaft of

the first metacarpal.

• Abductor pollicis longus

□ Palpation site: The most anterior of the 3 tendons at the

base of the CMC joint; palpate immediately proximal to

the CMC joint.

Secondary Movers

• Palmaris longus

• Extensor pollicis brevis

• Opponens pollicis


Subject position: Sitting or supine with the forearm supinated

and wrist in neutral with the hand resting on the dorsal surface;

thumb relaxed into adduction. The MCP and IP joints should

be flexed when testing the abductor pollicis longus to decrease

thumb extension.

Stabilization: The clinician stabilizes the palm of the hand

and wrist

• Grades 5/5 to 4/5: See Figures 122-3.


Figures 122-3.(A) Resistance is applied to the distal end of the

first metacarpal into adduction to test the abductor pollicis

longus and (B) the proximal phalanx for the abductor pollicis

brevis

SUBJECT DIRECTIVE: Move your thumb away from your

palm toward the ceiling and hold it. Do not let me push it

down.”


Figure 123-3.The subject abducts the thumb through the

maximal range of motion without resistance.




and wrist in neutral with the hand resting on the ulnar border,

thumb relaxed into adduction.

Stabilization: The clinician stabilizes the palm of the

hand and wrist. • Grade 2/5: See Figure 124-3.


Figure 124-3.The subject abducts the thumb through maximal

range of motion.


Figure 125-3.The abductor pollicis brevis is palpated in the

center of the thenar eminence, medial to the opponens, and the

abductor pollicis longus is palpated at the base of the first


metacarpal on the radial side of the extensor pollicis brevis as

the subject attempts to abduct the thumb.

(Shown: Palpating the abductor pollicis brevis.)

Substitution: If the thumb deviates toward the dorsal surface

of the forearm, the extensor pollicis brevis is being called in to

substitute for the abductor pollicis longus.

*The thumb will deviate radially if the abductor pollicis longus

is stronger than the brevis and ulnarly if the abductor pollici

sbrevis is stronger than the longus.

Thumb Adduction


• 60 to 0 degrees

Prime Movers

• Adductor pollicis

□ Palpation site: Deep in the first web space between the first

dorsal interossei and the first metacarpal bone.

Secondary Movers

• First dorsal interosseus



pronation and the hand hanging over the edge of a table,

supported by the clinician’s hand. The wrist is in neutral with

the thumb positioned loosely in abduction.


Stabilization: The clinician stabilizes the palm of the hand.


Figure 126-3.Resistance is applied on the medial aspect of the

proximal phalanx of the thumb into abduction.

SUBJECT DIRECTIVE: Move your thumb in toward your

index finger and hold it. Do not let me move it out.”


Figure 127-3.The subject adducts the thumb through the

maximal range of motion without resistance.

GRADES 2/5 (POOR), 1/5 (GOOD), AND 0/5 (ZERO)


in neutral with the ulnar border of the hand resting on the

tabletop with the thumb in abduction.


Stabilization: The clinician stabilizes the wrist and hand on the

tabletop.

• Grade 2/5: See Figure128-3.

Figure 128-3.The subject adducts the thumb through the

maximal range of motion



Figure 129-3.The adductor pollicis is palpated on the palmar

aspect of the first web space between the first dorsal

interosseus and the first metacarpal bone by grasping the web

space between the index finger and thumb.

Substitutions: The CMC joint will extend if the extensor

pollicislongus is activated while the subject attempts to adduct

the thumb and flexor pollicisbrevis and longus may flex the

thumb as the thumb is adducted.


Thumb Opposition


• Variable; “normal” range of motion allows for complete

motion until the tips of the thumb and fifth digit meet from

an open palm position.

Primary Movers

• Opponens pollicis

□ Palpation site: Deep to the abductor pollicis brevis along

the lateral shaft of the first metacarpal.


□ Palpation site: Along the shaft of the fifth metacarpal deep

to the abductor digiti minimi.

Secondary Movers





supination with the wrist in neutral, thumb adducted, and the



against the tabletop if necessary.

• Grades 5/5 to 4/5: See Figure 130-3


Figure 130-3.Resistance is applied at the head of the first

metacarpal into lateral rotation, extension, and adduction to

test the opponens pollicis and the palmar surface of the fifth

metacarpal (trying to “flatten” the palm) for the opponens

digiti minimi.

SUBJECT DIRECTIVE: “Put the pads of your thumb and little

finger together so they meet in the shape of an ‘O’ and do not

let me pull them apart.”


• Grade 3/5: See Figure 131-3

Figure 131-3.The subject is able to move the thumb away

from the palm and rotate it so that the pad of the thumb

touches the pad of the fifth digit.



supination with the wrist in neutral, thumb adducted and the



against the tabletop if necessary. Grade 2/5: Not pictured. The

two opponens muscles move through the range of motion, but

are evaluated individually.



Figure 132-3. (A) The opponens pollicis may be palpated

along the radial aspect of the first metacarpal, lateral to the

abductor pollicis brevis. (B) The opponens digiti minimi may

be palpated on the radial aspect of the fifth metacarpal as the

subject attempts to oppose the thumb.

Substitutions: If the thumb moves parallel to the surface of the

palm toward the little finger and touches the tips, not the pads

of the fingers, the flexor pollicis longus and brevis have been

activated. This is not considered opposition of the thumb.


THE CERVICAL SPINE GONIOMETRY

THE CERVICAL SPINE

Cervical Flexion

Range of motion:

• 0 degrees to 45 degrees with the goniometer

• 1.0 to 4.3 cm with tape measure

Preferred starting position: See Figure 1-2.

End position: See Figure 2-2.

Goniometric alignment:

• Axis: Center over the external auditory meatus


• Moving arm: Align parallel to the base of the nose

Alternate method/position for testing: See Figure 3-2.

Figure 1-2. The subject should be sitting with

the thoracic spine stabilized against a chair.

The head is in neutral position. The hands

should be in the subject's lap

Figure 2-2. The cervical spine should be in

a position of maximal flexion at the end of

the movement.


Figure 3-2. A tape measure may be used in place of a goniometer. The distance is measured between the chin and sternal notch. The subject's

mouth should be closed during testing. (A) Alternate starting position. (B) End position. (C) A fluid goniometer may also be used with the base resting

on top of the ear.

Cervical Extension/Hyperextension

Range of motion:

• 45 degrees to 0 degrees of extension (from full flexion)

• 0 degrees to 45 degrees of hyperextension

• Approximately 7 inches of extension, using a tape measure

• Approximately 10 inches of hyperextension (from full flexion)

using a tape measure




• Axis: Center over the external auditory meatus


• Moving arm: Align parallel to the base of the nose



.

Figure 4-2. The subject should be sitting with

the thoracic spine stabilized against a chair.

The head is in neutral position. The hands

should be in the subject's lap.

Figure 5-2. The cervical spine should be in full

cervical extension/hyperextension at the end

of the movement

Figure 6-2. A tape measure may be used in place of a goniometer. The distance is

measured between the chin and the sternal notch. (A) Alternate starting position. (B) End

position. (C) A fluid goniometer may also be used with the base resting on top of the ear.

Cervical Lateral Flexion

Range of motion:

• 0 degrees to 45 degrees

• Approximately 5 inches if using a tape

measure Preferred starting position: See

Figure 7-2.




• Axis: Center over the spinous process of C7


• Moving arm: Align over the external occipital protuberance of

the occiput


Figure 7-2. The subject should be sitting

with the thoracic spine stabilized against a

chair. The head is in a neutral position. The

hands should be in the subject's lap.

Figure 8-2. The cervical spine should be in

full lateral cervical flexion at the end of the

movement.


Figure 9-2. (A) A tape measure may be used in place of a goniometer. The distance between

the mastoid process and acromion process is measured. It is important to measure and

record the differences in length between the starting position and end position in determining

the range of motion. (B) A fluid goniometer may also be used with the base aligned with the

external occipital protuberance.

Cervical Rotation

Range of motion:


• Approximately 5 inches if using a tape measure





• Axis: Align over the center of the top of the head

• Stationary arm: Align with the acromion process of the tested

side

• Moving arm: Align with the tip of the nose


Figure 10-2. The subject should be sitting with the head in neutral

position and the hands in the subject's lap.

Figure 11-2. The cervical spine should be in full cervical rotation

at the end of the movement

.

Figure 12-2. A tape measure may be used in place of a

goniometer. The distance between the top of the chin and the

same side acromion process is measured. It is important to

measure and record the differences in length between the starting

position and end position in determining the range of motion.



Practical MMT of Cervical Spine NECK FLEXION


• 0 to 45 degrees with a goniometer

• 1.0 to 4.3 inch with a tape measure

Prime Movers

• Sternocleidomastoid (SCM) □ Palpation site: Anterolateral aspect of the neck.

Secondary Movers

• Rectus capitits anterior

• Rectus capitis lateralis

• Suprahyoid

• Infrahyoid

• Platysma

• Scalenes

• Longus capitis

• Longus colli

Anti-Gravity

Subject position: Supine on a table.

Stabilization: Weight of the trunk and clinician’s hand on the

thorax. • Grades 5/5 to +3/5: See Figure 1-3.

.


Figure 1-3. Resistance is applied to the anterior forehead

SUBJECT DIRECTIVE: “Lift your head up off the table. Do not

lift your shoulders up and do not let me push your head down.”

*The 2 SCM muscles may be tested individually by rotation of

the head to one side with neck flexion.


Figure 2-3. (A) The subject flexes the neck through the maximal range of motion without resistance. (B) Cervical rotation with flexion.

• Grades -3/5 to +2/5: See Figure 3-3.


Figure 3-3. The subject flexes through partial range of motion.

Gravity Minimized


surface. Stabilization: The clinician stabilizes the lower thorax.

• Grades 2/5 to -2/5: See Figure 4-3 A.

Grade 2/5: See Figure 4-3 B.

Figure 4-3. (A) The subject flexes the neck through the maximal range of

motion. (B) As an option, the subject may be asked to rotate the head to one side and then to the other.

Grades 1/5 to 0/5: See Figure 5-3

llA

fl


Figure 5-3. The sternocleidomastoid muscles are palpated on the

sides of the neck while the subject attempts to flex.

Substitutions: The corners of the subject’s mouth may be pulled

down if the platysma contracts.

Points of interest: Torticollis may result if the

sternocleidomastoid becomes dystonic.

EXTENSION

Active Range of Motion • 0 to 45 degrees

Prime Movers • Splenius capitis


trapezius. • Semispinalis capitis


trapezius.

• Cervicis muscles □ Palpation site: Under the lateral borders of the upper

trapezius.


Secondary Movers • Upper trapezius

Anti-Gravity

Subject position: Prone on a table

Stabilization: Weight of the trunk and the clinician’s hand on the

upper thoracic area and scapulae.

• Grades 5/5 to +3/5: See Figure 6-3.

Figure 6-3. Resistance is applied to the occiput.

SUBJECT DIRECTIVE: "Lift your head up toward the ceiling.

Do not let me push your head down.”



Figure 7-3. The subject extends the neck through the maximal


• Grades -3/5 to +2/5: See Figure 8-3.

Figure 8-3. The subject extends the neck through partial range of

motion.

Gravity Minimized


surface. Stabilization: Weight of the trunk on the table.

• Grades 2/5 to -2/5: See Figure 9-3.


Figure 9-3. The subject extends the neck through the

maximal range of motion


Figure 10-3. The splenius capitis semi spinalis capitis, and

cervicis muscles are palpated on the posterior aspect of the neck

while the subject tries to extend.

Substitutions: The subject may try to use the back muscles to lift

the upper trunk from the table.

Points of interest: Tasks such as reaching overhead into a high

cabinet, the top shelf in a closet, or drinking out of a cup require

the contraction of the cervical extensors at the end of the range of

motion.


THORACIC AND LUMBAR SPINE GONIOMETRY

Thoracolumbar Flexion

Range of motion:

• Approximately 4-inch difference between initial and ending

measurements



Measurement of motion: The distance between the spinous

processes of C7 and S1 is first measured in standing. The subject

then flexes the trunk as far forward as possible and the second

measurement is taken. The difference between the two

measurements is the amount of flexion present.

Substitutions: See Figure 105-2.

Figure 104-2. The thoracolumbar spine is maximally flexed forward.


Figure 105-2. The subject may try to flex the hips and/or the

knees during movement to gain more flexion. This may occur as

the hamstrings are maximally stretched

Thoracolumbar Extension/ Hyperextension

Range of motion:

• Approximately 2-inch difference between the initial and

ending measurements





extends the trunk as far backward as possible and a second



measurements is the amount of extension present.


Figure 106-2. The subject should be standing in an erect position with the

arms by the sides.

Figure 107-2. The thoracolumbar spine is maximally extended at the

end of the motion.

Figure 108-2. The subject may try to laterally bend or rotate the

trunk during testing to gain more motion or avoid pain. The

subject may also bend the knees as the hip flexors are maximally

stretched


Thoracolumbar Lateral Flexion

Range of motion:

• Range of motion is variable because of the differences in arm

and trunk length. The amount of motion is determined by the

comparison of both sides.



Measurement of motion: The distance between the tip of the

middle finger and floor is taken first. The subject then laterally

flexes to the side as far as possible and a second measurement is

taken. The difference between the two measurements is the amount

of lateral flexion present.


Figure 109-2. The subject should be standing in an Figure 110-2. The thoracolumbar spine is maximally

erect position with the arms by the sides. laterally flexed to the tested side.


Figure 111-2. The subject may try to flex, extend, or rotate the

trunk during testing or lift the opposite lower extremity off the

floor to gain more motion

Thoracolumbar Rotation

Range of motion:






• Stationary arm: Align parallel to an imaginary line between the

two iliac crests

• Moving arm: Align parallel to the top of the shoulder, siting the

acromion process


Alternate method/position for testing: None.

Figure 112-2. Preferably, the subject should be sitting without a back

support to ensure full mobility. The cervical, thoracic, and lumbar spine should be in a neutral position with the arms resting by the sides.

Figure 113-2. The thorax should be maximally rotated to the tested side at the end of the movement.


THE THORACOLUMBAR

SPINE GONIOMETRY Type of joint: The thoracic and lumbar spine are very complex

structures involving segmented movement at numerous vertebral

articulations. As a result, it is not possible to accurately measure all

movements occurring along this area of the spine with a

goniometer. An alternative method will be addressed.

Capsular pattern: Lateral flexion = rotation/extension.

Thoracolumbar Flexion

Planes/axis of movement: Movement occurs in the sagittal plane

around a coronal axis.

Range of motion:

• Approximately 4-inch difference between initial and ending

measurements



then flexes the trunk as far forward as possible and the second


measurements is the amount of flexion present.

Stabilization: The pelvis should be stabilized to prevent anterior

tilting. Stabilization is achieved through subject compliance.

Thoracolumbar Extension/

Hyperextension

Planes/axis of movement: Extension is the return motion from full


thoracolumbar flexion. Beyond 0 degrees starting position is

considered hyperextension. Motion occurs in the sagittal plane

around a coronal axis.

Range of motion:

• Approximately 2-inch difference between the initial and ending

measurements



extends the trunk as far backward as possible and a second


measurements is the amount of extension present.

Stabilization: The pelvis should be stabilized to prevent posterior

tilting. Stabilization is achieved through subject compliance.

Thoracolumbar Lateral Flexion

Planes/axis of movement: Motion occurs in the frontal plane


Range of motion:

• Range of motion is variable because of the differences in arm and

trunk length. The amount of motion is determined by the

comparison of both sides.

Measurement of motion: The distance between the tip of the

middle finger and floor is taken first. The subject then laterally

flexes to the side as far as possible and a second measurement is

taken. The difference between the two measurements is the amount

of lateral flexion present.

Stabilization: The pelvis should be stabilized during testing.

Stabilization is achieved through subject compliance.


Thoracolumbar Rotation

Planes/axis of movement: Motion occurs in the transverse plane

around a vertical axis.

Range of motion:




• Stationary arm: Align parallel to an imaginary line between the

two iliac crests

• Moving arm: Align parallel to the top of the shoulder, siting the

acromion process

Stabilization: The pelvis should be stabilized during testing.

Stabilization is achieved through subject compliance.

Substitutions: The subject may try to flex, extend, or laterally flex

the trunk to increase the motion. He/she may also try to raise the

pelvis.


MMT for Thoracic and lumbar Spine

TRUNK FLEXION

Prime Movers

• Rectus abdominus

□ Palpation sites: Upper rectus: both sides of the midline

between the umbilicus and xiphoid process. Lower rectus:

both sides of the midline between the umbilicus and symphysis

pubis.


□ Palpation site: Opposite side of direction of rotation just below



□ Palpation site: Just medial to the anterior superior iliac spine

along the lateral aspect of the abdomen.

Secondary Movers

• Psoas major

Psoas minor

Anti-Gravity

• Upper rectus abdominus

Subject position: Supine on a table with both lower extremities

in extension.

Stabilization: No stabilization of the pelvis is provided if the hip


flexors are strong. If weak hip flexors are noted, the clinician

stabilizes the pelvis against the table.


Figure 133-3.With the hands clasped behind the head, the subject

moves through the range of motion until the inferior angles of the

scapulae are off the table. The arms create the resistance.

SUBJECT DIRECTIVE: “Curl your head, shoulders, and torso up

until your shoulder blades are off the table.”

• Grades 4/5 and 3/5: See Figures 134-3 and 135-3.


Figure 134-3.With the arms crossed over the chest, the subject

moves through the range of motion until the inferior angles of the

scapulae are off the table for a grade of 4/5.

Figure 135-3.With the arms fully outstretched over the trunk, the

subject completes the range of motion until the inferior angles of

the scapulae are off the table for a grade of 3/5.


Substitutions: The subject may rise up rapidly to use momentum

to lift the trunk or use his arms to push off the tabletop. If the

subject inhales deeply, it may cause depression of the lower

thorax. The umbilicus may deviate to the stronger side.

Gravity Minimized

• Upper rectus abdominis


Stabilization: The clinician stabilizes the subject’s pelvis against

the table.


Figure 136-3.The subject is able to raise his head against gravity


• • Grade 1/5: See Figure 137-3.

Figure 137-3.If there is no depression of the rib cage but there is

visable muscle activity noted, contraction of the upper rectus

abdominis is palpated on both sides of the midline between the

umbilicus and xiphoid process.

Anti-Gravity

• Lower rectus abdominus

Subject position: Supine on a table with both knees flexed.

Stabilization: The weight of the pelvis and lower extremities

provide the necessary stabilization. See Figure 138-3.


Figure 138-3.The subject is able to bring both knees toward the

chest and lift the sacrum through the maximal range of motion 10

times for a grade of 5/5 and 4 to 6 times for a grade of 4/5. A

grade of 3/5 is assigned if the subject can only complete the

motion once.

SUBJECT DIRECTIVE: “Lift both your knees toward your chest

and lift your buttocks off the table.”

Substitutions: The subject may use the arms to push up or use

momentum to lift up the sacrum. The umbilicus may deviate to

the stronger side.

Gravity Minimized

• Lower rectus abdominis


Stabilization: The weight of the trunk and lower extremities

stabilizes the subject’s pelvis against the table. See Figures 139-3

and140-3.


Figure 139-3.Subject is able to perform a pelvic tilt for a grade of

2/5.

Points of interest: The rectus abdominis and internal and external

obliques act together to stabilize the pelvis and contribute to proper

postural alignment. Weakness of the abdominal obliques may

decrease respiratory efficiency and reduce support of the

abdominal viscera.


Figure 140-3.Contraction of the lower rectus abdominis is

palpated on both sides of the midline between the umbilicus and

symphysis pubis for a grade of 1/5

ROTATION

Prime Movers


□ Palpation site: Below the ribs and costal cartilages of the

lowest ribs in the midclavicular line.


□ Palpation site: Immediately medial to the anterior superior

iliac spine along the midclavicular line.

Anti-Gravity

Subject position: Supine on a table with the lower extremities

extended.


The scapula corresponding to the external oblique must clear the


table for a grade of 5/5. See Figure 141-3.

Figure 141-3.With the hands clasped behind the head, the subject

flexes the trunk and rotates to one side first and then to the

opposite side.

SUBJECT DIRECTIVE: “Lift your head and shoulders off the

table and turn to your left elbow toward your right knee.”• Grades

4/5 and 3/5: See Figures 142-3 and 143-3.

*Instruct the subject to turn the right elbow toward the left knee


to test the opposite side/musculature. When moving the right

elbow toward the left knee, the right external and left internal

obliques are tested.

Figure 142-3.The

subject completes

the movement with

the hands crossed

over the chest for a

grade of 4/5.

Figure 143-3.The

subject completes

the movement with

the arms

outstretched in front

of the body for a

grade of 3/5.

Substitutions: The

pectoralis major

may cause the shoulders to shrug or slightly lift the shoulder off the

table.


Gravity Minimized

Subject position: Supine on the table with the lower extremities

extended.


See Figure 144-3.

Figure 144-3.The subject is able to initiate the elevation of the

opposite scapula with the upper extremities by the sides for a

grade of +2/5.


Figures 145-3.(A) The internal obliques are palpated on the side

toward which the patient turns just medial to the ASIS on the

lateral aspect of the abdomen. (B) The external obliques are

palpated on the side away from the direction of turning just below



Note: The direction of the muscle fibers of the internal obliques

can be mimicked by crossing the arms over the abdomen and

placing the fingertips on each anterior superior iliac spine. The

fingers will parallel the muscle fibers (up and in). The direction of

the muscle fibers of the external obliques can be mimicked by

positioning the hands into the pants pockets (down and in).


EXTENSION

Prime Movers

Note: Palpation sites are not listed as the individual muscles

cannot be isolated.

• Iliocostalis thoracis

• Longissimus thoracis

• Semispinalis thoracis

• Multifidi

• Rotatores thoracis and lumborum

• Interspinalis thoracis and lumborum

• Intertransversarii thoracis and lumborum


Secondary Movers

Gluteus maximus

Anti-Gravity

• Lumbar

Subject position: Prone with the hands clasped behind the head.

^Alternate position: Prone with pillows under the subject’s hips

and the hands clasped on the buttocks.

Stabilization: The clinician stabilizes the pelvis and hips.

SUBJECT DIRECTIVE: "Lift your head and chest up toward the

ceiling as high as possible and hold it.”See Figures 147-3 and

148-3


Figure 147-3.The subject is able to easily reach the endpoint of

the movement and hold it against gravity with minimal effort

(grade 5/5). For grade 4/5, the subject is able to reach the

endpoint of the movement but demonstrates increased effort

trying to maintain the position.

Figure 148-3.The subject is able to complete the maximal range

of motion (so that the umbilicus clears the table) with the arms at

the subject's sides for a grade of 3/5.


Gravity Minimized

• Lumbar

Subject position: Sitting backwards on a chair or on a stool with

the hands resting on a tabletop

Stabilization: Achieved by the weight of the subject on the chair

and subject compliance. See Figure 149-3

Figure 149-3.The subject extends the lumbar spine, anteriorly

tiliting the pelvis, causing increased lumbar lordosis for a grade of

2/5.



Figure 150-3.The lumbar erector spinae musculature is palpated

adjacent to both sides of the spine as the subject attempts to

extend.

Anti-Gravity

• Thoracic

Subject position: Prone with the head and upper trunk draped at

chest level off the edge of a table with the hands clasped behind the

head.

^Alternate position: Prone with pillows under the abdomen and

with the hands clasped on the buttocks.

Stabilization: The clinician stabilizes the pelvis and lumbar

vertebrae.

SUBJECT DIRECTIVE: "Liftyour head, shoulders, and chest up


toward the ceiling as high as possible and hold it.” See Figures

151-3 and 152-3.

Figure 151-3.The subject is easily able to raise the upper trunk so

it is at least horizontal to the tabletop with minimal effort for a

grade of 5/5. For grade 4/5, the subject is able to extend the trunk

so that it is horizontal to the table level but with some effort.


Figure 152-3.The subject is able to complete the

maximal range of motion so that the umbilicus clears the

table with the arms at the subject's sides for a grade of

3/5.

Gravity Minimized

• Thoracic

Subject position: Sitting backwards on a chair with the thoracic

spine relaxed and the hands resting on the back of the chair.

Stabilization: Weight of the subject on the chair and subject

compliance. See Figure 153-3.


Figure 153-3.The subject extends the thoracic and lumbar spine

through the maximal range of motion for a grade of 2/5.



Figure 154-3.The thoracic erector spinae musculature is palpated

adjacent to both sides of the spine as the subject attempts to

extend.

Substitutions: The subject may use momentum by forcefully

pushing the shoulders backwards.

Points of interest: The longissimus is the predominant muscle

that is active during all motions of the trunk.


PELVIC ELEVATION

Prime Movers


□ Palpation site: Too deep to be palpated.

Secondary Movers

• Latissimus dorsi

• Iliocostalis lumborum

Anti-Gravity

Subject position: Standing on a stool or step with the clinician

supporting the subject for balance, the test limb hanging free.

Stabilization: The clinician stabilizes the pelvis on the opposite

side.

• Grades 5/5 to 4/5: See

Figure 155-3.

Figure 155-3.The

subject hikes the hip,

elevating the pelvis on

the side being tested.

Resistance is applied in a

downward direction on

the iliac crest on the

tested side, attempting to

laterally tilt the pelvis.


SUBJECT DIRECTIVE: “Hike your hip up toward your ribs and

hold it


Figure 156-3.The subject hikes the pelvis through the range of


Substitution: The subject may laterally flex the trunk away from

the tested side.


Gravity Minimized

Subject position: Supine or prone on a table with the lower

extremities in extension.

Stabilization: The subject may hold onto the sides of the table for

resistance


Figure 157-3.The subject hip hikes through the available range of

motion.


Functional Muscle Testing

MUSCLES OF THE FACE

Muscle Tested:

a. Frontalis (Frontal belly)

b. Corrugator supercilii

c. Procerus

d. Nasalis

Test Procedures:

In the testing of the face muscles, positioning is not a factor, and, with

the exception of the muscles of mastication, only very fine movements are

involved. Grades which may be used are: zero, if no contraction can be

elicited; trace, for minimal muscle contraction; fair, for performance of the

movement with difficulty; and normal, for completion of the movement

with case and control. Resistance may be given in the tests for the muscles

of mastication.

Occipitofrontalis (frontal belly):

Command: raise eyebrows, forming horizontal wrinkles in forehead

(expression of surprise) ------ Relax.

Corrugator Supercilii:

Command: draws eyebrows medially and downward, forming vertical

wrinkles between brows (frowning) ------Relax.


Procerus:

Command: Lift lateral borders of nostrils, forming diagonal wrinkles

along bridge of nose (expression of distaste).

Nasalis:

Command: Dilate nostrils alar part of nasalis followed by compression

(transverse portion) ----- Relax.

MUSCLES OF THE FACE


MUSCLES OF THE EYE

Muscle Tested:

a. Orbicularis oculi

b. Levator palpebrae superioris

c. Rectus superior:

d. Rectus inferior

e. Rectus medialis:

f. Rectus lateralis:

g. Superior oblique:

h. Inferior oblique:

Test Procedures:

Orbicularis oculi

Command: Close your eyes tightly ------ Relax.

Levator palpebrae superioris

Command: Lift your upper eyelids completely as eyes are turned

upward ------ Relax.


Inferior oblique (right) and superior rectus (left)

Command: move your eyes in a direction upward and to the right ----

- Relax.

Superior oblique (left) and inferior rectus (right)

Command: move your eyes in a direction downward and to the left ----- Relax.

The rectus medialis and rectus lateralis may be tested by movement of

the eyes horizontally to the right and left. (Not illustrated. )

MUSCLES OF THE EYE



Muscle Tested:

a. Orbicularis oris:

b. Zygomaticus minor:

c. Levator anguli oris:

d. Zygomaticus major:

e. Risorius:

f. Buccinator

g. Depressor anguli oris

h. Depressor labii inferioris:

i. Mentalis

j. Platysma


Test Procedure:

Orbicularis Oris

Command: Approximate and compress your lips ----- Relax.

Zygomaticus Minor

Command: Protrude your upper lip ------- Relax.

Levator Anguli Oris:

Command: Lift your upper border of lip on one side without raising

lateral angle of mouth (sneering) ------- Relax. Zygomaticus Major:

Command: Raise your lateral angle of mouth upward and lateralward

(smiling) ------ Relax.

Risorius:

Command: Approximate your lips and draw your corners of mouth

lateralward (grimacing) ----- Relax.

Buccinator

Command: Approximate your lips and compress your

cheeks(blowing) ------ Relax.

Depressor Labii Inferior:

Command: Protrude your lower lip (pouting) ------ Relax.

Depressor Anguli Oris and Platysma:

Command: Draw your corners of mouth downward strongly -----

Relax.

Mentalis

Command: Draw your tip of chin upward ------ Relax



Muscle Tested:

Temporalis:

Masseter:

Pterygoid externus:

Pterygoid internus:

Mylohyoid:

Geniohyoid:

Digastricus:

Stylohyoid:

Sternohyoid:

Styreohyoid:


Sternothyroid:

Omohyoid:

Test Procedures:

Temporalis, Masseter and Pterygoid internus

Command: Close your jaws tightly ----- Relax.

Pterygoid externus and internus (left)

Command: Move your mandible laterally and forward to the right ---

- Relax.

Digastric and suprahyoid muscles;

(hyoid bond is fixed by Infrahyoid muscles)

Command: Depress your mandible ------ Relax.


References

Essential books (Text Books):

1. George V. Lawry. Systematic Musculoskeletal

Examinations. The M cGraw-Hill Companie Isn,.

2012

2. Silvano M. Muscle Testing, Techniques of Ma

nual Examination. JCCA: 29(1). 2017

3. Measurement Guide. Joint Active

Systems, Inc.

www.jointactivesystems.com. 2015

Required Text:

1. Williams A., Stephen E., Shannon E., and

Lindsay C. Tests and Measures Used by Specialist

Physical Therapists When Examining Patients with

Stroke. JNPT;32: 122–128. 2008

2. Palmer & Epler. Fundamentals of

Musculoskeletal Assessment Techniques 2nd ed.

1998.

http://www.jointactivesystems.com/

Faculty quality assurance unit Academic year 2020/2021

University: Modern University for Technology and Information

Faculty: Physical Therapy

Course Specifications

A. Basic Information

1. Program Title: Physical therapy

2. Department Offering The Program (s): Department of Basic science

3. Department Responsible For The Course: Department of Basic science

4. Course Title And Code: Patient evaluation (2) (PT2304)

5. Year/ Level: Second year/Level 3

1. Credit hours: 3

Lecture: 1 H/W Practical: 2 H/W Contact hours: 5 H/W

6. Authorization Date Of Course Specification: Spring 2021

B. Professional Information

1. Course Aims:

This course emphasizes on evaluation in general, anthropometric measurement and goniometry

measurement for different joints of the upper limb. It is teach students how to apply manual

muscle testing for the upper limb. In addition, the students learn about flexibility test for upper

limb, equipment’s for test and measurement and the techniques of the applications.

2. Intended Learning Outcomes From The Course (ILOs):

Express the ILOs of the course in terms of:

A- Knowledge and understanding

Upon successful completion of the course the students should be able to:

a.1- Identify the normal and pathological end feel and their relation to physical therapy

evaluation.

a.2- Demonstrate the basic principles for techniques of applications

a.3- State evaluation items based on evaluation sheet.

B- intellectual skills


b.1- Formulate plan of care to achieve realistic goals.


b.2- Write concise and accurate patient problems according to problem oriented medical

records and SOAP.

b.3- Extract data from literature, using information technology and library resources to solve

patient problems.

C- Professional and practical skills


c.1- Apply definitive physical therapy evaluation according to different patient’s conditions.

c.2- Construct the problem list from collected information ( subjective and objective data).

c.3-Design a specific evaluation for joints and muscles of upper extremity.

c.4- Modify physical therapy program according to periodical evaluation.

D- General and transferable skills


d.1- Use computer programs to interact with related information sources.

d.2- Communicate as part of the health services teamwork within the standardized professional

behavior.

d.3- Mange time and emotional stresses.

C- Course Content:

# Topics No. of Semester Hour (s)

Lecture Practical Teaching methods

1. 1 Goniometry, Anthropometry &

special tests for LL

1 2 Contact traditional teaching in

addition to e-learning

2. 2 Manual muscle test for scapular

abduction upward rotation- scapular

elevation



3. 3 Manual muscle test for Scapular

adduction- adduction with

depression-scapular adduction

downward rotation




4. 4 Manual muscle test for shoulder

flexion, extension & abduction



5. 5 Manual muscle test for shoulder

horizontal abduction, horizontal

adduction, internal and external

rotation



6. 6 Manual muscle test for elbow

flexion -extension & forearm

supination-pronation



7. 7 Manual muscle test for thumb and

fingers



8. 8 Manual muscle test for neck 1 2 Contact traditional teaching in


9. 9 Manual muscle test for trunk &

pelvis



D- Teaching and Learning Methods:

4.1-Lecture, presentation and discussion

4.2- Problem solving and Relative journals

E- Student Assessment:

# Assessment Method Assessed ILO

5.1 final written exam with supply questions(define, enumerate,

differentiate, describe, explain, calculate) and selection

questions (multiple choice, matching) addition to e-learning

research

a1,2,3- b 1,2,3

5.2 final exam with case based questions in addition to e-learning

exam

c 2,3- d 2,3

5.3 Practical and oral exam (Modefied OSPE) addition to contact

practical exam

c 1,2,3,4- d1


# Assessment method Semester

week

Weighting

(%)

1. Theoretical Examination

period

40%=40 M

2. Practical Examination

period

20%=20M

3. Course work During

course

40%=40 M

Total 100%=100 M

F- List of Text Books and References:

a- Lectures Notes:

Patient evaluation 2

b- Essential books (Text Books):

-George V. Lawry. Systematic Musculoskeletal Examinations. The M cGraw-Hill

Companie Isn,. 2012

-Silvano M. Muscle Testing, Techniques of Manual Examination. JCCA: 29(1). 2017

-Measurement Guide. Joint Active Systems, Inc. www.jointactivesystems.com. 2015

Required Text:

Williams A., Stephen E., Shannon E., and Lindsay C. Tests and Measures Used by Specialist

Physical Therapists When Examining Patients with Stroke. JNPT;32: 122–128. 2008

Palmer & Epler. Fundamentals of Musculoskeletal Assessment Techniques 2nd ed. 1998.

c- General references:

- Recommended Books and Reference Material (Journals, Reports, etc) (Attach List)

G- Facilities Required For Teaching And Learning:

- Computer-based programs/CD and data show, professional standards/regulations

- Lecture room

- Specialized clinical site/ Labs with plinths, Goniometer, tape measurement and pillows.

Course Coordinator/ Instructor: Ass.Prof .Dr: Amir N Wadee

Dean: Prof.Dr. Naguib Salem

Date: Spring 2021

https://www.researchgate.net/journal/0008-3194_JCCA_Journal_of_the_Canadian_Chiropractic_Association_Journal_de_lAssociation_chiropratique_canadienne

http://www.jointactivesystems.com/

-الجامعة الحديثة للتكنولوجيا والمعلومات:-رؤية كلية العلاج الطبيعي

تطع كهيخ انعلاج انطجيعي ثبندبيعخ انحذيثخ نهتكىنىخيب وانعهىيبد ثأ تكى صرحب

رائذا نهتعهيى اندبيع ف يدبل انعلاج انطجيع عه انطتىي انحه و الإلهي و انعبن ورنك

.0205ثحهىل عبو

-الجامعة الحديثة للتكنولوجيا والمعلومات:-رسالة كلية العلاج الطبيعي ئعذاد خريدي ف ثكهيخ انعلاج انطجيعي ثبندبيعخ انحذيثخ نهتكىنىخيب وانعهىيبد تهتسو

يدبل انعلاج انطجيع يؤههي نهبفطخ ف يدبل انعلاج انطجيع وتهجيخ أحتيبخبد ضىق انعم

برف وانهبراد انلازيخ نهبرضخ الإكهييكيخ انمبئخ عه انجراهي و رنك ي ويسودي ثبنع

خلال ثربيح تعهي يتيس عهيب و تعهييب و انتطىير انطتر نهتعهيى وانتعهى وانذعى انطتر

نلإثذاع و الإثتكبر ف يدبل انجحث انعه وانشبركخ اندتعيخ انثرح ف إطبر انميى

. والأخلاليبد

قيم الكلية: تتجع كهيخ انعلاج انطجيعي ثبندبيعخ انحذيثخ نهتكىنىخيب وانعهىيبد انميى الآتيخ :

الاحتراو وانتمذير، اندذيخ في انتعبيم ، الإنتساو ، انشفبفيخ ، انعذانخ ، انصذاليخ وانعم ثروذ

انفريك.

غايات الكلية: يخ ثبنكهيه.رفع كفبءح انعهيخ انتعهي (:1الغاية رقم )

دعى و تطىير انجحث انعه. (:2الغاية رقم )

تيخ خذيه اندتع و انعم عه تحميك انرضب اندتع. (:3الغاية رقم )

الأهداف الإستراتيجية للكلية : (1) :لتحقيق الغاية رقم

تطىير وإعتبد ثربيح ويمرراد يرحهه انجكبنىريىش. -1

و انتطهيلاد انذاعخ.تطىير أضبنيت انتعهيى وانتعهى -0

أكتطبة ثمخ اندتع انذاخه وانخبرخ ف انكهيخ والإرتمبء ثطتىي انطلاة. -3

الإرتمبء ثطتىي انطبدح أعضبء هيئخ انتذريص و انهيئخ انعبوخ. -4

تطىير انعهيخ الإداريخ وانتعهييخ ثبنكهيخ. -5

: (2) لتحقيق الغاية رقم

طخ انعهيخ.الإرتمبء ثطتىي انجحث انعه و الأش .1

يطبهخ انجحث انعه ف دعى و تعسيس انعهيخ انتعهييخ وخذيخ اندتع. .0

(3) : لتحقيق الغاية رقم

تهجيخ إحتيبخبد اندتع وتيخ انجيئخ. .1

تعسيس انتىاصم انثر يع اندتع. .0

mti university faculty of physical therapy patient's

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