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Manual musle testing
1. Muscle Testing of the Upper
and Lower Extremities
Physiotherapy Division
Dr. Mikhled Maayah
2. Guide muscle testing
• This guide was developed out of a need to assist the
therapist in utilizing a standard method of muscle
testing in patients at this facility.
• It is based on the denials and Worthingham method
of muscle testing.
• It was originally developed approximately a long
time ago as a procedure to assist physiotherapy
students who working with the physically disabled.
• Since that time it has been utilized by staff, who
have given suggestions over a period of years to
make it more meaningful and useful to gain
proficiency and consistency in muscle testing.
3. Introduction
• The general direction of treatment today is to
consider the whole patient in terms of what we do to
help him gain maximum recovery and independence.
• To accomplish this we must think of him in terms of
his status at the beginning of treatment, the
prognosis, the plan of treatment and the progress
noted under this plan.
• It should be a matter of professional pride that we be
able to provide accurate and meaningful information,
when it is requested of us.
4. Introduction- continue
As therapists, we consider muscle evaluations
from two points of view:
• For our use own as guides to planning of specific
treatment routines and to determine the success or
failure of these routines.
• To provide the physicians with whom we work with
information which will be helpful to them in:
– diagnosis
– prescription for treatment
– prescription for bracing
– determination of progress and prognosis.
5. Introduction- continue
• There are certain specific things which we want to
knew. These are:
– Is the muscle active?
– Is the muscle functional?
– How functional is it?
– Is spasticity present?
– What substitute patterns are present?
– What positions the patients assumes at rest?
– What positions the patients assumes on activity?
– What deformities are present and to what degree?
– What stage of motor development has been reached?
– What are the specific motor handicaps which keep him
developing more rapidly or becoming more independent?
6. Introduction- continue
• In addition, the therapist must be able to convey to
the patient what is expected of him in a testing
procedure and then be able to record the results of
the test in concise way.
• Testing by a well trained therapist saves time for the
physician and can be great help to him.
• Objective testing done at stated intervals serves not
only to record progress, or lack of it, but gives us an
excellent opportunity to evaluate the technique
used.
• It also gives information needed to report
intelligently to the physician on the status of the
patient.
7. Definition of muscle test
A muscle test is an attempt to determine the ability
of a patient to activate skeletal muscle.
Available range of motion: this is the passive range
which is easily obtained by the examiner without
feeling resistance.
Example: If passive range measured in elbow flexion
is 0 – 90 degree and patient actively moves 0 – 90
degree, then he will have moved through complete
available range of motion.
8. Muscle test is used as:-
• Basis of muscle re-education and
exercise.
• Determining factor for supportive
apparatus.
• Aid in determining diagnosis.
• Aid in prognosis of a patient.
9. Requisites for good muscle
testing
– Knowledge of anatomy as well as functional.
– Correct starting position-changes with muscle being tested.
– Stabilization of proximal segment and body as a whole.
– Area of palpation-knowledge of where and how to palpate.
– knowledge of the substitutions muscles (synergic muscles,
assisting muscles, direct fixation muscles, indirect fixation
muscles and antagonistic muscles).
– Recognition of substitution.
– Knowledge of normal muscle and muscle groups (action
and appearances).
– Ability to convey ideas to patient and guide the movement.
– Record deformities, limitations in motion, spasticity and
tremor, strength within range must be recorded (grade low
when in doubt about strength of a muscle).
10. Terminology
• Test Range: is set up for specific test of specify muscle –
not necessarily complete ROM.
• Easy Test: gravity eliminated test or position that will
give you a grade of 0, Trace, Poor -,
Poor.
• Hard Test: anti-gravity (against), method used to obtain
grades from Fair+ to normal.
• Palpation: ability of therapist to feel contraction of muscle
being tested.
• Resistance: applied at the end of ROM, pressure should
be applied in a direction as nearly
opposite to the line of pull of the
muscle or group, as possible.
11. Muscle grading techniques
• Grades are obtained on varies of gravity,
gravity eliminated, against gravity, gravity
plus manual resistance.
• Some grades are obtained by palpation.
• Stretch range used for some grades – range
beyond neutral position, usually used in
rotation.
12. Grades
• The following muscle grades are described in
comparison with a normal muscle.
• It is important to keep in mind that muscles of normal
strength vary in strength tremendously within the body.,
owing to the size of the muscle and to the work each
muscle is normally required to perform.
• Normal strength likewise varies between individuals,
owing to differences in age and body requirements.
• Therefore, in grading muscles above ‘fair’, the degree of
objectivity increases with the therapist’s increasing
knowledge of normal strength of various age groups and
body requirements for that particular muscle, prior to
illness or injury.
13. Grades
• Zero (O): No movement of part; contraction cannot be palpated
• Trace (T): Contraction can be palpated; no movement of part.
• Poor minus (P-): Gravity eliminated, part moves through only a
portion of the range of available, not necessarily normal,
passive ROM.
• Poor (P): Gravity eliminated, part moves through complete
available ROM.
• Fair: Against gravity, part moves through complete available
ROM, but cannot take additional resistance.
• Fair Plus (F+): Part moves through complete available ROM
against gravity with ‘slight’ resistance (for that muscle) at end
of range.
• Good (G): Part moves through complete available ROM against
gravity and takes “moderately strong” resistance (for that
muscle) at end of range.
• Normal (N): Part moves through complete available ROM
against gravity and takes “strong” resistance (for that muscle)
at the end of range.
14. Recording
• All grades below fair are recorded in red for easily
identifiable areas of weakness; grades of fair and
above are recorded in blue or black ink and dated.
• Indicate all muscles not tested during any
evaluation by marking “N.T” in the appropriate
place.
15. Outline of technique for administering
the manual muscle test
• Determine the ROM of joint (joints) passively.
• Line up the part with fibers of the muscle to be
tested.
• Provide adequate stabilization.
• Have the patient attempt motion through the test
range.
• Look at the muscle or movement first.
• Palpate at the tendon or muscle belly.
• Apply resistance at the end of the range if the
muscle is strong enough (Break Test).
16. Outline of technique for administering
the manual muscle test
• Resistance should be applied firmly and
smoothly in line with direction of the muscle of
segment of a muscle being tested.
• You may compare the strength of the normal
segment with the one being tested to aid in
determine the strength grade.
• Never give a grade on motion alone. It must
possible to palpate the muscle.
• Record grade and date and initial the test form.
• Normal in relation to muscle testing: normal for
are, sex and sounded parts.
17. Some basic principles
1. Take your time.
2. Start with a gross observation of function
around a joint.
3. Patient instruction.
4. Be consistent.
5. Grading.
6. Check yourself.
7. Suggested sequence of extremities muscle
test.
18. Some basic principles
1. Take your time:
– Don’t rush to a conclusion about a grade.
– Use plus or minus if patient’s performance is
consistent with stated definitions of grades.
– If patient’s performance is not consistent
with stated definitions, use descriptive
terminology, e.g. biceps remains F+ but is
taking more resistance than last test.
19. 2. Start with a gross observation of function
around a joint:
– Observe the ROM around the joint as it is often a clue
to muscle imbalance.
– Then observe gross movement around the joint before
touching with hands.
– Observe muscle atrophy.
– Observe and check muscle tone.
– The presence of spasticity may negate the value and
appropriateness of performing a manual muscle test.
– Be aware of sensory deficits as they may affect
patient’s ability to follow directions.
20. 3. Patient instruction:
– It is important to give patients all sensory
and verbal clues needed for best
performance.
– This may include:
• Demonstrations
• Taking part through motion desired
• Allowing patient to see part being tested
• Allowing practice through muscle re-education
techniques (when appropriate)
• Using simple instructions.
21. 4. Be consistent:
– Begin by testing the muscle against-gravity,
then test in a gravity-eliminated position if
muscle is below “Fair”.
– Always apply resistance at the end of the motion
rather than during the motion.
– Resistance is usually applied at the distal end of
the part and opposite to the direction of pull.
22. 5. Grading:
– When utilizing the grading system above, examiner
must observe proper testing position of the patient
for the muscle being tested.
– When it is not possible to assume proper testing
position, e.g. due to contractures, casts, medical
precautions, it is important to determine presence
or absence of muscle in question.
– In this case, the degree of contraction can be
determined as weak or strong, utilizing palpation
and observable active motion.
– Because some body parts cannot be positioned to
work against gravity, the grading of some muscles
is modified, as indicated in the procedure to follow.
– Recognize that larger muscles would take maximum
effort by tester to resist a strong muscle and
proportionally less effort for smaller muscles.
23. The gravity factor in Grading
• For other muscles, the gravity free and ant-gravity
positions are impractical because gravity may not be an
important factor (Finger flexors, toe flexors, forearm
pronators and supinators, rotators of the shoulders and
hips).
• From a mechanical stand-point this is true because the
weight of the part is so small in comparison with strength
of the muscle.
• Foot, hand or their range of motion is much that if the
initial position is anti-gravity, the end position is with
gravity.
• Supinators and pronators could be scored:
• Tr : perception of attempted assistance in stretch range
24. 6. Check yourself on the following factors:
– What is the primary action of the muscle
being tested?
– Is the patient in the proper test position?
For example, if patient’s biceps is less than
F in a sitting position, have I repositioned
for gravity eliminated grading?
– Have I stabilized the part proximal to the
part on which the muscle acts?
25. – Have I observed to see that the motion
produced is the motion requested, e.g. is
there extraneous motion at joints proximal
and/or distal to the part being tested?
– Have I palpated after observing the motion?
– Have I applied resistance in the proper place
at the end of motion?
– Have I graded, using the proper definition of
grades.
26. 7. Suggested sequence of extremities muscle
test
• The following suggested sequence first
provided to enable the tester to efficiently
perform all the tests with the least amount
of re-positioning of the patient.
• Note that all muscles which can be tested
for both above and below F are grouped
together.
27. Suggested sequence of upper extremity
muscle test
A. UPRIGHT:
– Elbow, Forearm, wrist and Hand.
– Serratus anterior and pectoral is major
(clavicular).
– Anterior deltoid
– Middle deltoid
– Upper trapezius
– Latissimus dorsi F+ and above
29. C. Sideling: with weight of arm supported on a smooth
board.
– Anterior deltoid
D. SUPINE
– Pectoralis major (sternal)
– Triceps (alternate position) support weight.
– Elbow flexors (alternate position of arm on smooth
Middle deltoid).
E. Upright (below Fair):
Posterior deltoid
Pectoral is major (sternal).
External rotators
Internal rotators
30. Suggested sequence of lower extremity muscle
test
• Turning the patient from one position into
another is fatiguing to the patient and
wasting for the therapist’s time.
• Supine: Toe flexors and extensors, tibialis
posterior and anterior, peroneals and triceps.
• Side lying: Gluteus medius and minimums
adductors, lateral abdominals and tensor
fascia lata.
• Prone: Hamstrings, gluteus maximums.
• Sitting: Quadriceps, internal and external
rotators of the hip, iliopsoas, sartorious
31. Manual Muscle Testing
Mikhled Maayah PhD, PT
Jordan university of science and technology
JUST
34. Sternocleidomatioideus
Origin: Anterior and superior manubrium and superior medial
third of clavicle
Insertion: Lateral aspect of mastoid process and anterior half of
superior nuchal line
Nerve supply: Axillary N.
35. Note
• Factors Limiting Motion:
1- Tension of posterior longitudinal ligament, ligamenta
flava, and interspinal and supraspinal ligaments
2- Tension of posterior muscles of neck
3- Apposition of lower lips of vertebral bodies anteriorly
with surfaces of subjacent vertebrae
4- Compression of intervertebral fibrocartilages in front
• Fixation:
1- Contraction of anterior abdominal muscles
2-Weight of thorax and upper extremities
36. Normal & Good
• Position: Supine.
• Stabilization: Stabilize lower thorax.
• Desired Motion: Patient flexes cervical spine through
range of motion.
• Resistance: Is given on forehead
37. Note
►If there is a difference in strength of the two
Sternocleidomastoideus muscles, they may be
tested separately by rotation of head to one side
and flexion of neck.
► Resistance is given above ear.
38. Fair & Poor
• Position: supine.
• Stabilization: Stabilize lower thorax.
• Desired Motion: Patient flexes cervical spine through
full ROM for fair grade and through partial range
for poor.
39. Trace & Zero
• The Sternocleidomastoideus muscles maybe
palpated on each side of neck as patient
attempts to flex.
40. Muscles contribute to Neck Extension
Splenius capitis Trapezius (superior fibers) Splenius cervicis Semispinalis capitis
41. Splenius capitis
• Origin: Lower ligament nuchae, spinous
processes and supraspinous ligaments T1-3
• Insertion: Lateral occiput between superior
and inferior nuchal lines
• Nerve supply: Greater occipital nerve
42. Trapezius (superior fibers)
• Origin: Base of the skull & posterior
ligaments of the neck
• Insertion: Posterior aspect of the lateral 3rd
of clavicle
• N. supply: Greater occipital nerve
43. Splenius cervicis
• Origin: Spinous processes and supraspinous ligaments of T3-T6
• Insertion: Posterior tubercles of transverse processes of C1-C3
• Action: Neck Extension
• Nerve supply:
44. Semispinalis capitis
• Origin: Transverse processes of first 6 or 7 thoracic and 7th
cervical vertebrae & Articular processes of fourth, fifth and
sixth cervical vertebrae
• Insertion: Between superior & inferior nuchal lines of
occipital bone
• Nerve supply: Greater occipital nerve
45. Note
• Factors Limiting Motion:
1-Tension of anterior longitudinal ligament of spine
2-Tension of ventral neck muscles
3-Approximation of spinous processes
• Fixation:
1-Contraction of spinal extensor muscles of thorax and
depressor muscles of scapulae and clavicles
2- Weight of trunk and upper extremities
46. Normal & Good
• Position: Prone with neck in flexion.
• Stabilization: Stabilize upper thoracic area and
scapulae.
• Desired Motion: Patient extends cervical spine
through ROM.
• Resistance: Is given on occiput.
Note:
Extensor muscles on right may be tested by
rotation of head to right with extension, and
vice versa
47. Fair & Poor
• Position: Prone with neck flexed.
• Stabilization: Stabilize upper thoracic area and
scapulae.
• Desired Motion: Patient extends cervical spine
through full ROM for fair grade or through
partial range for poor
48. Trace & Zero
• Position: Prone
• A trace may be determined by observation and
palpation of the muscles of the dorsal area of the neck.
(Test may be given with head resting on table.)
49. Note
• Be sure patient completes full range of motion of neck
extension. Back muscles may contract and lift upper
trunk from table, giving the appearance of extension in
cervical
53. Serratus Anterior
• Origin: lateral, anterior surface of the upper 8th- 9th ribs
• Insertion: Anterior aspect of the medial vertebral border of
the scapula
• Action: Shoulder Abduction to 90º
• Nerve supply: Long thoracic nerve (C5 – C7)
54. Note
• Factors Limiting Motion:
1-Tension of trapezoid ligament (limits forward
rotation of scapula upon clavicle).
2-Tension of trapezius and Rhomboid major and
minor muscles
• Fixation:
1- In strong scapular abduction, pull of external
Obliquus externus abdominus on same side.
2-Weight of thorax
55. Normal & Good
• Position: Supine with arm flexed to 90º with slight abduction,
and elbow in extension.
• Stabilization & Palpation Point: None
• Desired Motion: Patient moves arm upward by abducting the
scapula.
• Resistance: Is given by grasping around forearm and elbow.
Pressure is downward and inward toward table.
Alternate
Alternate
56. Fair
• Position: Supine with arm flexed to 90º and scapula
resting on table.
• Stabilization and Palpation: None
• Desired Motion: Patient forces arm upward. Scapula
should be completely abducted without "winging' (If
extensor muscles of elbow are weak, elbow may be flexed
or forearm may be supported.
Alternate
57. Poor
• Position: Sitting with arm flexed to 90º and arm
resting on table.
• Stabilization: Stabilize thorax.
• Desired Motion: Patient moves arm forward by
abducting scapula
Alternate
58. Trace & Zero
• Examiner lightly forces arm backward to determine
presence of a contraction of Serratus anterior.
• Scapula should be observed for "winging."
• Digitations of Serratus anterior may be palpated on
outer surface of ribs for a contraction
60. Upper Trapezius
• Origin: Base of the skull & posterior ligaments of the neck
• Insertion: Posterior aspect of the lateral 3rd of clavicle
• Nerve supply: Accessory nerve (C3 – C4)
61. Lavetor scapulae
• Origin: Transverse process of 1st four cervical
• Insertion: Medial border of the scapula
• Nerve supply: Dorsal Scapular Nerve (C5)
62. Note
• Factors Limiting Motion:
1-Tension of costoclavicular ligament
2- Tension of muscles depressing scapula and clavicle:
Pectoralis minor, subclavius, and Trapezius (lower
fibers).
• Fixation:
1-Flexor muscles of cervical spine (for tests done in
sitting position).
2-Weight of head (foe tests done in prone position).
63. Normal & Good
• Position: Sitting with arms at sides.
• Stabilization: No fixation necessary.
• Palpation point: Between lateral neck and acromion.
• Desired Motion: Patient raises shoulders as high as
possible
• Resistance: Is given downward on top of shoulders.
64. Fair
• Position: Sitting with arms at sides.
• Desired Motion: Patient elevates shoulders through
ROM.
65. Poor
• Position: Prone with shoulders supported by
examiner and forehead resting on table.
• Desired Motion: Patient moves shoulders toward
ears through ROM.
66. Trace & Zero
• Examiner palpates upper fibers of Trapezius parallel
to cervical Vertebrae and near their insertion above
clavicle.
69. Middle Trapezius
• Origin: Spinous process of 7th cervical & 1st -3rd thoracic
• Insertion:
– Medial border of acromion process
– Upper border of scapular spine
• Nerve supply: XI Accessory nerve (C3 – C4)
70. Note
• Factors Limiting Motion:
1-Tension of conoid ligament (limits backward rotation
of scapula upon clavicle)
2-Tension of Pectoralis major and minor and Serratus
anterior muscles.
3-Contact of vertebral border of scapula with spinal
musculature.
• Fixation:
• Weight of trunk.
71. Normal & Good
• Position: Prone with arm abducted to 90º and laterally rotated,
elbow flexed to a right angle.
• Stabilization: Stabilize thorax.
• Palpation point: Base of spine of scapula, fibers run horizontally
down to vertebra
• Desired Motion:
• Patient raises arm in horizontal abduction, motion taking place
primarily between the scapula and thorax and not at
glenohumeral joint.
• Scapula is adducted and fixed by middle section of the trapezius.
• Resistance: Is given on lateral angle of scapula. (no pressure is
placed on the humerus).
72. Fair
• Position: Prone with arm abducted to 90º and laterally
rotated, elbow flexed to a right angle.
• Stabilization: Stabilize thoracic
• Desired Motion: Patient raises arm and adducts
scapula
73. Poor
• Position: Sitting with arm resting on table midway
between flexion and abduction.
• Stabilization: Stabilize thorax
• Desired Motion: Patient horizontally abducts arm
and adducts scapula.
74. Trace & Zero
• Position: Sitting or Face lying.
• Palpation: Middle fibers of Trapezius are palpated
between root of spine of scapula and vertebral column
to determine presence of a contraction.
76. Lower Trapezius
• Origin: Spinous process of 4th - 12th Thoracic
• Insertion: Triangular space at the base of the
scapular spine
• Nerve supply: Accessory nerve
77. Note
• Factors Limiting Motion:
1- Tension of interclavicles ligament and articular disk
of sternoclavicular joint.
2- Tension of Trapezius (upper fibers), Levator scapular
and sternocleidomastoideus (clavicular head).
• Fixation:
1-Contraction of spinal extensor muscles
2- Weight of trunk.
78. Normal & Good
• Position: Prone with forehead resting
on table and arm to be tested extended
overhead.
• Palpation point:
• Diagonally down and medially from
the base of the spine of scapula.
• Desired Motion:
• Patient raises arm and fixates scapula
strongly with lower part of Trapezius.
• Resistance:
• Is given on lateral angle of scapula in
upward and outward direction. If
shoulder flexion is limited, arm may
be placed over edge of table.)
79. Normal & Good ***(Alternate)***
• Note:
• If Deltoideous is weak, arm is passively raised by
examiner.
• Patient attempts to assist.
• Resistance is given on scapula.
80. Fair & Poor
• Position:
• Prone with forehead resting on
table and arm overhead.
• Desired Motion:
• Patient lifts arm from table
through full range of motion
without upward movement of
the scapula or forward sagging
of the acromion process for F
grade or through partial range
for P grade.
81. Trace & Zero
• Examiner palpates fibers of lower part of Trapezius
between last thoracic vertebrae and scapula.
83. Rhomboid Major
• Origin: Spinous process of T 2 –T 7 vertebrae
• Insertion: Medial border of scapula inferior
to spine
• Nerve supply: Dorsal Scapular nerve (C5)
84. Rhomboid Minor
• Origin: Spinous process of C7 –T 1 vertebrae
• Insertion: Medial border of scapula superior to
spine
• Nerve supply: Dorsal Scapular nerve (C5)
85. Note
• Factors Limiting Motion:
1-Tension of conoid ligament (limits backward rotation of scapula
upon clavicle).
2-Tension of Pectoralis major and minor and Serratus anterior
muscles
3-Contact of vertebral border of scapula with spinal musculature
• Fixation:
Caution !!!!
• Weight of trunk
• Substitutions:
1-Middle trapezius
2-Pectoralis Minor
3-Lower trapezius
4-Latissimus Dorsi
5-Levator Scapula
86. Normal & Good
• Position: Prone with arm medially rotated and adducted
across back, with the elbow flexed and hand on buttocks.
Shoulders relaxed.
• Stabilization: Roll the shoulder forward to pull vertebral
border of scapula, to eliminate Pectoralis major.
• Palpation Point: Along vertebral border of scapula.
• Desired Motion: Patient raises arm and adducts scapula.
• Resistance: Is given on vertebral border of scapula in outward
and slightly downward direction.
87. Fair
• Position:
• Prone with arm medially
rotated and adducted across
back and shoulders relaxed.
• Desired Motion:
• Patient raises arm and adducts
scapula through range of
motion. (If the glenohumeral
muscles are weak, slight
resistance may be given to the
scapula for a fair grade.)
88. Poor
• Position:
• Sitting with arm medially rotated
and add net ed behind back.
• Stabilization:
• Stabilize trunk with anterior and
posterior pressure to prevent
flexion and rotation.
• Desired Motion:
• Patient adducts scapula through
range of motion.
89. Trace & Zero
• Examiner palpates Rhomboid muscles at the angle
formed by the vertebral border of the scapula and the
lateral fibers of the lower Trapezius.
94. Muscles contribute to Shoulder Flexion
Anterior Deltoid
• Origin:
• Anterior lateral third of the clavicle
• Insertion:
• Deltoid tuberosity on the lateral humerus
• Action:
• Shoulder Flexion
• Nerve supply:
95. Muscles contributes to Shoulder Flexion
Ccoracobrachialis
• Origin:
• Coracoid process of the scapula
• Insertion:
• Middle 1/3 of the medial surface of the
humerus
• Action:
• Shoulder Flexion
• Nerve supply:
96. Normal and Good
• Position:
• Sitting with arm at side and elbow slightly
flexed
• Stabilization:
• Stabilize scapula.
• Palpation Point:
• Between lateral portion of clavicle and
coracoid process.
• Desired motion:
• Patient flexes arm to 90º (palm down to prevent
lateral rotation with substitution by the Biceps
brachii)
• Resistance:
• Is given above elbow.( Patient should not be
allowed to rotate or horizontally adduct or
abduct arm)
97. Fair
• The same as Normal and Good
techniques but without given
resistance
98. Poor
• Position:
• Patient sideling with arm at side
resting on smooth board (or
supported by examiner) and
elbow slightly flexed.
• Stabilization:
• Stabilize scapula.
• Palpation Point:
• Between lateral portion of
clavicle and coracoid process.
• Desired motion:
• Patient brings arm forward to
90º of flexion
99. Trace and Zero
• Position:
• Back lying.
• Palpation:
• Examiner palpates fibers
of anterior portion of
Deltoid on anterior aspect
of shoulder joint.
101. Notes
• Range Of motion: 0-90º
• Factors Limiting Motion: None, Rang of
motion is incomplete
• Fixation:
• Contraction Trapezius & Serratus anterior
muscles.
• Serratus anterior and upper fibers of Trapezius
assist in upward rotation of scapula as well as
in fixation
104. Muscles contribute to Shoulder Extension
Latissimus dorsi
• Origin:
• a- Spines of lower 6 thoracic and lumbar vertebrae
• b- Posterior surface of sacrum& Posterior aspect of
crest of ileum
• c- Lower 3-4 ribs
• d- Inferior angle of scapula
• Insertion:
• Intertubercle groove of humerus
• Action:
Shoulder Extension
• Nerve supply:
105. Muscles contribute to Shoulder Extension
Teres Major
• Origin:
• Lower 1/3 of the axillary border of the
scapula
• Insertion:
• Medial lip of intertubercular groove of
humerus
• Action:
Shoulder Extension
• Nerve supply:
106. Muscles contribute to Shoulder Extension
Teres Minor
• Origin:
• Posteriorly on upper & middle aspect of
lateral border of scapula
• Insertion:
• Posterior surface of greater tubercle of the
humerus
• Action:
Shoulder Extension
• Nerve supply:
107. Normal & Good
• Position:
• Prone with arm medially rotated
and Adducted (palm up to
prevent lateral rotation).
• Stabilization:
• Stabilize scapula.
• Desired Motion:
• Patient extends arm through
range of motion.
• Resistance:
• Is given proximal to elbow.
108. Fair
• Position:
• Prone with arm at side.
• Stabilization:
• Stabilize scapula.
• Desired Motion:
• Patient extends arm through
range of motion.
109. Poor
• Position:
• Sideling with arm flexed and
resting on smooth board (or
supported by examiner).
• Stabilization:
• Stabilize scapula.
• Desired Motion:
• Patient extends arm in position
of medial rotation through range.
of motion.
110. Trace & Zero
• Position:
• Prone.
• Examiner palpates fibers of Teres major on lower part
of axillary border of scapula (not shown) and fibers of
Latissimus dorsi slightly below.
111. Note
• Range Of motion: 0-50º
• Factors Limiting Motion:
• 1-Tension of shoulder flexor muscles.
• 2-Contact of greater tubercle of humerus with
acromion posteriorly.
• Fixation:
• Contraction of Rhomboideous major and minor and
Trapezius muscles.
• Weight of trunk
113. Muscles contribute to
Shoulder Horizontal Abduction
Deltoid (posterior portion)
• Origin:
• Inferior edge of the scapular spine
• Insertion:
• Deltoid tuberosity on the lateral humerus
• Action:
Shoulder Horizontal Abduction
• Nerve supply:
114. Normal & Good
• Position:
• Prone with shoulder abducted to 90º, upper arm
resting on table and lower arm hanging vertically
over edge.
• Stabilize:
• scapula in adduction.
• Palpation point:
• Below the spine of the scapula.
• Desired motion:
• Horizontal abduction of humerus to the level of
the table 90º.
• Resistance :
• Is given proximal to elbow.
• Motion takes place primarily at glenohumeral
joint and not between scapula and thorax
115. Fair
• Position:
• Prone with shoulder abducted
to 90 degrees, upper arm
resting on table and lower arm
hanging vertically over edge.
• Stabilization:
• Stabilize scapula.
• Desired motion:
• Patient abducts upper arm
through range of motion
116. Poor
• Position:
• Sitting with arm supported in
a position of 90º of flexion.
• Stabilization:
• Stabilize scapula.
• Desired Motion:
• Patient horizontally abducts
arm through range of
motion.
117. Trace & Zero
• Muscle fibers of posterior portion of Deltoid are
palpated on posterior aspect of shoulder joint.
118. Note
• Factors Limiting Motion:
1-Tension of anterior fibers of capsule of glenohumeral joint
2- Tension of Pectoralis major and Deltoid (anterior fibers)
• Fixation:
• Contraction of Rhomboid major and minor and Trapezius
(primarily) middle and lower fibers)
• Substitution:
• 1- Adduction of scapula with Trapezius.
Caution !!!!!
• 2- Long head of the triceps.
• 3- Teres Major
• 4- Latissimus to some extend
120. Muscles contribute to
Shoulder Horizontal Adduction
Upper pectoralis major
• Origin:
• Medial half of anterior surface of clavicle
• Insertion:
• Intertubercle groove of humerus
• Action:
• Shoulder Horizontal Adduction
• Nerve supply:
121. Muscles contribute to
Shoulder Horizontal Adduction
Lower pectoralis major
• Origin:
• Anterior surface of costal cartilage of first six
ribs, adjacent portion of sternum
• Insertion:
• Intertubercle groove of humerus
• Action:
• Shoulder Horizontal Adduction
• Nerve supply:
122. Normal & Good
• Position:
• Supine with arm abducted to 90
degrees.
• Stabilization:
• Stabilize scapula to prevent abduction
of the scapula.
• Palpation:
• Below and near the origin at sternal
end of the clavicle.
Palpation
• Desired Motion:
• Patient adducts arm through range of
motion.
• Resistance:
• Is given proximal to elbow joint.
123. Fair
• Position:
• Supine with arm abducted to
90º.
• Stabilization:
• Stabilize scapula to prevent
abduction of the scapula.
• Palpation:
• Below and near the origin at
sternal end of the clavicle.
• Desired motion:
• Patient adducts arm to
vertical position.
124. Poor
• Position:
• Sitting with arm resting on
table in 90º of abduction.
• Stabilization:
• Stabilize trunk.
• Palpation:
• Below and near the origin at
sternal end of the clavicle.
• Desired motion:
• Patient brings arm forward
through ROM.
125. Trace & Zero
• Examiner palpates tendon of Pectoralis major near insertion
on anterior aspect of upper arm.
• Muscle fibers of both sternal and clavicular portions may be
observed and palpated on upper anterior aspect of thoracic.
126. Note
• Factor limiting Motion:
• Tension of shoulder extensor muscles
• Contact of arm with trunk.
• Fixation:
• In forceful horizontal adduction, contraction of
Obliquus externus abdominus muscle on same side.
• Substitution:
• 1-Anterior portion of deltoid
• 2-Coracobrachialis
• 3- Short Head of biceps.
128. Muscles contribute to
Shoulder External Rotation
Teres Minor
• Origin:
• Posteriorly on upper & middle aspect
of lateral border of scapula
• Insertion:
• Posterior surface of greater tubercle of
the humerus
• Action:
Shoulder Extension
• Nerve supply:
129. Muscles contribute to
Shoulder External Rotation
Infraspinatus
• Origin:
• Posteriorly on upper & middle aspect of
lateral border of scapula
• Insertion:
• Posterior surface of greater tubercle of
the humerus
• Action:
Shoulder Extension
• Nerve supply:
130. Normal & Good
• Position:
• Prone with shoulder abducted to 90º,
upper arm supported on table and lower
arm hanging vertically over edge.
• Stabilization:
• Stabilize scapula with hand and
forearm, but allow freedom for rotation.
• Palpation point:
• None
• Desired motion:
• Patient swings lower arm forward and
up-ward and 'laterally rotates shoulder
through range of motion.
• Resistance:
• Is given above wrist on forearm.
131. Fair
• Position:
• Prone with shoulder abducted to 90º,
upper arm supported on table and lower
arm hanging vertically over edge.
• Stabilization:
• Stabilize scapula and place hand against
anterior surface of arm to prevent
abduction (without interfering with
motion).
• Palpation:
• None
• Desired motion:
• Patient swings lower arm forward and
up-ward and laterally rotates shoulder
through ROM.
132. Poor
• Position:
• Prone with entire arm over edge table
in medially rotated positron.
• Stabilization:
• Stabilize scapula.
• Palpation:
• None
• Desired Motion:
• Patient laterally rotates arm through
range of motion. (supination of the
forearm should not be allowed to
substitute for full range in lateral
rotation.)
133. Trace & Zero
• The Teres minor may be palpated on axillary
border of scapula, and Infraspinatus over body of
scapula below the spine.
134. Note
• Factors Limiting Motion:
• a- Tension of superior portion of scapular ligament.
• b- Tension of lateral rotator muscles of shoulder.
• Fixation:
• a- Weight of trunk.
• b- Contraction of Trapezius and Rhomboid major
and minor muscles to fix scapula
• Substitutions:
1. Wrist extensors
2. Roll the shoulder backwards.
136. Muscles contribute to
Shoulder Internal Rotation
Subscapularis
• Origin:
• Anterior surface of subscapular
fossa
• Insertion:
• Lesser tubercle of the humerus
• Action:
• Shoulder Internal Rotation
• Nerve supply:
137. Muscles contribute to
Shoulder Internal Rotation
Upper pectoralis major
• Origin:
• Medial half of anterior surface of clavicle
• Insertion:
• Intertubercle groove of humerus
• Action:
• Shoulder Internal Rotation
• Nerve supply:
138. Muscles contribute to
Shoulder Internal Rotation
Lower pectoralis major
• Origin:
• Anterior surface of costal cartilage of first six
ribs, adjacent portion of sternum
• Insertion:
• Intertubercle groove of humerus
• Action:
• Shoulder Internal Rotation
• Nerve supply:
139. Muscles contribute to
Shoulder Internal Rotation
Latissimus dorsi
• Origin:
• a- Spines of lower 6 thoracic and lumbar vertebrae
• b- Posterior surface of sacrum& Posterior aspect of
crest of ileum
• c- Lower 3-4 ribs
• d- Inferior angle of scapula
• Insertion:
• Intertubercle groove of humerus
• Action:
• Shoulder Internal Rotation
• Nerve supply:
140. Normal & Good
• Position:
• Prone with shoulder abducted to 90 degrees,
upper arm supported on table and lower arm
hanging vertically over edge.
• Stabilization:
• Stabilize scapula with hand and forearm, but
allow freedom for rotation.
• Palpation:
• None
• Desired Motion:
• Patient swings lower arm backward and up-
ward and medially rotates shoulder through
range of motion.
• Resistance:
• Is proximal to wrist on forearm.
141. Fair
• Position:
• Prone with shoulder abducted to 90 degrees, upper arm
supported on table and lower arm hanging vertically over
edge.
• Stabilization:
• Stabilize scapula.
• Palpation:
• None
• Desired Motion:
• Patient swings lower arm backward and up-ward and
medially rotates shoulder through range of motion.
142. Poor
• Position:
• Prone with arm over edge of table in lateral rotation.
• Stabilization:
• Stabilize scapula.
• Palpation:
• None
• Desired Motion:
• Patient medially rotates arm through range of motion.
(Pronation of the forearm should not be
allowed to substitute for full range in medial
rotation.)
143. Trace & Zero
• Fibers of Subscapularis may be palpated deep in axilla
near insertion.
145. Muscles contribute to
Shoulder Abduction to 90º
Middle Deltoid
• Origin:
• Acromion process
• Insertion:
• Deltoid tuberosity on the lateral humerus
• Action:
• Shoulder Abduction to 90º
• Nerve supply:
146. Muscles contribute to
Shoulder Abduction to 90º
Supraspinatus
• Origin:
• Supraspinatus fossa
• Insertion:
• Greater tubercle of the humerus
• Action:
• Shoulder Abduction to 90º
• Nerve supply:
147. Note
• Factors Limiting Motion:
• None: range of motion incomplete.
• Fixation:
• Contraction of Trapezius and Serratus anterior
muscles.
• Serratus anterior and upper fibers of trapezius
assist in upward rotation of scapula as well as
in fixation.
148. Normal & Good
• Position:
• Sitting with arm at side in mid-position
between medial and lateral rotation.
• Elbow flexed a few decrees.
• Stabilization:
• Stabilize scapula.
• Palpation:
• Just below the acromion process of the
scapula.
• Desired Motion:
• Patient abducts the humerus to 90º(palm
down).
• Resistance :
• Is given proximal to elbow
149. Fair
• Position:
• Sitting with arm at side in midposition
between medial and lateral rotation.
• Elbow flexed a few degrees.
• Stabilization:
• Stabilize scapula.
• Palpation:
• Just below the acromion process.
• Desired Motion:
• Patient abducts arm to 90º (palm down).
150. Poor
• Position:
• Supine with arm at side in
midposition between medial and
lateral rotation.
• Elbow slightly flexed.
• Stabilization:
• Stabilize scapula over acromion.
Alternate
• Desired Motion:
• Patient abducts arm to 90º
without Lateral rotation at
shoulder joint
151. Trace & Zero
• Examiner palpates middle section of Deltoid on
lateral surface of upper third of arm
152. Note
• Patient may laterally rotate arm and attempt to
substitute Biceps brachii during abduction.
• Arm should be kept in midposition between medial and
lateral rotation.
153. Note
• Range of Motion: 0° TO 90°
• Factors Limiting Motion:
• Tension of expansions of extensor ten-dons of
fingers.
• Fixation:
• Weight of arm
155. Introduction
1. It is the measuring of angles created by the bones
of the body at the joints.
2. These joints are measured by a goniometer.
3. It has a moving arm, stationary arm, and the
fulcrum.
4. The fulcrum or body is placed over the joint being
measured and on it is a scale from 0 to 180°.
5. The stationary arm will be aligned with the inactive
part of the joint measured, while the moving arm is
placed on the part of the limb which is moved in
the joint’s motion.
6. For example, when measuring knee flexion, the
stationary arm will be aligned over the thigh in line
with the greater trochanter of the femur.
156. Introduction - continue
7. The fulcrum is aligned over the knee joint or lateral epicondyle of
the femur, and the moving arm with the midline of the leg or
lateral malleolus.
8. Performing these tests is important for many reasons.
• The mobility of joints is important for diagnosis and
determining the presence or absence of dysfunction.
9. In a chronic condition, goniometry can measure the progression
of the disorder.
• An example of this is the progression of rheumatoid
arthritis.
10. Furthermore, joint motion measurement can evaluate
improvements or lack of progression during rehabilitation.
11. This not only provides motivation for the patient when there are
improvements, but also can decipher if modifications need to
be made if treatment is not effective.
157. Flexion
Patient Instructions:
• Once the goniometer is aligned
properly ask the patient to lift the arm
up just as if they were raising their
hand to ask a question.
• Be sure that the patient keeps the palm
of their hand facing in toward their
body.
158. Starting Position
• Patient is supine with
arm at side and the palm
of the hand facing the
body.
• The fulcrum of the
goniometer is placed
over the acromion
process.
• The stationary and
moving arms are aligned
with the midline of the
humerus and lateral
epicondyle.
159. Ending Position
• The moving arm remains in line
with the lateral epicondyle and
midline of the humerus.
• The examiner supporting the
patient’s extremity.
• The stationary arm should
remain in its starting position,
only now it should be in line
with the lateral midline of the
thorax.
• Normal ROM for glenohumeral
flexion is 160 to 180º; in the
picture the patient is in 180º of
flexion.
161. Starting Position
• Patient is prone with
arm at side; make sure
the head is facing away
from the shoulder being
tested.
• Elbow bent slightly and
the palm facing in
toward the body.
• The fulcrum is placed
over the acromion
process.
• The stationary and
moving arms are aligned
with the lateral midline
of the humerus and the
lateral epicondyle.
162. Ending Position
• The moving arm remains in
line with the lateral
epicondyle and the
examiner should support
the patient’s extremity.
• The stationary arm in line
with the midline of the
thorax.
• Normal ROM for
glenohumeral extension is
40 to 60º; in the picture the
patient is in 61º of
extension.
163. Abduction
• Patient Instructions:
• Have the patient bring their arm out to
their side and as close to their head as
they can.
• Make sure that their palm faces upward
throughout the motion.
164. Starting Position
• The patient is supine
with arm at side; the
palm should be facing
interiorly.
• The fulcrum is placed at
the acromion process.
• The stationary and
moving arms are
aligned with the
anterior midline of the
humerus.
165. Ending Position
• The stationary arm
should remain still and
parallel to the sternum.
• The moving arm
should still be resting
at the anterior midline
of the humerus.
• Normal ROM between
160 and 180º; the
patient in the picture is
in 174º of abduction
166. Medial (Internal( Rotation
• Patient Instructions:
• Ask the patient to rotate their arm
down as far as they can.
167. Starting Position
• Supine with 90º of
shoulder abduction and
the elbow is in 90º of
flexion.
• The table should not
support the elbow.
• The fulcrum centered over
the olecranon process.
• The moving arm is aligned
with the ulnar styloid and
the stationary arm should
be perpendicular to the
floor.
168. Ending Position
• Same as above
• Normal ROM is 60-
70 ˚ ; the patient is in
68º of internal
rotation.
169. Lateral (External( Rotation
• Patient Instructions:
• Ask the patient to rotate their arm up
toward their head as far as they can.
170. Starting and Ending Position
• Supine with 90º of shoulder
abduction and 90º of elbow
flexion.
• The table should not support
the elbow. (Refer to above
picture)
• Fulcrum on the olecranon
process.
• The moving arm should be
aligned with the ulnar styloid
and the stationary arm
should be perpendicular to
the floor.
• Ending Position:
• Same as before
171. Normal ROM Reference
Values
Shoulder Typical ROM
Flexion 160 - 180˚
Extension 40 - 60˚
Abduction 160 - 180˚
Internal Rotation 60-70˚
External Rotation 40 - 45˚
175. SURFACE ANATOMY OF THE
ELBOW
• Lateral elbow - labeled
Lateral Epicondyle
Olecranon
176. The bones (Figs. 1-4)
Figure 1 Diagrammatic AP view of elbow joint
Figure 2 Diagrammatic lateral view of elbow
joint. Note that the elbow is slightly twisted in
respect of the axis of the ulna.
177. • Figure 5 Diagrammatic view of the
medial collateral ligament, with its
three bundles. The anterior bundle
is the most important functionally,
since it provides valgus and
anteroposterior stability.
Figure 6 Diagrammatic view of the
lateral ligament complex. It would
appear that the most import
structure is the lateral collateral
ligament, which blends with the
annular ligament. The lateral ulnar
collateral ligament is indissociable
from the lateral collateral ligament,
at its attachment to the lateral
epicondyle. Distally, it branches
off, and attaches to the supinator
crest. The role of the accessory
lateral collateral ligament is poorly
understood.
Figure 7 Diagrammatic view of the
origin and insertion of anconeus,
which covers the capsule and
collateral ligaments on the lateral
side.
178. Diseases of the elbow joint
• Arthritis
• Fractures
• Bursitis
• Tendonitis (Tinness elbow and Glover's
elbow)
• Cubital Tunnel Syndrome
183. INSPECTION
• The patient should be standing, with shoulders slightly
braced back, to display the elbow.
• When the forearm is in full extension and supination, there
will be a physiological valgus ("carrying angle") of 9-14°; in
women, the angle will be 2-3° greater
• This angle has been found to be 10-15° greater in the
dominant arm of throwing athletes
• This angle allows the elbow to be tucked into the waist
depression above the iliac crest; it increases when a
heavy object is being lifted
• Any increase in, or loss of, this physiological angle is
indicative either of major elbow instability or of malunion.
• However, the angle varies from valgus in extension to
varus in flexion, and its measurement is not of any
practical importance.
184. Inspection
• Sometimes, on the side of the elbow, bulging
in the para-olecranon groove will be seen;
such a swelling is produced by an effusion or
by synovial tissue proliferation
• On the back, prominence of the olecranon is
a sign of posterior subluxation of the elbow,
a feature commonly found in RA .
• Rheumatoid nodules are extremely
common
• Bursitis is also a frequently encountered
pathology, especially in RA patients.
• Skin atrophy at steroid injection sites, or
scars from previous surgery.
185. Figure 8
The physiological valgus (“carrying angle”) of the
elbow is increased when a load is being carried.
Normally, the angle is between 9 and 14° when the
elbow is extended and the forearm is supinated.
186. PALPATION
• Palpation starts at the posterior aspect,
with the patient standing with his or her
shoulder braced backwards.
• The three palpation landmarks - the two
epicondyles and the apex of the olecranon
- form an equilateral triangle when the
elbow is flexed 90°, and a straight line
when the elbow is in extension (Figs. 9,
10).
187. PALPATION
Figures 9, 10
Three bony landmarks - the medial epicondyle, the lateral
epicondyle, and the apex of the olecranon - form an
equilateral triangle when the elbow is flexed 90°, and a
straight line when the elbow is in extension
188. PALPATION
• Since the elbow is a very superficial joint, it can
be readily palpated from behind and from the
sides.
• The posterior aspect has the olecranon mid-way
between the medial and the lateral condyle.
• Slight elbow flexion will bring the olecranon out
of the olecranon fossa, in which it lodges in
extension; in this position, the proximal portion of
the fossa on either side of the triceps tendon
may be palpated (Fig. 11)
189. PALPATION
• Figure 11 Flexing the elbow allows
palpation of the olecranon fossa on
either side of the triceps tendon.
• Figure 12 Anatomical landmarks
on the lateral aspect of the elbow:
The lateral epicondyle continues
proximally in the supracondylar
ridge.
• Two 2cms distally, the main
landmark is formed by the radial
head.
190. • The olecranon bursa is not in communication with
the synovial cavity.
• This is why the elbow may be mobilized in
bursitis, and why even massive bursitis will not be
tender.
• In chronic bursitis, a boggy globular mass may be
palpated; the overlying skin will be thickened. Flat,
hard nodules may be felt under the palpating
fingertips.
• In infected bursitis, the skin will be tight and
shiny; streaks of lymphangitis will be commonly
seen; while in 25% of the cases, the axillary
lymph nodes will be enlarged.
• On the lateral side, the main landmarks are the
lateral epicondyle proximally and the radial head
distally.
191. • The supracondylar ridge is also very accessible to
palpation; its chief value is that of a landmark for
surgical approaches (Fig. 12).
• Sometimes, palpation may be carried out all the
way up to the deltoid tuberosity.
• The radial head is palpated with the examiner’s
thumb, while the other hand is used to pronate and
supinate the forearm (Fig. 13).
• The head is about 2 cm distal to the lateral
epicondyle
• Inside the triangle formed by the bony
prominences of the lateral epicondyle, the radial
head and the olecranon, the joint itself is palpated,
to detect even very minor effusions or low-grade
synovitis (Fig. 14(
192. Figure 13
• Anatomical landmarks on the lateral aspect of the elbow:
• The radial head is palpated with the thumb, while the
examiner’s other hand is used to pronate and supinate the
forearm
PALPATION
.Figure 14
• The elbow joint may be palpated inside a triangle formed by
the bony prominences of the lateral epicondyle, the radial
head, and the olecranon.
• This palpation will reveal even minor effusions or mild
synovitis.
• Puncture for joint aspiration is performed inside this triangle.
• Similarly, an arthroscopy portal may be placed there
(posterolateral portal(
193. • Figure 15 Palpation and
testing of brachioradialis,
a forearm flexor.
• Figure 16 Palpation and
testing of the wrist
extensors
PALPATION
194. PALPATION
• From the medial side, the joint is not very accessible to palpation, and the
small amount of synovial tissue on the medial border of the olecranon
makes joint palpation difficult
• Palpation of the ridge that provides insertion for the intermuscular septum is
useful mainly as a guide for surgical approaches. Also, the supracondylar
lymph nodes may be palpated at this site (Fig. 17).
• Over, and slightly anterior to, the supracondylar ridge, a bony excrescence
may be palpated; this outgrowth may irritate the median nerve
• This supracondylar process is present in 1-3% of the population, and is
seen at a distance of 5-7 cm above the joint line
• Behind the septum, the ulnar nerve may be palpated; in patients with a very
mobile nerve, it may be seen to roll on the medial condyle(10) (Fig. 18).
• Ulnar nerve instability is more easily tested with the arm in slight abduction
and external rotation, with the elbow flexed between 20 and 70°.
195. Figure 17
• Palpation of the medial aspect of the elbow.
• Above the medial epicondyle is the ridge on
which the intermuscular septum inserts.
• Two centimetres above the epicondyle is the
site used for lymph node palpation.
Figure 18
The ulnar nerve is palpated
behind the intermuscular
septum.
It may sometimes sublux or roll
on the epicondyle.
Ulnar nerve instability is more
readily demonstrated if the
elbow is flexed 60° and the
upper limb is abducted and
externally rotated.
196. PALPATION
• Anteriorly, the bulk of the flexor-pronator group restricts the
extent of joint palpation.
• The flexor-pronator muscles must be tested as a unit, by
asking the patient to perform wrist adduction and flexion
against resistance (Fig. 19).
• Next, each one of these muscles should be tested individually.
• The anterior aspect does not lend itself to palpation, since it is
tucked away behind the muscles.
• Laterally, brachioradialis will be felt; and in the middle, the
biceps tendon is readily accessible if the patient is made to flex
the forearm against resistance.
• Lacertus fibrosus is palpated medial to the biceps tendon; the
pulse of the brachial artery will be felt deep to this aponeurosis
(Fig. 20).
• Sometimes anterior protrusion cysts produced by herniated
synovial membrane may be felt.
197. Figure 19
Diagrammatic view of the pattern of
the flexor-pronator group: The thumb
represents pronator teres; the index,
flexor carpi radialis; the middle
finger, palmaris longus; and the ring
finger, flexor carpi ulnaris.
Figure 20
Palpation of the medial biceps
expansion (lacertus fibrosus), which
courses over the brachial vessels
and the median nerve.
198. MOBILITY
• The main function of the elbow is to bring the hand
to the mouth; this is why the investigation of the
elbow range of movement (ROM) is an important part
of the examination process.
• Any difference between passive and active mobility
is usually due to reflex inhibition from pain
• The end-feel - the feeling transmitted to the
examiner’s hands at the extreme range of passive
motion - must also be assessed (Table 1)
• If the feel is abnormal, there is usually something
wrong with the joint.
199. Table 1 Classification and description of end-feels
(modified from TS Ellenbecker & AJ Mattalino)(12a(
Bony Two hard surfaces meeting,
bone to bone (elbow
extension(
Capsular Leathery feel, further motion
available (forearm pronation
and supination(
Soft tissue approximation Soft tissue contact (elbow
flexion(
Spasm Muscle contraction limits
motion
Springy block Intra-articular block;
rebound is felt
Empty Movement causes pain, pain
limits movement
200. ELBOW JOINT
• The elbow is a complex joint with three different
articulations.
• The humeroulnar joint is a hinge joint, and
allows the forearm to flex and extend, and
provides stability.
• The radiohumeral and radioulnar joints allow for
flexion, extension and rotation of the radius on
the ulna, which in turn allows the forearm to
pronate and supinate.
201. RANGE OF MOTION
• Flex and extend, and supinate and
pronate.
• Normal elbow range of motion
• Extension: 0°
• Flexion: 150°
• Pronation: 70°
• Supination: 90°
204. Starting Position
• Position: Supine, arm in the anatomical position with arm of the
patient is resting on the edge of the table.
• The fulcrum aligned with the lateral epicondyle of the humerus.
• The stationary arm is positioned along the midline of the humerus
• The moving arm is aligned with the radial styloid process.
205. Ending Position
• The arm is now flexed at the elbow, the goniometer
should still be aligned with the correct anatomical
landmarks as described below.
• Normal ROM is between 150-160º, the patient has 155º
of elbow flexion.
206. Pronation
• Patient Instructions:
• Have the patient turn their wrist down toward the ground.
• Starting Position:
• Patient sitting up with elbow bent 90 degrees and at patient’s
side, wrist in a handshake position.
• The fulcrum is placed just behind the ulnar styloid process.
• The moving arm and stationary arm are parallel with the anterior
midline of the humerus.
207. Ending Position
• The fulcrum should remain in the same position as above.
• The stationary arm will still be aligned parallel to the midline of
the humerus, the moving arm will lie across the dorsum of the
forearm just behind the ulnar and radial styloid processes.
• Normal ROM is 90-96º, the patient has 95º of pronation.
208. Supination
• Patient Instructions:
• Have the patient turn their palm up as if they are holding
something in the palm of their hand.
• Starting Position:
• Patient position is the same as for pronation.
• The goniometer is placed on the medial aspect of the forearm
with the fulcrum at the radioulnar joint.
• The arms are both aligned with the anterior midline of the
humerus.
209. Ending Position
• The moving arm will be resting on the medial forearm
at the radioulnar joint.
• The moving arm should remain parallel to the midline
of the humerus.
• Normal ROM is 81-93º, the patient has 90º of
Supination.
210. Normal ROM Reference
Values
Elbow Typical ROM
Flexion 150-160º
Extension 0
Pronation 90-96º
Supination 81-93º
213. Muscles contribute to Elbow Flexion
Brachioradialis
• Origin:
• Upper 2/3 of lateral supracondylar ridge of
humerus
• Insertion:
• Styloid process of radius
• Action:
• Elbow Flexion
• Nerve supply:
214. Muscles contribute to Elbow Flexion
Biceps Brachii
• Origin:
• Long head: supraglenoid tubercle
• Short head: coracoid process
• Insertion:
• Radial tuberosity
• Action:
• Elbow Flexion
• Nerve supply
215. Muscles contribute to Elbow Flexion
Brachialis
• Origin:
• Lower portion of anterior surface of humerus
• Insertion:
• Coronoid process of ulna
• Action:
• Elbow Flexion
• Nerve supply
216. Normal & Good
• Position:
• Sitting with slight shoulder flexion and the
elbow flexed past 90°, forearm is supinated.
• Ask the patient to, “hold your elbow bent,
and don’t let me straighten it out.”
• Palpation:
• Muscle belly or just medial on crease of
elbow tendon.
• Stabilization:
• Stabilizing hand is placed on the shoulder.
• Desired Motion:
• Patient flexes elbow through range of
motion.
• Resistance
• Is given at the wrist in a downward direction.
217. Normal & Good
Biceps brctchii : forearm in supination Brachialis : forearm in pronation
Brachioradialis: forearm in midposition between
pronation and supination
218. Fair
• Position:
• Sitting with arm at side and
forearm supinated
• Stabilization:
• Stabilize upper arm.
• Desired Motion:
• Patient flexes elbow through
range of motion.
219. Poor
• Position:
• Supine with shoulder abducted to 90 and
laterally rotated ْ.
• Stabilization:
• stabilizing hand is placed on the shoulder.
• Desired Motion:
• Patient slides forearm along table
through complete range of elbow flexion.
• (If range of motion is limited in lateral
rotation at shoulder joint, test may be
given with arm medially rotated.)
220. Trace & Zero
• Examiners palpate the flexors on the forearm; muscle
fibers may be found on anterior surface of arm.
221. Alternate Test for Elbow Flexion
• This alternate test is performed if
the biceps and brachialis are
weak.
• Pronating the hand will instead
use the brachioradialis, extensor
carpi radialis longus, pronator
teres, and other wrist flexors.
• Patients positioning is the same,
except the forearm is now
pronated and the stabilizing hand
is under the elbow joint.
• Testing procedure is the same as
before.
222. Note
• Note:
• The wrist flexors may be contracted for assistance in
elbow flexion.
• Wrist will be strongly flexed as a result. Wrist should
be relaxed.
223. Note
• Range of motion: 0º to 145º - 160º
• Factors Limiting Motion:
1-Contact of muscle masses volar aspect of arm and forearm.
2-Contact of coronoid process with coronoid fossa of humerus
• Fixation:
1-Weight of arm
2-Fixator muscles of scapula
• Substitutions:
1. Brachioradialis
2. Flexors group of the wrist and fingers:FCR, FCU, palmaris
longus, FDS, FPL and pronator teres.
225. Muscles contribute to Elbow Extension
Triceps Brachii
• Origin:
• Long head: Scapula, infraglenoid tubercle
• Lateral head: Humerus, 1/3 lateral-posterior surface
• Medial head: Humerus, lower 3/4 of posterior surface
• Insertion: Olecranon process of ulna
• Nerve supply
226. Note
• Range of Motion: 145º – 160º to 0º
• Factors Limiting Motion:
1-Tension of anterior, radial and ulnar collateral ligaments of
elbow joint.
2-Tension of flexor muscles of forearm.
3-Contact of olecranon process with olecranon fossa on posterior
aspect of humerus.
• Fixation:
1-Weight of arm
2-Contraction of Fixator muscles of scapula.
• Substitutions Muscles:
1-Rotators
2-Wrist extensors
3-Anconeous
227. Normal & Good
• Position:
• Patient is prone on the table with the shoulder abducted to 90°,
the entire arm should be off the table and the therapist can
stabilize the arm at the humerus just above the elbow. The elbow
should be in full extension.
• Palpation: Proximal to olecranon process.
• Stabilization: Stabilize arm.
• Desired Motion: Patient extends elbow through ROM.
• Resistance: Is applied at wrist in a downward direction.
228. Fair
• Position: Supine with shoulder flexed to 90ْ and elbow flexed.
• Palpation: The same as before
• Stabilization: Stabilize arm.
• Desired Motion: Patient extends elbow through range of
motion
Alternate
229. Poor
• Position: Supine with arm abducted to 90 degrees and laterally
rotated. Elbow is flexed.
• Stabilization: Stabilize arm.
• Desired Motion: Ask the patient to, “straighten your elbow,
don’t let him bend it down.
(if range of motion is limited in lateral rotation at shoulder
joint, test may be given with arm medially rotated)
230. Trace & Zero
• Examiner may palpate tendon of Triceps brachii at the
elbow joint and muscle fibers on posterior surface of
arm.
232. Biceps Brachii
• Origin:
• Long head: supraglenoid tubercle
• Short head: coracoid process
• Insertion: Radial tuberosity
• Nerve supply
233. Muscles contribute to Forearm Supination
Supinator Teres
• Origin:
• lateral epicondyle of Humerus
• posterior part of ulna
• Insertion: upper 1/3 lateral surface of Radius.
• Nerve supply
234. Note
• Range of motion: 0ºTO 90º Supination from
midposition
• Factors Limiting Motion:
1-Tension of Volar radioulnar ligament and ulnar
collateral ligament of wrist joint.
2-Tension of oblique cord and lowest fibers of
interosseous muscles of forearm.
• Fixation:
• Weight of arm
235. Normal & Good
• Position: Sitting with arm at side, elbow flexed to 90 degrees and
forearm pronated to prevent rotation at the shoulder. Muscles of
wrist and fingers are; relaxed.
• Stabilization: Stabilize arm.
• Desired Motion: Patient supinates forearm.
• Resistance: Is given on dorsal surface of distal end of radius.
(Resistance may be given by grasping around the dorsal surface of
the hand instead of the position illustrated.)
236. Fair & Poor
• Position: Fair
• Silting with arm at side, elbow flexed
to 90º, forearm pronated and
supported by examiner.
• Muscles of wrist and fingers are
relaxed.
• Desired Motion:
Poor
• Patient supinates forearm through full
range of motion for fair grade and
through partial for poor grade.
237. Trace & Zero
• Supinator muscle is palpable on radial side of
forearm if overlying extensor muscles are not
functioning. Tendon of Biceps brachii is found in
antecubital space
238. Note
• Patient should not be allowed to laterally
rotate arm and move elbow across
thorax as forearm is supinated.
• As a result of this movement the forearm
may appear to be supinated, but range of
motion is incomplete.
• This motion may "roll" the forearm into
supination without a muscular contraction
taking place.
241. Note
• Range of motion: 0º to 90º Pronation from
midposition
• Factors Limiting Motion:
1-Tension of dorsal radioulnar, ulnar collateral and
dorsal radiocarpal ligaments.
2-Tension of lowest fibers of interosseous membrane.
• Fixation:
• Weight of arm
242. Normal & Good
• Position:
• Sitting with arm at side, elbow flexed to 90º
to prevent rotation at the shoulder and
forearm supinated. Muscles of wrist and
fingers are relaxed.
• Stabilization:
• Stabilize arm.
• Desired Motion:
• Patient pronates forearm through ROM.
• Resistance :
• Is given on volar surface of distal end of
radius with counterpressure against the
dorsal surface of the ulna.
243. Fair & Poor
• Position: Fair
• Sitting with arm at side, elbow flexed
to 90º, forearm supinated and
supported by examiner. Muscles of
wrist and fingers are relaxed.
• Desired Motion:
• Patient pronates forearm through full
Poor
range of motion for fair grade and
through partial range for poor grade
244. Trace & Zero
• Position:
• Sitting.
• Palpation:
• Examiner palpates fibers of
Pronator teres on upper third of
volar surface of forearm on a
diagonal line from medial condyle
of humerus to lateral border of
radius
245. Note
• Patient should not be allowed to medially rotate or abduct
upper arm during pronation.
• This movement makes the ROM in pronation appear complete
and allows forearm to roll into pronated position
251. Flexor carpi radialis
• Origin: Medial epicondyle of humerus
• Insertion: Base of 2nd & 3rd metacarpals,
anterior surface
• Nerve supply: Median Nerve (C6, C7)
252. Flexor carpi ulnaris
• Origin: Medial epicondyle of humerus
• Insertion: Pisiform, hamate & base of 5th
metacarpal
• Nerve supply: Ulnar Nerve C7, T1)
253. Note
• Range of Motion: Wrist flexion: 0 to 90 ْ
• Factors Limiting Motion:
• Tension of dorsal radiocarpal ligament
• Fixation:
• Weight of arm
254. Normal & Good
• Position: Sitting with forearm resting on table
with forearm supinated.
• Muscles of thumb and fingers relaxed.
• Stabilization: Stabilize forearm.
• Desired Motion: Patient flexes wrist
255. Note
• To test Flexor carpi radialis, resistance is
given at base of second metacarpal bone in
direction of extension and ulnar deviation
256. Note
• To test Flexor carpi ulnaris, resistance is given
at base of fifth metacarpal bone in direction of
extension and radial deviation
257. Fair
• Position: Sitting with forearm resting on table with forearm
supinated. Muscles of thumb and fingers relaxed.
• Stabilization: Stabilize forearm.
• Desired Motion: Patient flexes wrist with radial deviation or
ulnar deviation
Flexor carpi radialis
Flexor carpi ulnaris
258. Poor
• Position: Sitting, forearm supported, hand resting on medial
border. Muscles of thumb and fingers relaxed.
• Stabilization: Stabilize forearm.
• Desired Motion: Patient flexes wrist, sliding hand along
table. Deviation should be observed and muscles graded
accordingly.
259. Trace & Zero
• Examiner palpates tendon of Flexor carpi radialis
on lateral palmar aspect of wrist and tendon of
Flexor carpi ulnaris on medial palmar surface.
261. Muscles contribute to Wrist Extension
Extensor carpi radialis longus
• Origin: Humerus, lower 3rd of lateral supracondylar ridge
and lateral epicondyle of humerus
• Insertion: Base of 2nd metacarpal (dorsal surface)
• Nerve supply: Radial Nerve
262. Extensor carpi radialis Brevis
• Origin: Lateral epicondyle of humerus
• Insertion: Base of 3rd metacarpal (dorsal surface)
• Nerve supply: Radial Nerve
263. Extensor carpi Ulnaris
• Origin: Lateral epicondyle of humerus
• Insertion: Base of 5th metacarpal
• Nerve supply: Ulnar Nerve
264. Note
• Range of Motion:
• Wrist extension beyond midline; 0 to 70º
• Factors Limiting Motion:
• Tension of palmar radiocarpal ligament
• Fixation:
• Weight of arm
Caution!!!!
265. Normal & Good
• Position:
• Sitting with forearm resting on the table and pronated.
• Muscles of fingers and thumb relaxed.
• Stabilization: Stabilize forearm.
• Desired Motion: Patient extends wrist.
266. Note
• To test Extensor carpi radialis longus and
Brevis, resistance is given on dorsal surface of second
and third metacarpal bones in direction of flexion and
ulnar deviation.
267. Note
• To test Extensor carpi ulnaris, resistance is given on
dorsal surface of fifth metacarpal bone in direction of
flexion and radial deviation.
268. Fair
• Position:
• Sitting with forearm resting on the table and pronated.
• Muscles of fingers and thumb relaxed.
• Stabilization: Stabilize forearm.
• Desired Motion: Patient extends wrist with radial
deviation or ulnar deviation.
269. Poor
• Position: Sitting, forearm supported, hand resting on medial
border.
• Stabilization: Stabilize forearm.
• Desired Motion:
• Patient extends wrist, sliding hand along table through range of
motion.
• Deviation should be observed and muscles graded accordingly
270. Trace & Zero
• Tendons of wrist extensors may be found on lateral dorsal
surface of wrist in line with second and third metacarpal
bones and on medial dorsal surface proximal to fifth
metacarpal bone.
274. Muscles contribute to Flexion of
metacarpophalangeal joints of fingers
Lumbricales
• Origin:
• Four tendons of flexor digitorum
profundus.
• Radial 2: radial side only (unipennate).
• Ulnar 2: cleft between tendons ( bipennate)
• Insertion:
• Proximal phalanx of fingers 2-5 radial side
• Action:
• Flexion of MP joints
• Nerve supply
275. Normal & Good
• Position:
• Sitting with hand resting on dorsal
surface.
• Stabilization:
• Stabilize metacarpals.
• Desired Motion:
• Patient flexes fingers at MCP joints,
keeping IP joints extended.
• Resistance:
• Is given on palmar surface of proximal
row of phalanges.
• Note: Resistance may be given to each
finger separately if Lumbricales are
unequal in strength.
276. Fair & Poor
• Position:
• Sitting with hand supported.
• Stabilization:
• Stabilize metacarpals.
• Desired Motion:
• Patient flexes fingers at MCP joints
through ROM, keeping IP joints
extended.
• Patient flexes MCP joints through full
ROM for fair grade and through partial
range for poor grade.
277. Trace & Zero
• Contraction of Lumbricales may be detected by light
pressure against palmar surface of proximal phalanges as
patient attempts to flex at MCP joints.
278. Note
• The Flexor digitorum superficialis and Flexor digitorum
profundus should not be allowed to substitute for
Lumbricales with flexion of fingers.
• These muscles should be kept relaxed as much as possible
with motion limited to meta-carpophalangeal joint.
• Individual testing of fingers (in all tests) is often desirable
as they vary in strength.
Caution!!!!
279. Flexion of Proximal Interphalangeal Joints of Fingers
Flexor digitorum superficialis
285. Trigger Finger
• Definition
• Trigger finger is an inflammation of the synovial sheath
that encloses the flexor tendons of the thumb and
fingers. Tendons are the cords that connect bones to
muscles in the body. Usually, tendons slide easily
through the sheath as the finger moves.
• In the case of trigger finger, however, the synovial
sheath becomes swollen and the tendon cannot move
easily through small pulleys in the finger, causing the
finger to remain in a flexed (bent) position.
• In mild cases, the finger may be straightened with a
pop, like a trigger being released.
• In severe cases, the finger becomes stuck in the bent
position.
• Usually this condition can easily be treated; contact
your doctor if you think you may have trigger finger.
286. Causes
• Often, the cause of trigger finger is unknown.
However, many cases of trigger finger are caused by
one of the following:
• Overuse of the hand from repetitive motions
– Computer operation
– Machine operation
– Repeated use of hand tools
– Playing musical instruments
• Inflammation caused by a disease
– Rheumatoid arthritis
– Gout
– Hypothyroidism
287. Risk Factors
• The following factors increase your
chances of developing trigger finger:
• Age: 40-60
• History of repetitive hand motions for work
or play
• Sex: female
• History of certain diseases:
– Rheumatoid arthritis
– Gout
– Hypothyroidism
288. Symptoms
• If you experience any of these symptoms do
not assume it is due to trigger finger. Some
of these symptoms may be caused by other
health conditions. If you experience any one
of them for a period of time, see your
physician.
– Finger or thumb stiffness
– Finger, thumb, or hand pain
– Swelling or a lump in the palm
– Catching or popping when straightening the
finger or thumb
– Finger or thumb stuck in bent position
289. Diagnosis
• Your doctor will ask about your symptoms
and medical history, and perform a
physical exam. The physical exam may
include:
• Asking you to move the affected finger or
thumb
• Feeling the hand and fingers
• For severe cases of trigger finger, your
doctor may refer you to a hand specialist.
290. Treatment
• The goals of treatment for
tenosynovitis are:
–to reduce swelling and pain
–to allow the tendon to move
freely with the tendon
sheath.
291. • Treatment options include the
following:
• Rest
• Stopping movement in the finger or
thumb, sometimes with the help of a
brace or splint, is often the best
treatment for mild cases of trigger
finger.
• Rest may be combined with
stretching of the muscle tendon unit
involved.
292. • Medications
• Several medications are used to treat tenosynovitis.
These include:
• Corticosteroids, given as an injection into the
synovial tendon sheath to reduce swelling of the
tendon sheath
• Nonsteroidal anti-inflammatory drugs (NSAIDs) to
help reduce inflammation and pain:
– Ibuprofen (Advil, Motrin)
– Naproxen (Aleve, Naprosyn)
• For severe cases of trigger finger that do not respond
to medications, surgery may be used to release the
finger from a locked position and to allow the tendon
to move freely through the sheath.
• This surgery is usually performed on an outpatient
basis and requires only a small incision in the palm of
the hand.
293. Prevention
• The most important action you can take to
prevent trigger finger is to avoid overuse of
your thumb and fingers.
• If you have a job or hobby that involves
repetitive motions of the hand, you can take
the following steps:
– Adjust your workspace to minimize the strain on
your joints
– Alternate activities when possible
– Take breaks throughout the day
– Exercise regularly
294. Muscles contribute to Flexion of proximal interphalangeal
joints of fingers
Flexor digitorum superficialis
• Origin:
• Humeral head: common flexor origin of medial epicondyle
humerus, medial ligament of elbow.
• Ulnar head: medial border of coronoid process and fibrous arch.
• Radial head: whole length of anterior oblique line
• Insertion:
• Tendons split to insert onto sides of middle phalanges of medial
four fingers
• Action:
• Flexion of PIP & DIP joints
• Nerve supply
295. Normal & Good
• Position:
• Sitting with hand resting palm upward on
table and fingers extended.
• Stabilization:
• Stabilize proximal phalanx of finger.
• Desired Motion:
• Patient flexes middle phalanx.
• Resistance:
• Is given on palmar surface of middle
phalanx of finger.
296. Fair & Poor
• Patient flexes proximal phalanx through full range of
motion for fair grade and through partial range for
poor grade.
297. Trace & Zero
• Superficial portion of the Flexor digitorum
superficialis may be palpated at the wrist under the
Palmaris longus
299. Flexion of Distal Interphalangeal Joints of Fingers
Flexor digitorum profundus
300. Muscles contribute to Flexion of distal interphalangeal
joints of fingers
Flexor digitorum profundus
• Origin:
• Medial olecranon, upper three quarters of anterior and
medial surface of ulna as far round as subcutaneous
border and narrow strip of interosseous membrane
• Insertion:
• Distal phalanges of medial four fingers.
• Tendon to index finger separates early
• Action:
• Flexion of PIP & DIP joints
• Nerve supply
301. Normal & Good
• Position:
• Sitting with hand resting palm upward on table and fingers
extended.
• Stabilization:
• Stabilize middle phalanx of finger.
• Desired Motion:
• Patient flexes distal phalanx.
• Resistance:
• Is given on palmar surface of distal phalanx of finger
302. Fair & Poor
• Patient flexes distal phalanx through full ROM for
fair grade and through partial range for poor grade.
303. Trace & Zero
• Flexor digitorum profundus may be palpated
on the palmar surface of the middle phalanx
305. Extension of metacarpophalangeal joints of fingers
Extensor digitorum communis Extensor indicis proprius Extensor digiti minimi
306. Muscles contribute to Extension of
metacarpophalangeal joints of fingers
Extensor digitorum communis
• Origin:
• Common extensor origin on anterior aspect of lateral epicondyle
of humerus
• Insertion:
• External expansion to middle and distal phalanges by four
tendons. Tendons 3 and 4 usually fuse and little finger just
receives a slip
• Action:
• Extension of MP joints
• Nerve supply
307. Muscles contribute to Extension of
metacarpophalangeal joints of fingers
Extensor indicis proprius
• Origin:
• Lower posterior shaft of ulna (below extensor pollicis longus) and
adjacent interosseous membrane
• Insertion:
• Extensor expansion of index finger (tendon lies on ulnar side of
extensor digitorum tendon)
• Action:
• Extension of MP joints
• Nerve supply
308. Muscles contribute to Extension of
metacarpophalangeal joints of fingers
Extensor digiti minimi
• Origin:
• Common extensor origin on anterior aspect of lateral epicondyle
of humerus
• Insertion:
• Extensor expansion of little finger-usually two tendons which are
joined by a slip from extensor digitorum at metacarpophalangeal
joint
• Action:
• Extension of MP joints
• Nerve supply
309. Normal & Good
• Position:
• Arm resting on table, hand
supported, wrist in midposition,
fingers flexed.
• Stabilization:
• Stabilize metacarpals.
• Desired Motion:
• Patient extends proximal row of
phalanges with IP joints partially
flexed.
• Resistance :
• Is given on dorsal surface of
proximal row of phalanges of
fingers.
310. Fair & Poor
• Position:
• Sitting with hand supported, fingers
flexed and wrist in midposition.
• Stabilization:
• Stabilize metacarpals.
• Desired Motion:
• Patient extends proximal row of
phalanges to end of range, with IP
joints partially flexed.
• Patient extends MCP joints through
full ROM for grade of fair and
through partial range for grade of
poor
311. Trace & Zero
• The tendons of the finger extensors may easily be
located on dorsum of hand where they pass over
metacarpals.
313. Muscles contribute to Finger Abduction
Interossei dorsales
• Origin:
• Bipennate from inner aspects of shafts of all
metacarpals
• Insertion:
• Proximal phalanges and dorsal extensor
expansion on radial side of index and middle
fingers and ulnar side of middle and ring
fingers
• Action:
• Finger Abduction
• Nerve supply
314. Muscles contribute to Finger Abduction
Abductor digiti minimi
• Origin:
• Pisiform bone, pisohamate ligament and flexor
retinaculum
• Insertion:
• Ulnar side of base of proximal phalanx of little
finger and extensor expansion
• Action:
• Finger Abduction
• Nerve supply
