Muscle Testing of The Upper and Lower Extremities: Physiotherapy Division

Muscle Testing of the Upper
and Lower Extremities

Physiotherapy Division
Dr. Mikhled Maayah
Guide muscle testing

This guide was developed out of a need to assist the
therapist in utilizing a standard method of muscle
testing in patients at this facility.
It is based on the denials and Worthingham method
of muscle testing.
It was originally developed approximately a long
time ago as a procedure to assist physiotherapy
students who working with the physically disabled.
Since that time it has been utilized by staff, who
have given suggestions over a period of years to
make it more meaningful and useful to gain
proficiency and consistency in muscle testing.
Introduction
The general direction of treatment today is to
consider the whole patient in terms of what we do to
help him gain maximum recovery and independence.
To accomplish this we must think of him in terms of
his status at the beginning of treatment, the
prognosis, the plan of treatment and the progress
noted under this plan.
It should be a matter of professional pride that we be
able to provide accurate and meaningful information,
when it is requested of us.
Introduction- continue
As therapists, we consider muscle evaluations
from two points of view:
For our use own as guides to planning of specific
treatment routines and to determine the success or
failure of these routines.
To provide the physicians with whom we work with
information which will be helpful to them in:
diagnosis
prescription for treatment
prescription for bracing
determination of progress and prognosis.
There are certain specific things which we want to
knew. These are:
Is the muscle active?

Is the muscle functional?
How functional is it?
Is spasticity present?
What substitute patterns are present?
What positions the patients assumes at rest?
What positions the patients assumes on activity?
What deformities are present and to what degree?
What stage of motor development has been reached?
What are the specific motor handicaps which keep him
developing more rapidly or becoming more independent?
In addition, the therapist must be able to convey to
the patient what is expected of him in a testing
procedure and then be able to record the results of
the test in concise way.
Testing by a well trained therapist saves time for the
physician and can be great help to him.
Objective testing done at stated intervals serves not
only to record progress, or lack of it, but gives us an
excellent opportunity to evaluate the technique used.
It also gives information needed to report intelligently
to the physician on the status of the patient.
Definition of muscle test

A muscle test is an attempt to determine the ability
of a patient to activate skeletal muscle.
Available range of motion: this is the passive range
which is easily obtained by the examiner without
feeling resistance.
Example: If passive range measured in elbow flexion
is 0 90 degree and patient actively moves 0 90
degree, then he will have moved through complete
available range of motion.
Muscle test is used as: Basis of muscle re-education and

exercise.
Determining factor for supportive
apparatus.
Aid in determining diagnosis.
Aid in prognosis of a patient.
Requisites for good muscle

testing
Knowledge of anatomy as well as functional.

Correct starting position-changes with muscle being tested.
Stabilization of proximal segment and body as a whole.
Area of palpation-knowledge of where and how to palpate.
knowledge of the substitutions muscles (synergic muscles,
assisting muscles, direct fixation muscles, indirect fixation
muscles and antagonistic muscles).
Recognition of substitution.
Knowledge of normal muscle and muscle groups (action
and appearances).
Ability to convey ideas to patient and guide the movement.
Record deformities, limitations in motion, spasticity and
tremor, strength within range must be recorded (grade low
when in doubt about strength of a muscle).
Terminology
Test Range: is set up for specific test of specify muscle
not necessarily complete ROM.
Easy Test: gravity eliminated test or position that will give
you a grade of 0, Trace, Poor -, Poor.
Hard Test: anti-gravity (against), method used to obtain
grades from Fair+ to normal.
Palpation: ability of therapist to feel contraction of muscle
being tested.
Resistance: applied at the end of ROM, pressure should
be applied in a direction as nearly
opposite to
the line of pull of the
muscle or group, as
possible.
Muscle grading techniques

Grades are obtained on varies of gravity,
gravity eliminated, against gravity, gravity
plus manual resistance.
Some grades are obtained by palpation.
Stretch range used for some grades range
beyond neutral position, usually used in
rotation.
Grades
The following muscle grades are described in
comparison with a normal muscle.
It is important to keep in mind that muscles of normal
strength vary in strength tremendously within the body.,
owing to the size of the muscle and to the work each
muscle is normally required to perform.
Normal strength likewise varies between individuals,
owing to differences in age and body requirements.
Therefore, in grading muscles above fair, the degree of
objectivity increases with the therapists increasing
knowledge of normal strength of various age groups and
body requirements for that particular muscle, prior to
illness or injury.
Grades
Zero (O): No movement of part; contraction cannot be palpated

Trace (T): Contraction can be palpated; no movement of part.
Poor minus (P-): Gravity eliminated, part moves through only a
portion of the range of available, not necessarily normal, passive
ROM.
Poor (P): Gravity eliminated, part moves through complete available
ROM.
Fair: Against gravity, part moves through complete available ROM,
but cannot take additional resistance.
Fair Plus (F+): Part moves through complete available ROM against
gravity with slight resistance (for that muscle) at end of range.
Good (G): Part moves through complete available ROM against
gravity and takes moderately strong resistance (for that muscle)
at end of range.
Normal (N): Part moves through complete available ROM against
gravity and takes strong resistance (for that muscle) at the end of
range.
Recording
All grades below fair are recorded in red for easily
identifiable areas of weakness; grades of fair and
above are recorded in blue or black ink and dated.
Indicate all muscles not tested during any
evaluation by marking N.T in the appropriate
place.
Outline of technique for administering

the manual muscle test
Determine the ROM of joint (joints) passively.
Line up the part with fibers of the muscle to be
tested.
Provide adequate stabilization.
Have the patient attempt motion through the test
range.
Look at the muscle or movement first.
Palpate at the tendon or muscle belly.
Apply resistance at the end of the range if the
muscle is strong enough (Break Test).
Outline of technique for administering

the manual muscle test
Resistance should be applied firmly and
smoothly in line with direction of the muscle of
segment of a muscle being tested.
You may compare the strength of the normal
segment with the one being tested to aid in
determine the strength grade.
Never give a grade on motion alone. It must
possible to palpate the muscle.
Record grade and date and initial the test form.
Normal in relation to muscle testing: normal for
are, sex and sounded parts.
Some basic principles

1. Take your time.
2. Start with a gross observation of function
around a joint.
3. Patient instruction.
4. Be consistent.
5. Grading.
6. Check yourself.
7. Suggested sequence of extremities muscle
test.
Some basic principles

1. Take your time:
Dont rush to a conclusion about a grade.
Use plus or minus if patients performance is
consistent with stated definitions of grades.
If patients performance is not consistent
with stated definitions, use descriptive
terminology, e.g. biceps remains F+ but is
taking more resistance than last test.
2. Start with a gross observation of function

around a joint:
Observe the ROM around the joint as it is often a clue
to muscle imbalance.
Then observe gross movement around the joint before
touching with hands.
Observe muscle atrophy.
Observe and check muscle tone.
The presence of spasticity may negate the value and
appropriateness of performing a manual muscle test.
Be aware of sensory deficits as they may affect
patients ability to follow directions.
3. Patient instruction:
It is important to give patients all sensory
and verbal clues needed for best
performance.
This may include:
Demonstrations
Taking part through motion desired
Allowing patient to see part being tested
Allowing practice through muscle re-education
techniques (when appropriate)
Using simple instructions.
4. Be consistent:
Begin by testing the muscle against-gravity, then
test in a gravity-eliminated position if muscle is
below Fair.
Always apply resistance at the end of the motion
rather than during the motion.
Resistance is usually applied at the distal end of
the part and opposite to the direction of pull.
5. Grading:
When utilizing the grading system above, examiner
must observe proper testing position of the patient
for the muscle being tested.
When it is not possible to assume proper testing
position, e.g. due to contractures, casts, medical
precautions, it is important to determine presence
or absence of muscle in question.
In this case, the degree of contraction can be
determined as weak or strong, utilizing palpation
and observable active motion.
Because some body parts cannot be positioned to
work against gravity, the grading of some muscles
is modified, as indicated in the procedure to follow.
Recognize that larger muscles would take maximum
effort by tester to resist a strong muscle and
proportionally less effort for smaller muscles.
The gravity factor in Grading

For other muscles, the gravity free and ant-gravity
positions are impractical because gravity may not be an
important factor (Finger flexors, toe flexors, forearm
pronators and supinators, rotators of the shoulders and
hips).
From a mechanical stand-point this is true because the
weight of the part is so small in comparison with strength of
the muscle.
Foot, hand or their range of motion is much that if the initial
position is anti-gravity, the end position is with gravity.
Supinators and pronators could be scored:
Tr : perception of attempted assistance in stretch range
6. Check yourself on the following factors:

What is the primary action of the muscle
being tested?
Is the patient in the proper test position?
For example, if patients biceps is less than
F in a sitting position, have I repositioned
for gravity eliminated grading?
Have I stabilized the part proximal to the
part on which the muscle acts?
Have I observed to see that the motion

produced is the motion requested, e.g. is
there extraneous motion at joints proximal
and/or distal to the part being tested?
Have I palpated after observing the motion?
Have I applied resistance in the proper place
at the end of motion?
Have I graded, using the proper definition of
grades.
7. Suggested sequence of extremities muscle

test
The following suggested sequence first

provided to enable the tester to efficiently
perform all the tests with the least amount
of re-positioning of the patient.
Note that all muscles which can be tested
for both above and below F are grouped
together.
Suggested sequence of upper extremity

muscle test
A. UPRIGHT:
Elbow, Forearm, wrist and Hand.
Serratus anterior and pectoral is major
(clavicular).
Anterior deltoid
Middle deltoid
Upper trapezius
Latissimus dorsi F+ and above
B. PRONE:
Triceps
External rotators
Internal rotators
Posterior deltoid
Rhomboids
Middle trapezius
Lower trapezius
Latissimus F- and below.
C. Sideling: with weight of arm supported on a smooth

board.
Anterior deltoid
D. SUPINE
Pectoralis major (sternal)
Triceps (alternate position) support weight.
Elbow flexors (alternate position of arm on smooth
Middle deltoid).
E. Upright (below Fair):
Posterior deltoid
Pectoral is major (sternal).
External rotators
Internal rotators
Suggested sequence of lower extremity muscle

test
Turning the patient from one position into
another is fatiguing to the patient and
wasting for the therapists time.
Supine: Toe flexors and extensors, tibialis
posterior and anterior, peroneals and triceps.
Side lying: Gluteus medius and minimums
adductors, lateral abdominals and tensor
fascia lata.
Prone: Hamstrings, gluteus maximums.
Sitting: Quadriceps, internal and external
rotators of the hip, iliopsoas, sartorious
Manual Muscle Testing

Mikhled Maayah PhD, PT
Jordan university of science and technology
JUST
Neck Manual Muscle Testing
Neck Flexion
Sternocleidomatioideus
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.
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
Normal & Good

Position: Supine.
Stabilization: Stabilize lower thorax.
Desired Motion: Patient flexes cervical spine through
range of motion.
Resistance: Is given on forehead
Note
If there is a difference in strength of the two
Sternocleidomastoideus muscles, they may be
tested separately by rotation of head to one side
and flexion of neck.
Resistance is given above ear.
Fair & Poor

Position: supine.
Stabilization: Stabilize lower thorax.
Desired Motion: Patient flexes cervical spine through
full ROM for fair grade and through partial range
for poor.
Trace & Zero

The Sternocleidomastoideus muscles maybe
palpated on each side of neck as patient
attempts to flex.
Muscles contribute to Neck Extension
Splenius capitis Trapezius (superior fibers) Splenius cervicis Semispinalis capitis
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
Trapezius (superior fibers)

Origin:
Base of the skull & posterior

ligaments of the neck
Insertion: Posterior aspect of the lateral 3rd
of clavicle
N. supply: Greater occipital nerve
Splenius cervicis
Origin: Spinous processes and supraspinous ligaments of T3-T6

Insertion: Posterior tubercles of transverse processes of C1-C3
Action: Neck Extension
Nerve supply:
Semispinalis capitis
Origin: Transverse processes of first 6 or 7 thoracic and 7th
cervical vertebrae & Articular processes of fourth, fifth and
sixth cervical vertebrae
Insertion: Between superior & inferior nuchal lines of
occipital bone
Nerve supply: Greater occipital nerve
Note
1-Tension of anterior longitudinal ligament of spine
2-Tension of ventral neck muscles
3-Approximation of spinous processes
Fixation:
1-Contraction of spinal extensor muscles of thorax and
depressor muscles of scapulae and clavicles
2- Weight of trunk and upper extremities
Normal & Good

Position: Prone with neck in flexion.
Stabilization: Stabilize upper thoracic area and scapulae.
Desired Motion: Patient extends cervical spine through
ROM.
Resistance: Is given on occiput.
Note:
Extensor muscles on right may be tested by
rotation of head to right with extension, and
vice versa
Fair & Poor

Position: Prone with neck flexed.
Stabilization: Stabilize upper thoracic area and
scapulae.
Desired Motion: Patient extends cervical spine
through full ROM for fair grade or through
partial range for poor
Trace & Zero

Position: Prone
A trace may be determined by observation and
palpation of the muscles of the dorsal area of the neck.
(Test may be given with head resting on table.)
Note
Be sure patient completes full range of motion of neck
extension. Back muscles may contract and lift upper
trunk from table, giving the appearance of extension in
cervical
Scapular Motions
Muscles contribute to
Scapular Abduction & Upward Rotation
Serratus Anterior
Serratus Anterior
Origin: lateral, anterior surface of the upper 8th- 9th ribs
Insertion: Anterior aspect of the medial vertebral border of
the scapula
Action: Shoulder Abduction to 90
Nerve supply: Long thoracic nerve (C5 C7)
Note
1-Tension of trapezoid ligament (limits forward
rotation of scapula upon clavicle).
2-Tension of trapezius and Rhomboid major and
minor muscles
Fixation:
1- In strong scapular abduction, pull of external
Obliquus externus abdominus on same side.
2-Weight of thorax
Normal & Good

Position: Supine with arm flexed to 90 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
Fair
Position: Supine with arm flexed to 90 and scapula
resting on table.
Stabilization and Palpation: None
Desired Motion: Patient forces arm upward. Scapula
should be completely abducted without "winging' (If
extensor muscles of elbow are weak, elbow may be flexed
or forearm may be supported.
Alternate
Poor
Position: Sitting with arm flexed to 90 and arm
resting on table.
Stabilization: Stabilize thorax.
Desired Motion: Patient moves arm forward by
abducting scapula
Alternate
Trace & Zero

Examiner lightly forces arm backward to determine
presence of a contraction of Serratus anterior.
Scapula should be observed for "winging."
Digitations of Serratus anterior may be palpated on
outer surface of ribs for a contraction
Muscles contribute to Scapular Elevation
Upper Trapezius
Levator scapulae
Upper Trapezius
Origin: Base of the skull & posterior ligaments of the neck
Insertion: Posterior aspect of the lateral 3rd of clavicle
Nerve supply: Accessory nerve (C3 C4)
Lavetor scapulae
Origin: Transverse process of 1st four cervical
Insertion: Medial border of the scapula
Nerve supply: Dorsal Scapular Nerve (C5)
Note
1-Tension of costoclavicular ligament
2- Tension of muscles depressing scapula and clavicle:
Pectoralis minor, subclavius, and Trapezius (lower
fibers).
Fixation:
1-Flexor muscles of cervical spine (for tests done in
sitting position).
2-Weight of head (foe tests done in prone position).
Normal & Good
Position: Sitting with arms at sides.

Stabilization: No fixation necessary.
Palpation point: Between lateral neck and acromion.
Desired Motion: Patient raises shoulders as high as
possible
Resistance: Is given downward on top of shoulders.
Fair
Position: Sitting with arms at sides.
Desired Motion: Patient elevates shoulders through
ROM.
Poor
Position: Prone with shoulders supported by
examiner and forehead resting on table.
Desired Motion: Patient moves shoulders toward
ears through ROM.
Trace & Zero

Examiner palpates upper fibers of Trapezius parallel
to cervical Vertebrae and near their insertion above
clavicle.
Note
Muscles contribute to Scapular

Adduction
Middle Trapezius
Middle Trapezius
Origin: Spinous process of 7th cervical & 1st -3rd thoracic
Insertion:
Medial border of acromion process
Upper border of scapular spine
Nerve supply: XI Accessory nerve (C3 C4)
Note
1-Tension of conoid ligament (limits backward rotation
of scapula upon clavicle)
2-Tension of Pectoralis major and minor and Serratus
anterior muscles.
3-Contact of vertebral border of scapula with spinal
musculature.
Fixation:
Weight of trunk.
Normal & Good

Position: Prone with arm abducted to 90 and laterally rotated, elbow
flexed to a right angle.
Stabilization: Stabilize thorax.
Palpation point: Base of spine of scapula, fibers run horizontally down to
vertebra
Desired Motion:
Patient raises arm in horizontal abduction, motion taking place primarily
between the scapula and thorax and not at glenohumeral joint.
Scapula is adducted and fixed by middle section of the trapezius.
Resistance: Is given on lateral angle of scapula. (no pressure is placed on
the humerus).
Fair
Position: Prone with arm abducted to 90 and laterally
rotated, elbow flexed to a right angle.
Stabilization: Stabilize thoracic
Desired Motion: Patient raises arm and adducts
scapula
Poor
Position: Sitting with arm resting on table midway
between flexion and abduction.
Stabilization: Stabilize thorax
Desired Motion: Patient horizontally abducts arm
and adducts scapula.
Trace & Zero

Position: Sitting or Face lying.
Palpation: Middle fibers of Trapezius are palpated
between root of spine of scapula and vertebral column
to determine presence of a contraction.
Scapular Depression & Adduction
Lower Trapezius
Lower Trapezius
Origin: Spinous process of 4th - 12th Thoracic
Insertion: Triangular space at the base of the
scapular spine
Nerve supply: Accessory nerve
Note
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.
Normal & Good

Position: Prone with forehead resting
on table and arm to be tested extended
overhead.
Palpation point:
Diagonally down and medially from
the base of the spine of scapula.
Desired Motion:
Patient raises arm and fixates scapula
strongly with lower part of Trapezius.
Resistance:
Is given on lateral angle of scapula in
upward and outward direction. If
shoulder flexion is limited, arm may
be placed over edge of table.)
Normal & Good ***(Alternate)***

Note:
If Deltoideous is weak, arm is passively raised by
examiner.
Patient attempts to assist.
Resistance is given on scapula.
Fair & Poor

Position:
Prone with forehead resting on
table and arm overhead.
Desired Motion:
Patient lifts arm from table
through full range of motion
without upward movement of
the scapula or forward sagging
of the acromion process for F
grade or through partial range
for P grade.
Trace & Zero

Examiner palpates fibers of lower part of Trapezius
between last thoracic vertebrae and scapula.
Scapular Adduction & Downward Rotation
Rhomboid Major
Rhomboid Minor
Rhomboid Major
Origin: Spinous process of T 2 T 7 vertebrae
Insertion: Medial border of scapula inferior
to spine
Nerve supply: Dorsal Scapular nerve (C5)
Rhomboid Minor
Origin: Spinous process of C7 T 1 vertebrae
Insertion: Medial border of scapula superior to
spine
Nerve supply: Dorsal Scapular nerve (C5)
Note
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
Normal & Good

Position: Prone with arm medially rotated and adducted
across back, with the elbow flexed and hand on buttocks.
Shoulders relaxed.
Stabilization: Roll the shoulder forward to pull vertebral
border of scapula, to eliminate Pectoralis major.
Palpation Point: Along vertebral border of scapula.
Desired Motion: Patient raises arm and adducts scapula.
Resistance: Is given on vertebral border of scapula in outward
and slightly downward direction.
Fair
Position:
Prone with arm medially
rotated and adducted across
back and shoulders relaxed.
Desired Motion:
Patient raises arm and adducts
scapula through range of
motion. (If the glenohumeral
muscles are weak, slight
resistance may be given to the
scapula for a fair grade.)
Poor
Position:
Sitting with arm medially rotated
and add net ed behind back.
Stabilization:
Stabilize trunk with anterior and
posterior pressure to prevent
flexion and rotation.
Desired Motion:
Patient adducts scapula through
range of motion.
Trace & Zero

Examiner palpates Rhomboid muscles at the angle
formed by the vertebral border of the scapula and the
lateral fibers of the lower Trapezius.
Testing the
Muscles of the
Upper Extremity
Shoulder Joint
Shoulder Flexion
Anterior Deltoid
Ccoracobrachialis
Muscles contribute to Shoulder Flexion
Anterior Deltoid
Origin:
Anterior lateral third of the clavicle
Insertion:
Deltoid tuberosity on the lateral humerus
Action:
Shoulder Flexion
Nerve supply:
Muscles contributes to Shoulder Flexion
Ccoracobrachialis
Origin:
Coracoid process of the scapula
Insertion:
Middle 1/3 of the medial surface of the
humerus
Action:
Shoulder Flexion
Nerve supply:
Normal and Good

Position:
Sitting with arm at side and elbow slightly
flexed
Stabilization:
Stabilize scapula.
Palpation Point:
Between lateral portion of clavicle and
coracoid process.
Desired motion:
Patient flexes arm to 90 (palm down to prevent
lateral rotation with substitution by the Biceps
brachii)
Resistance:
Is given above elbow.( Patient should not be
allowed to rotate or horizontally adduct or
abduct arm)
Fair
The same as Normal and Good
techniques but without given
resistance
Poor
Position:
Patient sideling with arm at side
resting on smooth board (or
supported by examiner) and
elbow slightly flexed.
Stabilization:
Stabilize scapula.
Palpation Point:
Between lateral portion of
clavicle and coracoid process.
Desired motion:
Patient brings arm forward to
90 of flexion
Trace and Zero
Position:
Back lying.
Palpation:
Examiner palpates fibers
of anterior portion of
Deltoid on anterior aspect
of shoulder joint.
Caution!!!!
Notes
Range Of motion: 0-90
Factors Limiting Motion: None, Rang of motion
is incomplete
Fixation:
Contraction Trapezius & Serratus anterior
muscles.
Serratus anterior and upper fibers of Trapezius
assist in upward rotation of scapula as well as in
fixation
Shoulder Extension
Latissimus dorsi
Teres Major
Teres Minor
Muscles contribute to Shoulder Extension
Latissimus dorsi
Origin:
a- Spines of lower 6 thoracic and lumbar vertebrae
b- Posterior surface of sacrum& Posterior aspect of
crest of ileum
c- Lower 3-4 ribs
d- Inferior angle of scapula
Insertion:
Intertubercle groove of humerus
Action:
Shoulder Extension
Nerve supply:
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:
Teres Minor
Origin:
Posteriorly on upper & middle aspect of
lateral border of scapula
Insertion:
Posterior surface of greater tubercle of the
humerus
Action:
Shoulder Extension
Nerve supply:
Normal & Good

Position:
Prone with arm medially rotated
and Adducted (palm up to
prevent lateral rotation).
Stabilization:
Stabilize scapula.
Desired Motion:
Patient extends arm through
range of motion.
Resistance:
Is given proximal to elbow.
Fair
Position:
Prone with arm at side.
Stabilization:
Stabilize scapula.
Desired Motion:
Patient extends arm through
range of motion.
Poor
Position:
Sideling with arm flexed and
resting on smooth board (or
supported by examiner).
Stabilization:
Stabilize scapula.
Desired Motion:
Patient extends arm in position
of medial rotation through range.
of motion.
Trace & Zero

Position:
Prone.
Examiner palpates fibers of Teres major on lower part
of axillary border of scapula (not shown) and fibers of
Latissimus dorsi slightly below.
Note
Range Of motion: 0-50

1-Tension of shoulder flexor muscles.
2-Contact of greater tubercle of humerus with
acromion posteriorly.
Fixation:
Contraction of Rhomboideous major and minor and
Trapezius muscles.
Weight of trunk
Shoulder Horizontal Abduction
Deltoid (posterior portion)
Deltoid (posterior portion)
Origin:
Inferior edge of the scapular spine
Insertion:
Action:
Nerve supply:
Normal & Good
Position:
Prone with shoulder abducted to 90, 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 90.
Resistance :
Is given proximal to elbow.
Motion takes place primarily at glenohumeral
joint and not between scapula and thorax
Fair
Position:
Prone with shoulder abducted
to 90 degrees, upper arm
resting on table and lower arm
hanging vertically over edge.
Stabilization:
Stabilize scapula.
Desired motion:
Patient abducts upper arm
through range of motion
Poor
Position:
Sitting with arm supported in
a position of 90 of flexion.
Stabilization:
Stabilize scapula.
Desired Motion:
Patient horizontally abducts
arm through range of
motion.
Trace & Zero

Muscle fibers of posterior portion of Deltoid are
palpated on posterior aspect of shoulder joint.
Note
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
Shoulder Horizontal Adduction
Upper pectoralis major
Lower pectoralis major
Origin:
Medial half of anterior surface of clavicle
Insertion:
Action:
Nerve supply:
Origin:
Anterior surface of costal cartilage of first six
ribs, adjacent portion of sternum
Insertion:
Action:
Nerve supply:
Normal & Good
Position:
Supine with arm abducted to 90
degrees.
Stabilization:
Stabilize scapula to prevent abduction
of the scapula.
Palpation:
Below and near the origin at sternal
end of the clavicle.
Desired Motion:
Patient adducts arm through range of
motion.
Resistance:
Is given proximal to elbow joint.
Palpation
Fair
Position:
Supine with arm abducted to
90.
Stabilization:
Stabilize scapula to prevent
abduction of the scapula.
Palpation:
Below and near the origin at
sternal end of the clavicle.
Desired motion:
Patient adducts arm to
vertical position.
Poor
Position:
Sitting with arm resting on
table in 90 of abduction.
Stabilization:
Stabilize trunk.
Palpation:
Below and near the origin at
sternal end of the clavicle.
Desired motion:
Patient brings arm forward
through ROM.
Trace & Zero

Examiner palpates tendon of Pectoralis major near insertion
on anterior aspect of upper arm.
Muscle fibers of both sternal and clavicular portions may be
observed and palpated on upper anterior aspect of thoracic.
Note
Factor limiting Motion:

Tension of shoulder extensor muscles
Contact of arm with trunk.
Fixation:
In forceful horizontal adduction, contraction of
Obliquus externus abdominus muscle on same side.
Substitution:
1-Anterior portion of deltoid
2-Coracobrachialis
3- Short Head of biceps.
Shoulder External Rotation
Teres Minor
Infraspinatus
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:
Infraspinatus
Origin:
Posteriorly on upper & middle aspect of
lateral border of scapula
Insertion:
Posterior surface of greater tubercle of
the humerus
Action:
Shoulder Extension
Nerve supply:
Normal & Good
Position:
Prone with shoulder abducted to 90,
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
upward and 'laterally rotates shoulder
through range of motion.
Resistance:
Is given above wrist on forearm.
Fair
Position:
Prone with shoulder abducted to 90,
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
upward and laterally rotates shoulder
through ROM.
Poor
Position:
Prone with entire arm over edge table
in medially rotated positron.
Stabilization:
Stabilize scapula.
Palpation:
None
Desired Motion:
Patient laterally rotates arm through
range of motion. (supination of the
forearm should not be allowed to
substitute for full range in lateral
rotation.)
Trace & Zero

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

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.
Shoulder Internal Rotation
Subscapularis
U. Pectoralis Major
L. Pectoralis Major Latissimus Dorsi
Subscapularis
Origin:
Anterior surface of subscapular
fossa
Insertion:
Lesser tubercle of the humerus
Action:
Nerve supply:
Origin:
Medial half of anterior surface of clavicle
Insertion:
Action:
Nerve supply:
Origin:
Anterior surface of costal cartilage of first six
ribs, adjacent portion of sternum
Insertion:
Action:
Nerve supply:
Origin:
Latissimus dorsi
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:
Action:
Nerve supply:
Normal & Good
Position:
Prone with shoulder abducted to 90 degrees,
upper arm supported on table and lower arm
hanging vertically over edge.
Stabilization:
Stabilize scapula with hand and forearm, but
allow freedom for rotation.
Palpation:
None
Desired Motion:
Patient swings lower arm backward and up
ward and medially rotates shoulder through
range of motion.
Resistance:
Is proximal to wrist on forearm.
Fair
Position:
Prone with shoulder abducted to 90 degrees, upper arm
supported on table and lower arm hanging vertically over
edge.
Stabilization:
Stabilize scapula.
Palpation:
None
Desired Motion:
Patient swings lower arm backward and upward and
medially rotates shoulder through range of motion.
Poor
Position:
Prone with arm over edge of table in lateral rotation.
Stabilization:
Stabilize scapula.
Palpation:
None
Desired Motion:
Patient medially rotates arm through range of motion.
(Pronation of the forearm should not be allowed
to substitute for full range in medial rotation.)
Trace & Zero

Fibers of Subscapularis may be palpated deep in axilla
near insertion.
Shoulder Abduction to 90
Middle Deltoid
Supraspinatus
Middle Deltoid
Origin:
Acromion process
Insertion:
Action:
Nerve supply:
Supraspinatus
Origin:
Supraspinatus fossa
Insertion:
Greater tubercle of the humerus
Action:
Nerve supply:
Note

None: range of motion incomplete.
Fixation:
Contraction of Trapezius and Serratus anterior
muscles.
Serratus anterior and upper fibers of trapezius
assist in upward rotation of scapula as well as
in fixation.
Normal & Good

Position:
Sitting with arm at side in mid-position
between medial and lateral rotation.
Elbow flexed a few decrees.
Stabilization:
Stabilize scapula.
Palpation:
Just below the acromion process of the
scapula.
Desired Motion:
Patient abducts the humerus to 90(palm
down).
Resistance :
Is given proximal to elbow
Fair
Position:
Sitting with arm at side in midposition
between medial and lateral rotation.
Elbow flexed a few degrees.
Stabilization:
Stabilize scapula.
Palpation:
Just below the acromion process.
Desired Motion:
Patient abducts arm to 90 (palm down).
Poor
Position:
Supine with arm at side in
midposition between medial and
lateral rotation.
Elbow slightly flexed.
Stabilization:
Stabilize scapula over acromion.
Desired Motion:
Patient abducts arm to 90
without Lateral rotation at
shoulder joint
Alternate
Trace & Zero

Examiner palpates middle section of Deltoid on
lateral surface of upper third of arm
Note
Patient may laterally rotate arm and attempt to
substitute Biceps brachii during abduction.
Arm should be kept in midposition between medial and
lateral rotation.
Note
Range of Motion: 0 TO 90
Tension of expansions of extensor tendons of
fingers.
Fixation:
Weight of arm
Shoulder Goniometry
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
joints motion.
6. For example, when measuring knee flexion, the
stationary arm will be aligned over the thigh in line
with the greater trochanter of the femur.
Introduction - continue
7. The fulcrum is aligned over the knee joint or lateral epicondyle of
the femur, and the moving arm with the midline of the leg or
lateral malleolus.
8. Performing these tests is important for many reasons.
The mobility of joints is important for diagnosis and

determining the presence or absence of dysfunction.
9. In a chronic condition, goniometry can measure the progression
of the disorder.
An example of this is the progression of rheumatoid

arthritis.
10. Furthermore, joint motion measurement can evaluate
improvements or lack of progression during rehabilitation.
11. This not only provides motivation for the patient when there are
improvements, but also can decipher if modifications need to
be made if treatment is not effective.
Flexion
Patient Instructions:
Once the goniometer is aligned
properly ask the patient to lift the arm
up just as if they were raising their
hand to ask a question.
Be sure that the patient keeps the palm
of their hand facing in toward their
body.
Starting Position
Patient is supine with
arm at side and the palm
of the hand facing the
body.
The fulcrum of the
goniometer is placed
over the acromion
process.
The stationary and
moving arms are aligned
with the midline of the
humerus and lateral
epicondyle.
Ending Position
The moving arm remains in line

with the lateral epicondyle and
midline of the humerus.
The examiner supporting the
patients 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 180; in the
picture the patient is in 180 of
flexion.
Extension
Ask the patient to simply lift their arm off
the table as far as they can.
Starting Position
Patient is prone with arm at
side; make sure the head is
facing away from the
shoulder being tested.
Elbow bent slightly and the
palm facing in toward the
body.
The fulcrum is placed over
the acromion process.
The stationary and moving
arms are aligned with the
lateral midline of the
humerus and the lateral
epicondyle.
Ending Position
The moving arm remains in
line with the lateral
epicondyle and the
examiner should support
the patients extremity.
The stationary arm in line
with the midline of the
thorax.
Normal ROM for
glenohumeral extension is
40 to 60; in the picture the
patient is in 61 of
extension.
Abduction
Have the patient bring their arm out to
their side and as close to their head as
they can.
Make sure that their palm faces upward
throughout the motion.
Starting Position
The patient is supine
with arm at side; the
palm should be facing
interiorly.
The fulcrum is placed at
the acromion process.
The stationary and
moving arms are
aligned with the
anterior midline of the
humerus.
Ending Position
The stationary arm
should remain still and
parallel to the sternum.
The moving arm should
still be resting at the
anterior midline of the
humerus.
Normal ROM between
160 and 180; the
patient in the picture is
in 174 of abduction
Medial (Internal) Rotation

Ask the patient to rotate their arm
down as far as they can.
Starting Position
Supine with 90 of shoulder
abduction and the elbow is
in 90 of flexion.
The table should not
support the elbow.
The fulcrum centered over
the olecranon process.
The moving arm is aligned
with the ulnar styloid and
the stationary arm should
be perpendicular to the
floor.
Ending Position
Same as above
Normal ROM is 60-70;
the patient is in 68 of
internal rotation.
Lateral (External) Rotation

Ask the patient to rotate their arm up
toward their head as far as they can.
Starting and Ending Position

Supine with 90 of shoulder
abduction and 90 of elbow
flexion.
The table should not support
the elbow. (Refer to above
picture)
Fulcrum on the olecranon
process.
The moving arm should be
aligned with the ulnar styloid
and the stationary arm
should be perpendicular to
the floor.
Ending Position:
Same as before
Normal ROM Reference Values

Shoulder
Typical ROM
Flexion
160 - 180
Extension
40 - 60
Abduction
160 - 180
Internal Rotation
60-70
External Rotation
40 - 45
Painful Elbow Joint
Clinical Examination of the

Elbow
Anatomy Of the elbow
SURFACE ANATOMY OF THE

ELBOW
Lateral elbow - labeled
Lateral Epicondyle
Olecranon
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.
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.
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.
origin and insertion of anconeus,
which covers the capsule and
collateral ligaments on the lateral
side.
Diseases of the elbow joint
Arthritis
Fractures
Bursitis
Tendonitis (Tinness elbow and Glover's
elbow)
Cubital Tunnel Syndrome
Bursitis
Tinness elbow
Cubital Tunnel Syndrome
CLINICAL EXAMINATION
INSPECTION
The patient should be standing, with shoulders slightly
braced back, to display the elbow.
When the forearm is in full extension and supination, there
will be a physiological valgus ("carrying angle") of 9-14; in
women, the angle will be 2-3 greater
This angle has been found to be 10-15 greater in the
dominant arm of throwing athletes
This angle allows the elbow to be tucked into the waist
depression above the iliac crest; it increases when a heavy
object is being lifted
Any increase in, or loss of, this physiological angle is
indicative either of major elbow instability or of malunion.
However, the angle varies from valgus in extension to
varus in flexion, and its measurement is not of any
practical importance.
Inspection
Sometimes, on the side of the elbow, bulging
in the para-olecranon groove will be seen;
such a swelling is produced by an effusion or
by synovial tissue proliferation
On the back, prominence of the olecranon is
a sign of posterior subluxation of the elbow,
a feature commonly found in RA .
Rheumatoid nodules are extremely
common
Bursitis is also a frequently encountered
pathology, especially in RA patients.
Skin atrophy at steroid injection sites, or
scars from previous surgery.
Figure 8
The physiological valgus (carrying angle) of the
elbow is increased when a load is being carried.
Normally, the angle is between 9 and 14 when the
elbow is extended and the forearm is supinated.
PALPATION
Palpation starts at the posterior aspect,
with the patient standing with his or her
shoulder braced backwards.
The three palpation landmarks - the two
epicondyles and the apex of the olecranon
- form an equilateral triangle when the
elbow is flexed 90, and a straight line
when the elbow is in extension (Figs. 9,
10).
PALPATION
Figures 9, 10
Three bony landmarks - the medial epicondyle, the lateral
epicondyle, and the apex of the olecranon - form an
equilateral triangle when the elbow is flexed 90, and a
straight line when the elbow is in extension
PALPATION
Since the elbow is a very superficial joint, it can
be readily palpated from behind and from the
sides.
The posterior aspect has the olecranon mid-way
between the medial and the lateral condyle.
Slight elbow flexion will bring the olecranon out
of the olecranon fossa, in which it lodges in
extension; in this position, the proximal portion of
the fossa on either side of the triceps tendon
may be palpated (Fig. 11)
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.
The olecranon bursa is not in communication with

the synovial cavity.
This is why the elbow may be mobilized in
bursitis, and why even massive bursitis will not be
tender.
In chronic bursitis, a boggy globular mass may be
palpated; the overlying skin will be thickened. Flat,
hard nodules may be felt under the palpating
fingertips.
In infected bursitis, the skin will be tight and
shiny; streaks of lymphangitis will be commonly
seen; while in 25% of the cases, the axillary
lymph nodes will be enlarged.
On the lateral side, the main landmarks are the
lateral epicondyle proximally and the radial head
distally.
The supracondylar ridge is also very accessible to

palpation; its chief value is that of a landmark for
surgical approaches (Fig. 12).
Sometimes, palpation may be carried out all the
way up to the deltoid tuberosity.
The radial head is palpated with the examiners
thumb, while the other hand is used to pronate and
supinate the forearm (Fig. 13).
The head is about 2 cm distal to the lateral
epicondyle
Inside the triangle formed by the bony
prominences of the lateral epicondyle, the radial
head and the olecranon, the joint itself is palpated,
to detect even very minor effusions or low-grade
synovitis (Fig. 14(
Figure 13
Anatomical landmarks on the lateral aspect of the elbow:
The radial head is palpated with the thumb, while the examiners other hand is used to
pronate and supinate the forearm
.Figure 14
The elbow joint may be palpated inside
a triangle formed by the bony prominences of the
PALPATION
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(
Figure 15 Palpation and

testing of brachioradialis,
a forearm flexor.
Figure 16 Palpation and

testing of the wrist
extensors
PALPATION
PALPATION
From the medial side, the joint is not very accessible to palpation, and the
small amount of synovial tissue on the medial border of the olecranon
makes joint palpation difficult
Palpation of the ridge that provides insertion for the intermuscular septum is
useful mainly as a guide for surgical approaches. Also, the supracondylar
lymph nodes may be palpated at this site (Fig. 17).
Over, and slightly anterior to, the supracondylar ridge, a bony excrescence
may be palpated; this outgrowth may irritate the median nerve
This supracondylar process is present in 1-3% of the population, and is
seen at a distance of 5-7 cm above the joint line
Behind the septum, the ulnar nerve may be palpated; in patients with a very
mobile nerve, it may be seen to roll on the medial condyle(10) (Fig. 18).
Ulnar nerve instability is more easily tested with the arm in slight abduction
and external rotation, with the elbow flexed between 20 and 70.
Figure 17
Palpation of the medial aspect of the elbow.
Above the medial epicondyle is the ridge on
which the intermuscular septum inserts.
Two centimetres above the epicondyle is the
site used for lymph node palpation.
Figure 18
The ulnar nerve is palpated
behind the intermuscular
septum.
It may sometimes sublux or roll
on the epicondyle.
Ulnar nerve instability is more
readily demonstrated if the
elbow is flexed 60 and the
upper limb is abducted and
PALPATION
Anteriorly, the bulk of the flexor-pronator group restricts the

extent of joint palpation.
The flexor-pronator muscles must be tested as a unit, by
asking the patient to perform wrist adduction and flexion
against resistance (Fig. 19).
Next, each one of these muscles should be tested individually.
The anterior aspect does not lend itself to palpation, since it is
tucked away behind the muscles.
Laterally, brachioradialis will be felt; and in the middle, the
biceps tendon is readily accessible if the patient is made to flex
the forearm against resistance.
Lacertus fibrosus is palpated medial to the biceps tendon; the
pulse of the brachial artery will be felt deep to this aponeurosis
(Fig. 20).
Sometimes anterior protrusion cysts produced by herniated
synovial membrane may be felt.
Figure 19
Diagrammatic view of the pattern of
the flexor-pronator group: The thumb
represents pronator teres; the index,
flexor carpi radialis; the middle
finger, palmaris longus; and the ring
finger, flexor carpi ulnaris.
Figure 20
Palpation of the medial biceps
expansion (lacertus fibrosus), which
courses over the brachial vessels
and the median nerve.
MOBILITY
The main function of the elbow is to bring the hand
to the mouth; this is why the investigation of the
elbow range of movement (ROM) is an important part
of the examination process.
Any difference between passive and active mobility
is usually due to reflex inhibition from pain
The end-feel - the feeling transmitted to the
examiners hands at the extreme range of passive
motion - must also be assessed (Table 1)
If the feel is abnormal, there is usually something
wrong with the joint.
Table 1 Classification and description of end-feels

(modified from TS Ellenbecker & AJ Mattalino)(12a(
Bony
Two hard surfaces meeting,

bone to bone (elbow
extension(
Capsular
Leathery feel, further motion

available (forearm pronation
and supination(
Soft tissue approximation
Soft tissue contact (elbow

flexion(
Spasm
Muscle contraction limits

motion
Springy block
Intra-articular block;
rebound is felt
Empty
Movement causes pain, pain

limits movement
ELBOW JOINT
The elbow is a complex joint with three different
articulations.
The humeroulnar joint is a hinge joint, and
allows the forearm to flex and extend, and
provides stability.
The radiohumeral and radioulnar joints allow for
flexion, extension and rotation of the radius on
the ulna, which in turn allows the forearm to
pronate and supinate.
RANGE OF MOTION
Flex and extend, and supinate and
pronate.
Normal elbow range of motion
Extension: 0
Flexion: 150
Pronation: 70
Supination: 90
Elbow Goniometry
Flexion
Ask the patient to bend their elbow as far as
they can, try and touch their shoulder.
Starting Position
Position: Supine, arm in the anatomical position with arm of the

patient is resting on the edge of the table.
The fulcrum aligned with the lateral epicondyle of the humerus.
The stationary arm is positioned along the midline of the humerus
The moving arm is aligned with the radial styloid process.
Ending Position
The arm is now flexed at the elbow, the goniometer
should still be aligned with the correct anatomical
landmarks as described below.
Normal ROM is between 150-160, the patient has 155
of elbow flexion.
Pronation
Have the patient turn their wrist down toward the ground.
Starting Position:
Patient sitting up with elbow bent 90 degrees and at patients

side, wrist in a handshake position.
The fulcrum is placed just behind the ulnar styloid process.
The moving arm and stationary arm are parallel with the anterior
midline of the humerus.
Ending Position
The fulcrum should remain in the same position as above.

The stationary arm will still be aligned parallel to the midline of
the humerus, the moving arm will lie across the dorsum of the
forearm just behind the ulnar and radial styloid processes.
Normal ROM is 90-96, the patient has 95 of pronation.
Supination
Have the patient turn their palm up as if they are holding something
in the palm of their hand.
Starting Position:
Patient position is the same as for pronation.
The goniometer is placed on the medial aspect of the forearm with
the fulcrum at the radioulnar joint.
The arms are both aligned with the anterior midline of the humerus.
Ending Position
The moving arm will be resting on the medial forearm at
the radioulnar joint.
The moving arm should remain parallel to the midline of
the humerus.
Normal ROM is 81-93, the patient has 90 of Supination.
Normal ROM Reference

Values
Elbow
Typical ROM
Flexion
150-160
Extension
Pronation
90-96
Supination
81-93
Elbow Joint
Elbow Flexion
Brachioradialis
Biceps Brachii
Brachialis
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:
Biceps Brachii
Origin:
Long head: supraglenoid tubercle
Short head: coracoid process
Insertion:
Radial tuberosity
Action:
Elbow Flexion
Nerve supply
Brachialis
Origin:
Lower portion of anterior surface of humerus
Insertion:
Coronoid process of ulna
Action:
Elbow Flexion
Nerve supply
Normal & Good

Position:
Sitting with slight shoulder flexion and the
elbow flexed past 90, forearm is supinated.
Ask the patient to, hold your elbow bent,
and dont let me straighten it out.
Palpation:
Muscle belly or just medial on crease of
elbow tendon.
Stabilization:
Stabilizing hand is placed on the shoulder.
Desired Motion:
Patient flexes elbow through range of
motion.
Resistance
Is given at the wrist in a downward direction.
Normal & Good
Biceps brctchii : forearm in supination
Brachialis : forearm in pronation
Brachioradialis: forearm in midposition between

pronation and supination
Fair
Position:
Sitting with arm at side and
forearm supinated
Stabilization:
Stabilize upper arm.
Desired Motion:
Patient flexes elbow through
range of motion.
Poor
Position:
Supine with shoulder abducted to 90 and
laterally rotated .
Stabilization:
stabilizing hand is placed on the shoulder.
Desired Motion:
Patient slides forearm along table
through complete range of elbow flexion.
(If range of motion is limited in lateral
rotation at shoulder joint, test may be
given with arm medially rotated.)
Trace & Zero

Examiners palpate the flexors on the forearm; muscle
fibers may be found on anterior surface of arm.
Alternate Test for Elbow Flexion

This alternate test is performed if
the biceps and brachialis are
weak.
Pronating the hand will instead
use the brachioradialis, extensor
carpi radialis longus, pronator
teres, and other wrist flexors.
Patients positioning is the same,
except the forearm is now
pronated and the stabilizing hand
is under the elbow joint.
Testing procedure is the same as
before.
Note
Note:
The wrist flexors may be contracted for assistance in
elbow flexion.
Wrist will be strongly flexed as a result. Wrist should
be relaxed.
Note
Range of motion: 0 to 145 - 160
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.
Elbow Extension
Triceps Brachii
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
Note
Range of Motion: 145 160 to 0
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
Normal & Good

Position:
Patient is prone on the table with the shoulder abducted to 90,
the entire arm should be off the table and the therapist can
stabilize the arm at the humerus just above the elbow. The elbow
should be in full extension.
Palpation: Proximal to olecranon process.
Stabilization: Stabilize arm.
Desired Motion: Patient extends elbow through ROM.
Resistance: Is applied at wrist in a downward direction.
Fair
Position: Supine with shoulder flexed to 90 and elbow flexed.

Palpation: The same as before
Desired Motion: Patient extends elbow through range of
motion
Alternate
Poor
Position: Supine with arm abducted to 90 degrees and laterally
rotated. Elbow is flexed.
Desired Motion: Ask the patient to, straighten your elbow,
dont let him bend it down.
(if range of motion is limited in lateral rotation at shoulder
joint, test may be given with arm medially rotated)
Trace & Zero

Examiner may palpate tendon of Triceps brachii at the
elbow joint and muscle fibers on posterior surface of
arm.
Muscles contribute to Forearm

Supination
Biceps Brachii
Supinator Teres
Biceps Brachii
Origin:
Long head: supraglenoid tubercle
Short head: coracoid process
Insertion: Radial tuberosity
Nerve supply
Muscles contribute to Forearm Supination

Supinator Teres
Origin:
lateral epicondyle of Humerus
posterior part of ulna
Insertion: upper 1/3 lateral surface of Radius.
Nerve supply
Note
Range of motion: 0TO 90 Supination from
midposition
1-Tension of Volar radioulnar ligament and ulnar
collateral ligament of wrist joint.
2-Tension of oblique cord and lowest fibers of
interosseous muscles of forearm.
Fixation:
Weight of arm
Normal & Good

Position: Sitting with arm at side, elbow flexed to 90 degrees and
forearm pronated to prevent rotation at the shoulder. Muscles of
wrist and fingers are; relaxed.
Desired Motion: Patient supinates forearm.
Resistance: Is given on dorsal surface of distal end of radius.
(Resistance may be given by grasping around the dorsal surface of
the hand instead of the position illustrated.)
Fair & Poor

Position:
Silting with arm at side, elbow flexed
to 90, forearm pronated and
supported by examiner.
Muscles of wrist and fingers are
relaxed.
Desired Motion:
Patient supinates forearm through full
range of motion for fair grade and
through partial for poor grade.
Fair
Poor
Trace & Zero

Supinator muscle is palpable on radial side of
forearm if overlying extensor muscles are not
functioning. Tendon of Biceps brachii is found in
antecubital space
Note
Patient should not be allowed to laterally
rotate arm and move elbow across
thorax as forearm is supinated.
As a result of this movement the forearm
may appear to be supinated, but range of
motion is incomplete.
This motion may "roll" the forearm into
supination without a muscular contraction
taking place.
Forearm Pronation
Pronator Teres
Muscles contribute to Forearm Pronation

Pronator Teres
Origin:
Humerus, medial epicondyle
Insertion:
Radius, middle 3rd of lateral surface
Action:
Forearm Pronation
Nerve supply
Note
Range of motion: 0 to 90 Pronation from
midposition
1-Tension of dorsal radioulnar, ulnar collateral and
dorsal radiocarpal ligaments.
2-Tension of lowest fibers of interosseous membrane.
Fixation:
Weight of arm
Normal & Good
Position:
Sitting with arm at side, elbow flexed to 90
to prevent rotation at the shoulder and
forearm supinated. Muscles of wrist and
fingers are relaxed.
Stabilization:
Stabilize arm.
Desired Motion:
Patient pronates forearm through ROM.
Resistance :
Is given on volar surface of distal end of
radius with counterpressure against the
dorsal surface of the ulna.
Fair & Poor

Position:
Sitting with arm at side, elbow flexed
to 90, forearm supinated and
supported by examiner. Muscles of
wrist and fingers are relaxed.
Desired Motion:
Patient pronates forearm through full
through partial range for poor grade
Fair
Poor
Trace & Zero

Position:
Sitting.
Palpation:
Examiner palpates fibers of
Pronator teres on upper third of
volar surface of forearm on a
diagonal line from medial condyle
of humerus to lateral border of
radius
Note
Patient should not be allowed to medially rotate or abduct
upper arm during pronation.
This movement makes the ROM in pronation appear complete
and allows forearm to roll into pronated position
Wrist Joint
Painful Wrist
Trigger finger
De Quvarian syndrome
Fractures
Arthritis
Tendonitis
Peripheral nerve Injuries
Trigger finger
Muscles contribute to Wrist Flexion
Wrist Flexion
Flexor carpi radialis
Flexor carpi ulnaris

Origin: Medial epicondyle of humerus
Insertion: Base of 2nd & 3rd metacarpals,
anterior surface
Nerve supply: Median Nerve (C6, C7)

Origin: Medial epicondyle of humerus
Insertion: Pisiform, hamate & base of 5th
metacarpal
Nerve supply: Ulnar Nerve C7, T1)
Note
Range of Motion: Wrist flexion: 0 to 90

Tension of dorsal radiocarpal ligament
Fixation:
Weight of arm
Normal & Good

Position: Sitting with forearm resting on table
with forearm supinated.
Muscles of thumb and fingers relaxed.
Stabilization: Stabilize forearm.
Desired Motion: Patient flexes wrist
Note
To test Flexor carpi radialis, resistance is
given at base of second metacarpal bone in
direction of extension and ulnar deviation
Note
To test Flexor carpi ulnaris, resistance is given
at base of fifth metacarpal bone in direction of
extension and radial deviation
Fair
Position: Sitting with forearm resting on table with forearm
supinated. Muscles of thumb and fingers relaxed.
Desired Motion: Patient flexes wrist with radial deviation or
ulnar deviation
Poor
Position: Sitting, forearm supported, hand resting on medial
border. Muscles of thumb and fingers relaxed.
Desired Motion: Patient flexes wrist, sliding hand along
table. Deviation should be observed and muscles graded
accordingly.
Trace & Zero

Examiner palpates tendon of Flexor carpi radialis
on lateral palmar aspect of wrist and tendon of
Flexor carpi ulnaris on medial palmar surface.
Muscles contribute to Wrist Extension
Extensor carpi radialis longus Extensor carpi radialis Brevis Extensor carpi Ulnaris
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
Extensor carpi radialis Brevis

Origin: Lateral epicondyle of humerus
Insertion: Base of 3rd metacarpal (dorsal surface)
Nerve supply: Radial Nerve
Extensor carpi Ulnaris

Origin: Lateral epicondyle of humerus
Insertion: Base of 5th metacarpal
Nerve supply: Ulnar Nerve
Note
Range of Motion:
Wrist extension beyond midline; 0 to 70
Tension of palmar radiocarpal ligament
Fixation:
Weight of arm
Caution!!!!
Normal & Good
Position:
Sitting with forearm resting on the table and pronated.
Muscles of fingers and thumb relaxed.
Desired Motion: Patient extends wrist.
Note
To test Extensor carpi radialis longus and
Brevis, resistance is given on dorsal surface of second
and third metacarpal bones in direction of flexion and
ulnar deviation.
Note
To test Extensor carpi ulnaris, resistance is given on
dorsal surface of fifth metacarpal bone in direction of
flexion and radial deviation.
Fair
Position:
Sitting with forearm resting on the table and pronated.
Muscles of fingers and thumb relaxed.
Desired Motion: Patient extends wrist with radial
deviation or ulnar deviation.
Poor
Position: Sitting, forearm supported, hand resting on medial
border.
Desired Motion:
Patient extends wrist, sliding hand along table through range of
motion.
Deviation should be observed and muscles graded accordingly
Trace & Zero

Tendons of wrist extensors may be found on lateral dorsal
surface of wrist in line with second and third metacarpal
bones and on medial dorsal surface proximal to fifth
metacarpal bone.
Joints of Fingers
Flexion of metacarpophalangeal joints of fingers
Lumbricales
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
Normal & Good
Position:
Sitting with hand resting on dorsal surface.
Stabilization:
Stabilize metacarpals.
Desired Motion:
Patient flexes fingers at MCP joints,
keeping IP joints extended.
Resistance:
Is given on palmar surface of proximal
row of phalanges.
Note: Resistance may be given to each
finger separately if Lumbricales are
unequal in strength.
Fair & Poor
Position:
Sitting with hand supported.
Stabilization:
Desired Motion:
Patient flexes fingers at MCP joints
through ROM, keeping IP joints
extended.
Patient flexes MCP joints through full
ROM for fair grade and through partial
range for poor grade.
Trace & Zero

Contraction of Lumbricales may be detected by light
pressure against palmar surface of proximal phalanges as
patient attempts to flex at MCP joints.
Note
The Flexor digitorum superficialis and Flexor digitorum
profundus should not be allowed to substitute for
Lumbricales with flexion of fingers.
These muscles should be kept relaxed as much as possible
with motion limited to metacarpophalangeal joint.
Individual testing of fingers (in all tests) is often desirable
as they vary in strength.
Caution!!!!
Flexion of Proximal Interphalangeal Joints of Fingers
Flexor digitorum superficialis
Diseases of the fingers

Arthritis (rheumatoid arthritis, gout
arthritis)
Diabetes
Fractures
Trigger finger
Tendonitis
Trauma
Rheumatoid arthritis trigger
Trigger Finger
Definition
Trigger finger is an inflammation of the synovial sheath
that encloses the flexor tendons of the thumb and
fingers. Tendons are the cords that connect bones to
muscles in the body. Usually, tendons slide easily
through the sheath as the finger moves.
In the case of trigger finger, however, the synovial
sheath becomes swollen and the tendon cannot move
easily through small pulleys in the finger, causing the
finger to remain in a flexed (bent) position.
In mild cases, the finger may be straightened with a
pop, like a trigger being released.
In severe cases, the finger becomes stuck in the bent
position.
Usually this condition can easily be treated; contact
your doctor if you think you may have trigger finger.
Causes
Often, the cause of trigger finger is unknown.
However, many cases of trigger finger are caused by
one of the following:
Overuse of the hand from repetitive motions
Computer operation
Machine operation
Repeated use of hand tools
Playing musical instruments
Inflammation caused by a disease
Rheumatoid arthritis
Gout
Hypothyroidism
Risk Factors
The following factors increase your
chances of developing trigger finger:
Age: 40-60
History of repetitive hand motions for work
or play
Sex: female
History of certain diseases:
Rheumatoid arthritis
Gout
Hypothyroidism
Symptoms
If you experience any of these symptoms do
not assume it is due to trigger finger. Some
of these symptoms may be caused by other
health conditions. If you experience any one
of them for a period of time, see your
physician.
Finger or thumb stiffness

Finger, thumb, or hand pain
Swelling or a lump in the palm
Catching or popping when straightening the
finger or thumb
Finger or thumb stuck in bent position
Diagnosis
Your doctor will ask about your symptoms
and medical history, and perform a
physical exam. The physical exam may
include:
Asking you to move the affected finger or
thumb
Feeling the hand and fingers
For severe cases of trigger finger, your
doctor may refer you to a hand specialist.
Treatment
The goals of treatment for

tenosynovitis are:
to reduce swelling and pain
to allow the tendon to move
freely with the tendon
sheath.
Treatment options include the

following:
Rest
Stopping movement in the finger or
thumb, sometimes with the help of a
brace or splint, is often the best
treatment for mild cases of trigger
finger.
Rest may be combined with
stretching of the muscle tendon unit
involved.
Medications
Several medications are used to treat tenosynovitis.
These include:
Corticosteroids, given as an injection into the
synovial tendon sheath to reduce swelling of the
tendon sheath
Nonsteroidal anti-inflammatory drugs (NSAIDs) to
help reduce inflammation and pain:
Ibuprofen (Advil, Motrin)
Naproxen (Aleve, Naprosyn)
For severe cases of trigger finger that do not respond
to medications, surgery may be used to release the
finger from a locked position and to allow the tendon
to move freely through the sheath.
This surgery is usually performed on an outpatient
basis and requires only a small incision in the palm of
the hand.
Prevention
The most important action you can take to
prevent trigger finger is to avoid overuse of
your thumb and fingers.
If you have a job or hobby that involves
repetitive motions of the hand, you can take
the following steps:
Adjust your workspace to minimize the strain on
your joints
Alternate activities when possible
Take breaks throughout the day
Exercise regularly
Muscles contribute to Flexion of proximal interphalangeal

joints of fingers
Flexor digitorum superficialis
Origin:
Humeral head: common flexor origin of medial epicondyle

humerus, medial ligament of elbow.
Ulnar head: medial border of coronoid process and fibrous arch.
Radial head: whole length of anterior oblique line
Insertion:
Tendons split to insert onto sides of middle phalanges of medial

four fingers
Action:
Flexion of PIP & DIP joints
Nerve supply
Normal & Good

Position:
Sitting with hand resting palm upward on
table and fingers extended.
Stabilization:
Stabilize proximal phalanx of finger.
Desired Motion:
Patient flexes middle phalanx.
Resistance:
Is given on palmar surface of middle
phalanx of finger.
Fair & Poor

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

Superficial portion of the Flexor digitorum
superficialis may be palpated at the wrist under the
Palmaris longus
Caution!!!
Flexion of Distal Interphalangeal Joints of Fingers
Flexor digitorum profundus
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
Normal & Good

Position:
Sitting with hand resting palm upward on table and fingers
extended.
Stabilization:
Stabilize middle phalanx of finger.
Desired Motion:
Patient flexes distal phalanx.
Resistance:
Is given on palmar surface of distal phalanx of finger
Fair & Poor

Patient flexes distal phalanx through full ROM for
fair grade and through partial range for poor grade.
Trace & Zero

Flexor digitorum profundus may be palpated
on the palmar surface of the middle phalanx
Caution!!!!
Extension of metacarpophalangeal joints of fingers
Extensor digitorum communis Extensor indicis proprius
Extensor digiti minimi
Muscles contribute to Extension of

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

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:
Nerve supply

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:
Nerve supply
Normal & Good

Position:
Arm resting on table, hand
supported, wrist in midposition,
fingers flexed.
Stabilization:
Desired Motion:
Patient extends proximal row of
phalanges with IP joints partially
flexed.
Resistance :
Is given on dorsal surface of
proximal row of phalanges of
fingers.
Fair & Poor

Position:
Sitting with hand supported, fingers
flexed and wrist in midposition.
Stabilization:
Desired Motion:
Patient extends proximal row of
phalanges to end of range, with IP
joints partially flexed.
Patient extends MCP joints through
full ROM for grade of fair and
through partial range for grade of
poor
Trace & Zero

The tendons of the finger extensors may easily be
located on dorsum of hand where they pass over
metacarpals.
Finger Abduction
Interossei dorsales
Abductor digiti minimi
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
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
Normal & Good

Test for first and third Interossei dorsales
Position:
Sitting with hand supported palm downward,
fingers adducted.
Stabilization:
Desired Motion:
Patient abducts fingers.
Resistance:
Is given on radial side of second and ulnar side
of third finger, (To test individual fingers,
resistance is given on first phalanx)
Normal & Good

Test for second and fourth
Interossei
dorsales and Abductor digiti minimi
Position:
Sitting with hand supported palm
downward, fingers adducted.
Stabilization:
Desired Motion:
Patient abducts fingers.
Resistance:
Is given on ulnar side of fourth and fifth
fingers and on radial side of third finger.
Fair & Poor

Position:
Sitting with palm resting on table,
fingers adducted.
Desired Motion:
Patient abducts fingers through
ROM. (Third finger must be moved
in both directions.)
Patient abducts fingers through full
ROM for fair grade and through
partial range for poor grade.
Trace & Zero

The Interossei dorsales lie deep between the metacarpal bones
on the dorsum of the hand.
(Palpation of first Interosseus dorsales shown in illustration.)
Fingers Adduction
Interossei palmares
Muscles contribute to Finger Adduction

Interossei palmares
Origin:
Entire length of second, fourth and fifth
metacarpal bones on palmar surface
Insertion:
Side of base of proximal phalanx of
corresponding finger: first into ulnar side of
index finger; second and third into radial side of
ring and little fingersInto aponeurotic expansion
of Extensor digitorum tendon of same finger
Action:
Finger Adduction
Nerve supply
Normal & Good

Position :
Sitting with hand supported palm
clown ward, fingers abducted.
Desired Motion:
Patient adducts fingers.
Resistance:
Is given in radial direction on
second finger and in ulnar
direction on fourth and fifth
fingers.
Fair & Poor

Position:
Sitting with hand resting palm
downward on table, fingers in
abduction.
Desired Motion:
Patient adducts fingers through full
through partial range for poor grade
Trace & Zero

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

Thumbs joints
Flexor pollicis Brevis
Flexor pollicis Longus
Muscles contribute to Flexion of Metacarpophalangeal

& Interphalangeal of Thumbs joints
Flexor pollicis Brevis
Origin:
Flexor retinaculum and tubercle of trapezium
Insertion:
Base of proximal phalanx of thumb (via radial
sesamoid)
Action:
Flexion of MP & IP of the thumb
Nerve supply
Muscles contribute to Flexion of Metacarpophalangeal

Flexor pollicis Longus
Origin:
Anterior surface of radius below anterior
oblique line and adjacent interosseous
membrane
Insertion:
Base of distal phalanx of thumb
Action:
Flexion of MP & IP of the thumb
Nerve supply
Flexion of MCP Joint of Thumb
Normal & Good

Position:
Sitting with hand resting palm upward on
table.
Stabilization:
Stabilize first metacarpal.
Desired motion:
Patient Flexes first phalanx of thumb. &
distal phalanx remains relaxed.
Resistance:
Is given on palmar surface of proximal
phalanx
Fair & Poor

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

Contraction of Flexor pollicis Brevis may be
determined by pressure over palmar surface of first
metacarpal (medial to Abductor pollicis Brevis) as
patient attempts flexion.
Flexion of Interphalangeal Joint of Thumb
Normal & Good

Position:
Sitting with hand resting palm
upward on table.
Stabilization:
Stabilize first phalanx of thumb.
Desired motion:
Patient flexes distal phalanx
(motion takes place in plane of
palm).
Resistance:
Is given on palmar surface of
distal phalanx of thumb
Fair & Poor

Patient flexes distal phalanx through full ROM
for fair grade and through partial range for
poor grade.
Trace & Zero

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

Interphalangeal of Thumbs joints
Extensor pollicis Brevis
Extensor pollicis longus
Muscles contribute to Extension of Metacarpophalangeal

Extensor pollicis Brevis
Origin:
Lower third of posterior shaft of radius and adjacent interosseous
membrane
Insertion:
Over tendons of radial extensors and brachioradialis to base of
proximal phalanx of thumb
Action:
Extension of MP & IP of the thumb
Nerve supply
Muscles contribute to Extension of Metacarpophalangeal

Extensor pollicis longus
Origin:
Middle third of posterior ulna (below abductor pollicis longus)
and adjacent interosseous membrane
Insertion:
Base of distal phalanx of thumb via Lister's tubercle (dorsal
tubercle of radius).
Action:
Extension of MP & IP of the thumb
Nerve supply
Extension of Metacarpophalangeal Joint of

Thumb
Normal & Good
Position:
Sitting with hand resting on table.
Stabilization:
Stabilize first metacarpal.
Desired motion:
Patient extends first phalanx of thumb.
Resistance:
Is given on dorsal surface of proximal
phalanx.
Fair & Poor

Patient extends first phalanx of thumb through
full ROM for fair and through partial range for
poor
Trace & Zero

Tendon of Extensor pollicis Brevis may be found at
base of metacarpal of thumb
Extension of Interphalangeal Joint

of Thumb
Normal & Good

Position:
Sitting with hand resting on
ulnar border.
Stabilization:
Stabilize first phalanx of
thumb.
Desired motion:
Patient extends distal phalanx
(motion takes place in plane of
palm).
Resistance:
Is given on dorsal surface of
distal phalanx of thumb
Fair & Poor

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

Tendon of Extensor pollicis longus may be palpated
on dorsal surface of hand between head of first
metacarpal and base of second. It may also be found
on dorsal surface of first phalanx
Thumb Abduction
Abductor pollicis Brevis
Abductor pollicis longus
Muscles contribute to Thumb Abduction

Abductor pollicis Brevis
Origin:
Tubercle of scaphoid & flexor retinaculum
Insertion:
Radial sesamoid of proximal phalanx of thumb &
tendon of extensor pollicis longus
Action:
Thumb Abduction
Nerve supply
Muscles contribute to Thumb Abduction

Abductor pollicis longus
Origin:
Upper posterior surface of ulna and middle third of
posterior surface of radius and interosseous membrane
between
Insertion:
Over tendons of radial extensors and brachioradialis
to base of 1st metacarpal and trapezium
Action:
Thumb Abduction
Nerve supply
Normal & Good
Position:
Stabilization:
Stabilize medial four metacarpals
and wrist.
Desired motion:
Patient raises thumb vertically
through range of abduction.
Resistance:
Is given on lateral border of first
phalanx of thumb.
Note
If Abductor pollicis longus is stronger than the
Brevis, thumb will deviate toward radial side
of hand.
If Abductor pollicis Brevis is stronger,
deviation will be toward ulnar side
Fair & Poor
Position:
Stabilization:
Stabilize metacarpals and
wrist.
Desired motion:
Patient abducts thumb through
full ROM for fair grade and
through partial range for poor
grade
Trace & Zero

The Abductor pollicis Brevis fibers may easily be
found on thenar eminence lateral to the Flexor pollicis
Brevis. The tendon of the Abductor pollicis longus may
be palpated near its insertion
Thumb Adduction
Adductor Pollicis
Muscles contribute to Thumb Adduction

Adductor pollicis
Origin:
Oblique head: base of 2nd and 3rd metacarpals,
trapezoid and capitate. Transverse head: palmar
border and shaft of 3rd metacarpal
Insertion:
Ulnar sesamoid then ulnar side of base of proximal
phalanx and tendon of extensor pollicis longus
Action:
Thumb Adduction
Nerve supply
Normal & Good

Position :
Stabilize medial four
metacarpals.
Desired motion:
Patient adducts thumb.
Resistance:
Is given on medial border of
first phalanx
Fair & Poor
Position:
Stabilization:
Desired motion:
Patient adducts thumb
through full ROM for fair
grade and through partial
range for poor grade.
Trace & Zero

Muscle fibers may be
palpated between first
Interossei dorsales
muscle and first
metacarpal bone.
Note
Flexor pollicis longus and Flexor pollicis Brevis
may help pull thumb toward palm. These muscles
should remain relaxed during test.
Opposition of Thumb
Opponens pollicis
Opponens digiti minimi
Muscles contribute to Opposition of Thumb
Opponens pollicis
Origin:
Flexor retinaculum and tubercle of trapezium
Insertion:
Whole of radial border of 1st metacarpal
Action:
Thumb Opposition
Nerve supply
Muscles contribute to Opposition of Thumb

Opponens digiti minimi
Origin:
Flexor retinaculum and hook of hamate
Insertion:
Ulnar border of shaft of 5th metacarpal
Action:
Thumb Opposition
Nerve supply
Normal & Good

Position:
Sitting with hand resting palm upward
on table.
Desired motion:
Patient brings palmar surfaces of
distal phalanges of thumb and fifth
finger together.
The first and fifth metacarpals rotate
toward the midline of the hand. The
movement cannot be carried out by
muscles other than the two opponents.
Resistance:
Is given on distal end of first and fifth
metacarpals on palmar surface with
derogating pressure. The two muscles
are graded separately
Fair & Poor

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

Note:
The two muscles of
opposition cannot be
palpated unless the
overlying superficial
muscles are
nonfunctioning.
Trunk Manual Muscle Testing
Trunk Flexion
Rectus abdominis
Muscles contribute to Trunk Flexion
Rectus abdominis
Origin:
Pubic crest and pubic symphysis
Insertion:
5, 6, 7 costal cartilages, medial
inferiorcostal margin and posterior
aspect of xiphoid
Action:
Trunk Flexion
Nerve supply:
Normal
Position:
Supine with hands behind neck.
Stabilization:
Stabilize legs firmly.
Desired Motion:
Patient flexes thorax on pelvis
through ROM
Normal
Note:
If hip flexor muscles are weak, stabilize pelvis.
A curl up is emphasized and flexion is possible until
scapulae are raised from table.
Tests for neck flexion should precede those for trunk
flexion
Good
Position:
Backlying with arms at sides.
Stabilization:
Desired Motion:
If hip flexor muscles are weak,
stabilize pelvis.
Flexion is possible until scapula
are raised from table.
Fair
Position:
Supine with arms at sides.
Stabilization:
Desired Motion:
through partial range of motion.
Head, tips of shoulders and cranial
borders of scapulae should clear
table with inferior angle remaining
in contact with table.
If hip flexor muscles are weak,
stabilize pelvis
Poor
Position:
Supine with arms at sides
Desired Motion:
Patient flexes cervical spine.
Caudal portion of thorax is
depressed, and pelvis is tilted
until the lumbar area of spine is
flat on table.
Palpation will help to
determine smoothness of
contraction
Trace & Zero

Position:
Backlying.
A slight contraction may be
determined by palpation over
anterior abdominal wall as
patient attempts to cough (also
during rapid exhalation or as
patient attempts to lift head).
Observe deviation of umbilicus.
Cranial movement indicates
stronger contraction of upper
section of muscle, and caudal
movement, stronger contraction
of lower section (not illustrated.)
Note
1- Tension of posterior longitudinal ligament, ligamenta flava,
and interspinal and supraspinal ligaments
2- Tension of spinal extensor muscles
3-Apposition of caudal lips of vertebra bodies anteriorly with
surfaces of subjacent vertebrae
4-Compression of ventral part of intervertebral fibrocartilages
5-Contact of last ribs with abdomen
Fixation:
1-Reverse action of hip flexor muscles
2-Weight of legs and pelvis
Trunk Extension
Erector spinae Spinalis Erector spinae lliocostalis Erector spinae Longissimus
Muscles contribute to Trunk Extension

Erector spinae Spinalis
Origin:
Spinous processes
Insertion:
Spinous processes six levels above
Action:
Trunk Extension
Nerve supply:
Dorsal rami of spinal nerves

Erector spinae lliocostalis
Origin:
Iliac crest, sacrum, lumbar vertebrae
Insertion:
Ribs, cervical transverse processes
Action:
Trunk Extension
Nerve supply:

Erector spinae Longissimus
Origin:
Transverse processes of lumber vertebrae
Insertion:
Tip of Transverse processes of all thoracic
vertebrae
Action:
Trunk Extension
Nerve supply:
Normal & Good

Extension of lumbar spine
Position: Supine.
Stabilization: Stabilize pelvis.
Desired Motion:
Patient extends lumbar spine until caudal part of thorax is
raised from table.
Resistance: Is given on caudal portion of thoracic area.
Normal & Good
Extension of thoracic spine

Position:
Facelying.
Stabilization:
Stabilize pelvis and lower part of
thorax.
Desired Motion:
Patient extends thoracic spine to
horizontal position.
Resistance:
Is given on cranial portion of thorax.
A pad can he placed under caudal
portion of thorax if a greater range of
motion is needed.
Fair
Extension of thoracic and lumbar spine

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

Position:
Facelying.
Stabilization:
Stabilize pelvis.
Desired Motion:
Patients completes partial ROM
Trace & Zero

Position:
Facelying.
Examiner palpates spinal extensor muscles to
determine presence and degree of contraction as
patient attempts to raise trunk
Note
1-Tension of anterior longitudinal ligament of spine
2-Tension of anterior abdominal muscles
3-Contact of spinous processes
4-Contact of caudal articular margins with laminae
Fixation:
1-Contraction of Glutens maximums and
2-Hamstring muscles
3-Weight of pelvis and legs
Trunk Rotation
Obliquus externus abdominis Obliquus internus abdominis
Muscles contribute to Trunk Rotation

Obliquus externus abdominis
Origin:
Anterior angles of lower eight ribs
Insertion:
Outer anterior half of iliac crest, inguinal
leg, public tubercle and crest, and
aponeurosis of anterior rectus sheath
Action:
Trunk Rotation
Nerve supply:
Muscles contribute to Trunk Rotation

Obliquus internus abdominis
Origin:
Lumbar fascia, anterior two thirds of iliac
crest and lateral two thirds of inguinal
ligament
Insertion:
Costal margin, aponeurosis of rectus sheath
(anterior and posterior ), conjoint tendon to
pubic crest and pectineal line
Action:
Trunk Rotation
Nerve supply:
Normal
Position:
Backlying with hands behind neck.
Stabilization:
Desired Motion:
Patient rotates and flexes thorax to one
side.
Repeat to opposite side.
Note: Test for left Obliquus externus
abdominis and right Obliquns interims
abdominis is shown in illustration.
Rotation to left is brought about by
opposite muscles.
If hip flexor muscles are weak, stabilize
pelvis as in "Fair" test. Upper thorax
should be lifted from table with rotation.)
Good
Position:
Backlying with arms at sides.
Stabilization:
Desired Motion:
Patient rotates and flexes
thorax to one side.
Repeat to opposite side.
If hip flexor muscles are
weak, stabilize pelvic as in
"Fair" test.
Fair
Position:
Backlying with hands on
opposite shoulders.
Stabilization:
Stabilize pelvis.
Desired Motion:
Patient rotates thorax until
scapula on side of forward
shoulder is raised from table.
Repeat with rotation to opposite
side.
Poor
Position:
Sitting with arms relaxed at sides.
Stabilization:
Pelvis stabilized.
Desired Motion:
Patient rotates thorax.
Repeat with rotation to opposite side.
Trace & Zero

Examiner palpates muscles as patient attempts to approximate
thorax on left and pelvis on right. Repeat on opposite side.
Note: Observe deviation of umbilicus, which will move toward
strongest quadrant if there is a difference in strength of
opposing oblique muscles.
Muscle Testing (Lower

extremity)
MUSCLE THAT ACT ON THE

ANTERIOR THIGH (FEMUR)
MUSCLE THAT ACT ON THE

POSTERIOR THIGH (FEMUR)
Elevation of pelvis
QUADRATUS LUMBORUM
QUADRATUS LUMBORUM
ORIGIN: Inferior border of 12th rib
INSERTION
Apices of transverse processes of
L1-4, iliolumber ligament and
posterior third of iliac crest
ACTION
Fixes 12th rib during respiration
and lateral flexes trunk
NERVE
Anterior primary rami (T12-L3)
QUADRATUS LUMBORUM
Range of Motion:
In standing position pelvis may he raised on
one side until foot is well clear of floor.
(Reverse action of Quadratus lumborum.)
Tension of spinal ligaments on opposite
side
Contact of iliac crest with thorax
Fixation:
Contraction of spinal extensor muscles (o
fix thorax
NORMAL AND GOOD

Position: Backlying (or Facelying) with lumbar area of
spine in moderate extension. Patient grasps edge of
table to stabilize thorax. (If-arm and shoulder muscles
are weak, an assistant should stabilize thorax.)
Desired Motion: Patient draws pelvis toward thorax on
one side.
Resistance is given above ankle joint.
FAIR AND POOR

Position: Backlying with legs straight and with lumbar area of
spine in moderate extension.
Patient may grasp side of table to stabilize thorax (not shown
in picture).
Desired Motion: Patient draws pelvis upward toward thorax.
Slight resistance is given for a fair grade. Completion of range
is graded poor.
FAIR (Alternate)
Standing position.
Stabilize thorax.
Desired motion: Patient lifts pelvis toward
thorax through ROM
TRACE AND ZERO

As patient attempts to draw pelvis cranial
ward, a contraction of Quadratus lumborum
may be determined by deep palpation in
lumbar area under lateral edge of Erector
spinae.
Sartorius
Origin: Anterior superior iliac spine
Insertion: medial surface of the tibia
Function: Hip flexion, Abduction, and External Rotation with Knee
Position
Nerve supply:
Psoas major: lumbar plexus
Iliacus: lumbar plexus
Normal and Good

Position: Sitting with thighs supported on the
table and legs dangling off, the patient can
place their hands down for support.
Desired Motion: The patient flex, abduct, and
externally rotate at the hip, and flex at the
knee.
Resistance.
One hand will be placed on the lateral
surface of the knee, and the other will be
placed on the medial aspect of the ankle.
The hand at the knee will resist hip flexion
and abduction and the resistance will be
given in a down and inward direction.
The hand at the ankle will be resisting
external rotation and knee flexion and the
resistance is in an up and outward direction.
Ask the patient to, slide your heel up the

shin of your other leg, dont let me move
your leg or straighten your knee.
FAIR AND POOR

Position: Sitting with
thighs supported on
the table and legs
dangling off, the
patient can place their
hands down for
support.
Desired Motion: The
patient flex, abduct,
and externally rotate
at the hip, and flex at
the knee.
TRACE AND ZERO

Patient Position:
Supine, with the therapist supporting the limb.
The heel should be on the shin of the opposite leg.
While palpating the sartorius ask the patient to
slide their heel up to their knee.
Hip Flexion
Sartorius
PSOAS MAJOR
ILIACUS
PSOAS MAJOR
ORIGIN: Transverse processes of L1-5, bodies of T12-L5
and intervertebral discs below bodies of T12-L4
INSERTION: Middle surface of lesser trochanter of femur
ACTION:
Flexes and medially rotates hip
NERVE:
Anterior primary rami of L1,2
ILIACUS
ORIGIN: Iliac fossa within abdomen
INSERTION: Lowermost surface of lesser
trochanter of femur
ACTION: Flexes medially rotates hip
NERVE: Femoral nerve in abdomen (L2,3)
Hip Flexion
Range of Motion:

With knee Hexed, contact of thigh on abdomen
With knee extended, tension of hamstring muscles
Fixation:
1.Contraction of anterior abdominal muscle to fix lumber
spine and pelvis.
1.Weight at trunk
Normal and Good

Position: Sitting with legs over edge of table.
Desired Motion: Patient flexes hip through
last part of range of motion.
Resistance is given proximal to knee joint.
Fair
Sitting with legs over edge of table.
Stabilize pelvis.
Patient flexes hip through last part of ROM.
Poor
Position: Sidelying with upper leg supported. Trunk
pelvis and legs straight.
Stabilize pelvis.
Patient flexes hip through range of motion Knee is
allowed to flex to prevent hamstring tension.
TRACE AND ZERO

Supine with leg supported. It may be
possible to detect contraction in Psoas
major just distal to inguinal ligament on
medial side of Sartorius.
Note
Substitution by Sartorius in hip flexion will cause
lateral rotation and abduction of thigh. Muscle may
be seen and palpated near its origin during the
motion.
Substitution by Tensor Fasciae Latae in hip flexion
causes medial rotation and abduction of the thigh.
Muscle may be seen and palpated at its origin.
Hip Extension
GLUTEUS MAXIMUS
BICEPS FEMORIS
SEMIMEMBRANOSUS
SEMITENDINOSUS
GLUTEUS MAXIMUS
ORIGIN
Outer surface of ilium behind posterior gluteal line and posterior
third of iliac crest lumbar fascia, lateral mass of sacrum,
sacrotuberous ligament and coccyx
INSERTION
Deepest quarter into gluteal tuberosity of femur, remaining three
quarters into iliotibial tract (anterior surface of lateral condyle of
tibia)
ACTION
Extends and laterally rotates hip. Maintains knee extended via
iliotibial tract
NERVE: Inferior gluteal nerve (L5, S1,2)
BICEPS FEMORIS
ORIGIN
Long head: upper inner quadrant of posterior
surface of ischial tuberosity.
Short head: middle third of linea aspera, lateral
supracondylar ridge of femur
INSERTION
Styloid process of head of fibula. lateral collateral
ligament and lateral tibial condyle
ACTION
Flexes and laterally rotates knee. Long head
extends hip
NERVE
Long head: tibial portion of sciatic nerve. Short
head: common peroneal portion of sciatic nerve
(both L5, S1)
SEMIMEMBRANOSUS
ORIGIN
Upper outer quadrant of posterior surface
of ischial tuberosity
INSERTION
Medial condyle of tibia below articular
margin, fascia over popliteus and oblique
popliteal ligament
ACTION
Flexes and medially rotates knee.
Extends hip
NERVE
Tibial portion of sciatic nerve (L5, S1)
SEMITENDINOSUS
ORIGIN
Upper inner quadrant of posterior
surface of ischial tuberosity
INSERTION
Upper medial shaft of tibia below
Gracilis
ACTION
Flexes and medially rotates knee.
Extends hip
NERVE
Tibial portion of sciatic nerve (L5, S1)
Hip Extension
Range of Motion
Extension: 115 125 to 0
Extension beyond midline 0 to 10 - 15

Tension of iliofemoml ligament
Tension of hip flexor muscles
Fixation:
Contraction of Iliocustalis
and Quad rat us lumborum muscles
Weight of trunk
NORMAL AND GOOD

Prone with legs
extended.
Stabilize pelvis.
Patient extends, hip
through range of
motion.
Resistance is given
proximal to knee joint.
NORMAL AND GOOD

Test for isolation of Gluteus
Maximus)
Prone with knee flexed.
Stabilize pelvis.
Patient extends hip, keeping
knee flexed to decrease
action of hamstrings.
Resistance is given proximal
to knee joint.
Range of motion will be more
limited than in position
above, owing to tension in
the Rectus femoris
FAIR
Position: prone with legs extended.

Desired motion: Patient extends leg through range of
motion
POOR
Position: Sidelying with
hip flexed, knee
extended and upper leg
supported.
Stabilize pelvis.
Patient extends hip
through range of
motion.
(Knee may be flexed for
fair and poor to isolate
the action of the
Gluteus Maximus.)
TRACE AND ZERO

Prone.
Contraction of
Gluteus Maximus will
result in narrowing of
gluteal crease. Lower
and upper sections of
muscle should be pal
pated.
Note
Patient may lift pelvis
and support leg with
hamstrings, raising leg
from table by extending
lumbar spine.
Examiner must be
certain that pelvis is
stable and movement
takes place in hip joint.
Hip Abduction
GLUTEUS MEDIUS
SARTORIUS
GLUTEUS MEDIUS
ORIGIN
Outer surface of ilium between
posterior and middle gluteal
lines
INSERTION
Posterolateral surface of greater
trochanter of femur
ACTION
Abducts and medially rotates
hip. Tilts pelvis on walking
NERVE
Superior gluteal nerve (L4,5,S1)
Hip Abduction
Range of Motion:

Tension of distal band of iliofemoral ligament and
pubocapsular ligament.
Tension of hip adductor muscles
Fixation:
1.Contraction of lateral abdominal muscles and Latissimus
dorsi
2.Weight of trunk
NORMAL AND GOOD

Position: Sidelying with leg slightly
extended beyond midline. Lower knee flexed
for balance.
Desired motion: Patient abducts leg through
ROM without lateral rotation of the hip.
FAIR
Position: Sidelying with leg slightly extended
beyond midline. Lower knee flexed for balance.
Desired motion: Patient abducts leg through ROM.
POOR
Supine with legs extended.
Stabilize pelvis.
Patient abducts leg through ROM without
allowing leg to rotate.
TRACE AND ZERO

Fibers of the Gluteus medius maybe found
on lateral aspect of ilium above greater
trochanter of femur.
Note
Patient may bring pelvis
to thorax by strong
contraction of lateral
trunk muscles, thereby
lifting leg through
partial abduction.
Examiner must stabilize
pelvis to make sure
motion takes place in hip
joint.
Note
Lateral rotation at the hip should be
eliminated, or hip flexors may substitute for
Gluteus medius. Flexion of the hip allows
substitution by the Tensor fasciae Latae.
Hip Adduction
1.
2.
3.
4.
5.
GRACILIS
PECTINEUS
ADDUCTOR BREVIS
ADDUCTOR LONGUS
ADDUCTOR MAGNUS
GRACILIS
ORIGIN
Outer surface of ischiopubic ramus
INSERTION
Upper medial shaft of tibia below sartorius
ACTION
Adducts hip. Flexes knee and medially
rotates flexed knee
NERVE
Anterior division of obturator nerve (L2, 3)
PECTINEUS
ORIGIN
Pectineal line of pubis and narrow area
of superior pubic ramus below it
INSERTION
A vertical line between spiral line and
gluteal crest below lesser trochanter of
femur
ACTION
Flexes, adducts and medially rotates
hip
NERVE
Anterior division of femoral nerve (L2,
3). Occasional twig from obturator
nerve (anterior division - L2,3)
ADDUCTOR BREVIS
ORIGIN
Inferior ramus and body of
pubis
INSERTION
Upper third of linea aspera
ACTION: Adducts hip
NERVE
Anterior division of obturator
nerve (L2, 3)
ADDUCTOR LONGUS
ORIGIN
Body of pubis inferior and medial to
pubic tubercle
INSERTION
Lower two thirds of medial linea
aspera
ACTION
Adducts and medially rotates hip
NERVE
Anterior division of obturator nerve
(L2, 3)
ADDUCTOR MAGNUS
ORIGIN
Adductor portion: ischiopubic ramus. Hamstring
portion: lower outer quadrant of posterior surface of
ischial tuberosity
INSERTION
Adductor portion: lower gluteal line and linea aspera.
Hamstring portion: adductor tubercle
ACTION
Adductor portion: adducts and medially rotates hip.
Hamstring portion: extends hip
NERVE
Adductor portion: posterior division of obturator
nerve (L2-4). Hamstring portion: tibial portion of
sciatic (L4-S3)
Hip Adduction
Range of Motion:

Contact with opposite leg
When hip is flexed, tension of ischiofemoral ligament.
Fixation: Weight of trunk.
NORMAL AND GOOD

Sidelying with leg resting on table and upper
leg supported in approximately 25 of
abduction.
Patient adducts leg until it contacts upper
FAIR
Sidelying with leg resting on table and upper
leg supported in approximately 25 of
abduction.
Patient adducts leg until it contacts upper
leg.
POOR
Supine with leg in 45 of abduction.

Stabilize pelvis.
Patient adducts leg through ROM without
allowing rotation of hip.
TRACE AND ZERO

Contraction of fibers of adductor muscles
may he palpated on medial aspect of thigh.
Hip Lateral Rotation
SARTORIUS
GEMELLUS INFERIOR
GEMELLUS SUPERIOR
OBTURATOR EXTERNUS
OBTURATOR INTERNUS
QUADRATUS FEMORIS
PIRIFORMIS
GEMELLUS INFERIOR
ORIGIN
Upper border of ischial tuberosity
INSERTION
Middle part of medial aspect of
greater trochanter of femur
ACTION
laterally rotates and stabilizes hip
NERVE
Nerve to quadratus femoris (L4, 5,
S1)
GEMELLUS SUPERIOR
ORIGIN: Spine of ischium
INSERTION
ACTION
NERVE
Nerve to obturator internus (L5,
S1, 2)
OBTURATOR EXTERNUS
ORIGIN
Outer obturator membrane , rim of
pubis and ischium bordering it
INSERTION
Trochanteric fossa on medial
surface of greater trochanter
ACTION
laterally rotates hip
NERVE
Posterior division of obturator nerve
(L2,3,4)
OBTURATOR INTERNUS
ORIGIN
Inner surface of obturator membrane
and rim of pubis and ischium
bordering membrane
INSERTION
ACTION
NERVE
Nerve to obturator internus (L5, S1,2)
QUADRATUS FEMORIS
ORIGIN
Lateral border of ischial tuberosity
INSERTION
Quadrate tubercle of femur and a
vertical line below this to the level of
lesser trochanter
ACTION
NERVE
Nerve to quadratus femoris (L4, 5,
S1)
PIRIFORMIS
ORIGIN
2, 3, 4 costotransverse bars of
anterior sacrum, few fibers from
superior border of greater sciatic
notch
INSERTION
Anterior part of medial aspect of
ACTION
NERVE
Anterior primary rami of S1, 2
Range of Motion:

Tension of lateral hand of iliofemoral ligament
Tension of hip medial rotator muscles
Fixation:
Weight of trunk
TO 45 0
less with hip extended(
HIP LATERAL ROTATION
NORMAL AND GOOD

Sitting with legs over edge of
table.
Use counter pressure above
knee to prevent abduction
and flexion of hip. Patient
grasps edge of table to
stabilize pelvis.
Patient laterally rotates
thigh.
Resistance is given above
ankle joint.
FAIR
Sitting with legs over
edge of table.
Use eounterpressure
above knee.
Patient laterally rotates
thigh through range
of motion with
stabilization of pelvis In
patient
POOR
Backlying with leg in
internal rotation.
Stabilize pelvis.
Patient laterally
rotates leg through
range of motion.
TRACE AND ZERO

Presence of
contraction in lateral
rotators may be
determined by deep
palpation behind
greater trochanter.
Note:
Resistance should lie given slowly and
carefully in tests for rotation of the hip and
shoulder.
Use of the long lever arm can cause injury
to joint structures if not controlled.
Hip Medial Rotation

GLUTEUS MINIMUS
GLUTEUS MINIMUS
ORIGIN
Outer surface of ilium between
middle and inferior gluteal lines
INSERTION
Anterior surface of greater
trochanter of femur
ACTION
Abducts and medially rotates hip.
Tilts pelvis on walking.
NERVE
Superior gluteal nerve (L4, 5, S1)
HIP MEDIAL ROTATION

Range of Motion.
0 TO 45
)LESS WITH HIP EXTENDED(

1. When hip is extended, tension of iliofemoral ligament.
2. When hip is flexed, tension of ischiocapsular ligament.
3. Tension of hip lateral rotator muscles
Fixation: Weight of trunk
NORMAL AND GOOD

edge of table.
Use counterpressure
above knee to prevent
adduction of the hip.
(Patient grasps edge of
table to stabilize pelvis.)
Patient medially rotates
thigh. Resistance is given
above ankle joint.
FAIR
table. Use counter
prcssnre above knee.
Patient medially
rotates thigh through
range of motion with
stabilization of pelvis.
POOR
Backlying with leg in
lateral rotation.
Stabilize pelvis.
Patient medially
rotates leg through
range of motion.
TRACE AND ZERO

Tensor fasciae Latae
may be palpated near
its origin posterior and
distal to anterior
superior spine of
ilium.
Glutens Minimus
fibers lie beneath
Gluteus medius and
Tensor fasciae Latae.
Note
If patient lifts pelvis on side being tested to
assist in medial rotation, pelvis should be
stabilized.
Knee Flexion
Biceps femoris
Semitendinosus
Semimembranosus
Knee Flexion
Tension of the knee extensor muscles,
particularly Rectus femoris if hip is
extends
Contact of calf with posterior thigh
Fixation:
Contraction of Iliocostalis lumborum
and Quadratics lumborum muscles
Weight of thigh and pelvis
NORMAL AND GOOD

(Biceps femoris)
Prone with legs straight.
Stabilize pelvis.
Patient flexes knee. Grasping
above ankle, laterally rotate
leg (muscle is placed in better
alignment), and resist flexion
to test Biceps lemons.
NORMAL AND GOOD
Semitendinosus and Semimembranosus

Stabilize pelvis.
Patient Hexes knee. Grasping proximal to the ankle,
medially rotate leg and resist flexion to the
Semimembranosus and Semitendinosus.
FAIR

Stabilize thigh medially and laterally without pressure over
the, muscle group being tested.
Patient flexes knee through ROM. (if Gastrocnemious is
weak, knee may be flexed to 10 for starting position).
POOR
Sidelying with legs straight and upper leg supported.

Stabilize thigh.
Patient flexes knee through range of motion. Uneven
muscular pull will cause rotation of lower leg as above.
TRACE AND ZERO
Prone with knee partially flexed and

lower leg supported. Patient attempts to flex knee.
Tendons of knee flexor muscles may he palpated on
back of thigh near knee joint.
Note
Patient may flex hip in order to start movement with knee

partially flexed.
The Sartorius may be substituted, which causes flexion and
lateral rotation of hip.
Knee flexion in this position is less difficult, since lower leg
is not raised vertically against gravity.
Strong plantar flexion of the toot should not be allowed in
order to present substitution by the Gastrocnemious.
Knee extension
RECTUS FEMORIS
VASTUS INTERMEDIALIS
VASTUS LATERALIS
RECTUS FEMORIS
ORIGIN
Straight head: anterior inferior iliac spine.
Reflected head: ilium above acetabulum
INSERTION
Quadriceps tendon to patella , via ligamentum
patellae into tubercle of tibia
ACTION
Extends leg at knee. Flexes thigh at hip
NERVE
Posterior division of femoral nerve (L3, 4)
ORIGIN
Anterior and lateral shaft of femur
INSERTION
Quadriceps tendon to patella, via
ligamentum patellae into tubercle of tibia
ACTION: Extends knee
NERVE
Posterior division of femoral nerve (L3, 4)
VASTUS LATERALIS
ORIGIN
Upper intertrochanteric line, base of greater
trochanter, lateral linea aspera, lateral
supracondylar ridge and lateral intermuscular
septum
INSERTION
Lateral quadriceps tendon to patella, via
ligamentum patellae into tubercle of tibia
ACTION: Extends knee
NERVE: Posterior division of femoral nerve
(L3,4)
VASTUS MEDIALIS
ORIGIN
Lower intertrochanteric line, spiral line, medial
linea aspera and medial intermuscular septum
INSERTION
Medial quadriceps tendon to patella and
directly into medial patella, via ligamentum
patellae into tubercle of tibia
ACTION
Extends knee. Stabilizes patella
NERVE
Posterior division of femoral nerve (L3,4)
Knee extension
Range of Motion: I2O-13O TO 0'
Tension of oblique popliteal, cruciate
and collateral ligaments of knee joint
Tension of knee flexor muscles
Fixation:
Contraction of anterior abdominal
muscles to fix origin of Rectus femoris
Weight of thigh and pelvis
NORMAL AND GOOD

edge of table.
Stabilize pelvis without
pressure over Rectus
femoris at origin.
Patient extends knee
through range of motion
without terminal locking.
Resistance is given above
ankle joint. (Pad should
be used under knee.)
FAIR
Sitting with legs over edge of
table.
Stabilize pelvis.
Patient extends knee through
range of motion without medial
or lateral rotation at the hip
(rotation allows extension at an
angle, not in a vertical line
against gravity).
POOR
Sidelying with upper leg
supported. Leg to be tested
is flexed.
Stabilize thigh above knee
joint. (Avoid pressure over
Quadriceps femoris.)
Patient extends knee
through ROM.
TRACE AND ZERO

SUPINE with knee flexed and
supported.
Patient attempts to extend knee.
Contraction of Quadriceps
femoris is determined by
palpation of tendon between
patella and tuberosity of tibia
and fibers of muscle. (Latter not
illustrated.)

Muscle Testing of The Upper and Lower Extremities: Physiotherapy Division

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Muscle Testing of The Upper and Lower Extremities: Physiotherapy Division

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Muscle Testing of the Upper

and Lower Extremities

Dr. Mikhled Maayah

Guide muscle testing

Is the muscle active?

Definition of muscle test

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

Requisites for good muscle

Knowledge of anatomy as well as functional.

Muscle grading techniques

Zero (O): No movement of part; contraction cannot be palpated

Outline of technique for administering

Outline of technique for administering

Some basic principles

Some basic principles

2. Start with a gross observation of function

The gravity factor in Grading

6. Check yourself on the following factors:

Have I observed to see that the motion

7. Suggested sequence of extremities muscle

The following suggested sequence first

Suggested sequence of upper extremity

C. Sideling: with weight of arm supported on a smooth

Suggested sequence of lower extremity muscle

Manual Muscle Testing

Neck Manual Muscle Testing

Normal & Good

Fair & Poor

Trace & Zero

Muscles contribute to Neck Extension

Splenius capitis Trapezius (superior fibers) Splenius cervicis Semispinalis capitis

Trapezius (superior fibers)

Base of the skull & posterior

Origin: Spinous processes and supraspinous ligaments of T3-T6

Normal & Good

Fair & Poor

Trace & Zero

Normal & Good

Trace & Zero

Muscles contribute to Scapular Elevation

Normal & Good

Position: Sitting with arms at sides.

Trace & Zero

Muscles contribute to Scapular

Normal & Good

Trace & Zero

Scapular Depression & Adduction

Normal & Good

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

Fair & Poor

Trace & Zero

Scapular Adduction & Downward Rotation

Normal & Good

Trace & Zero

Muscles contribute to Shoulder Flexion

Muscles contributes to Shoulder Flexion

Normal and Good

Trace and Zero

Muscles contribute to Shoulder Extension

Muscles contribute to Shoulder Extension

Muscles contribute to Shoulder Extension

Normal & Good

Trace & Zero

Normal & Good (Alternate)