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PT Measurement:

- multiple choice (45-50), cumulative, similar to quiz


Quiz:
When examining leg length you have your client lie down on a plinth with both
knees flexed & feet flat (hooklying). You are viewing the client from the bottom (foot
end) of the plinth & you notice the clients right knee is higher than the left knee.
What does this indicate?
- true leg length discrepancy: left tibia shorter than right
A PT takes a tape measure & measures the distance from umbilicus to medial
malleolus? What are you measuring?
- apparent leg length
Most valid & reliable method for measuring true leg length discrepancy?
- radiographic X-ray
Patient whose proximal femur & distal tibia are excessively angled inward, toward
midline (bowlegged):
- genu varum
Patient has 17 degrees of hyperextension:
- genu recurvatum
Reliability of goni?
- intra is higher than inter
Which of the following correctly ranks instruments in order of accuracy for
evaluation of lumbar flexion & extension (from most to least)
- radiograph, dual inclinometer, visual estimation
evaluating patient from lateral view, note that acromion process lies anterior to
plumb line, scapula abducted?
- common cause: tightness of upper abdominals, shoulder adductors & pect
minor
assessing posture from anterior view, right foot pointing outward (toe out/laterally
rotated) more than the left?
- tightness of glut max & piriformis
patient can flex their shoulders through less than normal range against gravity, to
determine true ROM you..
- perform PROM screening

evaluating elbow ext, patient can actively extend elbow against gravity of normal
range, unchanged with PROM. Patient able to hold this position against gravity
with moderate resistance. Muscle grade:
- 4/5 in available ROM
following goni measurement, 0-83 of shoulder flexion
- most difficult brushing hair
UE motion to fasten bra from behind?
- wrist flex, IR & ext of shoulder
Gross Screening Of Posture:
- Looking for asymmetries from all sides, give analysis from all 3 views
A. Anterior View
- Head: lateral or rotatory deviation?
- Neck: lateral or rotatory deviation?
- Face: mandible (symmetry), nose (aligned with sternum?)
- Shoulder: UT muscles symmetry (unilateral hypertrophy or atrophy could be due
to dominance) shoulder level: should roughly be equal, AC & SC joint symmetry,
clavicles, step deformity
- Elbow: carrying angle (5-10 degrees in males & 10-15 degrees in female)
- Hip: ASIS symmetry
- Knees: patella (rotated toward/away), tibial torsion (excess of 25 degrees)
- Ankle & foot: malleoli, toe out angle (5-7 degrees), hammer toe/claw toe, hallux
valgus, pronation/supination, arch height
-

B. Posterior View
Head: upright (deviated right or left), torticollis or wry neck
Shoulder height: symmetry (dominant UE is usually lower)
Scapulae: Positional symmetry (by looking at the spines of the scapulae and the
inferior angles) Abducted/protraction or Adducted/retraction (by evaluating
distance between T-Spine and Medial Scapular borders: this is affected by muscle
imbalance, traps, stretch pectoralis Major & minor), note winging (weak serratus
anterior)
Spine: Scoliosis? Functional Scoliosis: straightens during forward trunk flexion.
Muscle imbalance or disease. Structural Scoliosis: Does not reverse during
flexion. Bony deformity. Rib protrusions may indicate scoliosis. Acute lumbar
scoliosis Lateral Shift as per McKenzie
Hip: symmetry of iliac crests, ASIS/PSIS, gluteal folds, greater trochanter (variety
of causes), leg length
Knee: varus/valgus
Ankle/foot: deviation of Achilles tendon, calcaneal valgum/varum (pronation/sup)

C. Lateral View
Head: forward head posture? (Will decrease cervical lordosis)
Cervical spine: cervical lordosis (excessive, reduced, or normal)
Shoulders: forward shoulder posture (can result from tight pec. minor, weak
retractors (Serratus anterior) could be one sided, or normal
Chest region: thoracic kyphosis (excessive: respiration issues, compression of
discs anteriorly, weak thoracic extensors, tightness of ALL ligament), reduced or
normal, Pectus Excavatum (Funnel chest depressed chest), Barrel Chest
(increased AP diameter), Pectus Cavinatum (Pigeon Chest anterior and
downward projection of the chest)
Abdomen: flat, protruding (how does this effect spine)
Lumbar spine: lumbar lordosis (excessive/reduced/normal), a/p pelvic tilt,
sway/flat back: reduced lumbar lordosis: anterior muscles weak, posterior muscles
tight (gluts & HS), posterior pelvic tilt can cause this
Knee joint: genu recurvatum (hyper-extension), flexed knee posture (too much)
Ankle joint: slightly anterior to lateral malleolus (obvious deviations/deformities)

Gross Screening Of Spine (remember to look at actual spine)


A. Cervical: seated
- Protrusion: lower mid c-spine flexion with upper c-spine extension
- Retraction: lower mid c-spine extension with upper c-spine flexion
- Flexion*: bring chin all the way to chest
- Extension*: look up to the ceiling as high as you can
- Rotation*: turn all the way to one side (watch jaw during overpressure)
- Lateral flexion*: bring ear twrd shoulder (bring shoulder down w/ overpressure)
B. Thoracic: seated in backless chair (overpressure: sandwich chest w/ hands)
- Flexion*: bring chest toward belly
- Extension*: bring chest up toward ceiling (look for reverse of kyphotic curve)
- Rotation*: hands across chest, turn body to side (overpressure on shoulders)
C. Lumbar: standing (no overpressure, just touch spine)
- Flexion: bend down towards feet (look for lordosis to reverse)
- Extension: hands on buttock, feet apart, back-bend
- Lateral Flexion: hands on side, run fingers towards knee (looking at sides &
from behind to see spine/skin folds)
**Apply gentle overpressure to check end feel
1. Cervical Goniometric Measurement: seated
- Expected ROM
Flexion: 50 degrees
Extension: 60 degrees (look up to ceiling 40-50 degrees)
Lateral Flexion: 45 degrees
Rotation: 80 degrees (rotation to look over shoulder 60-70 degrees)

A. Flexion:
Fulcrum: external auditory meatus
Proximal arm (fixed arm): perpendicular or parallel to ground
Distal arm (moving arm): base of nose

B. Extension: same as flexion


*Flexion/Extension are not typically measured with a goniometer in clinical situations
-

C. Lateral Flexion
Fulcrum: C7
Proximal Arm (fixed arm): spinous processes of thoracic perpendicular to ground
Distal arm (moving arm): dorsal midline of head

D. Rotation
Fulcrum: cranial aspect of head
Proximal Arm (fixed arm): imaginary line between 2 acromial processes
Distal arm (moving arm): tip of nose

2. Measuring Lumbar Spine (goniometer or tape)


- Expected ROM:
Flexion: 5-7 cm (tape), 80 degrees
Extension: 3-4 cm (tape), 25 degrees
Lateral Flexion: 35 degrees
(Values are for combined thoracic & lumbar motions)**
-

Flexion With Tape Measure:


Mark S2 & C7 with tape (S2: lined up with PSIS)
Stabilize pelvis, measure distance (tape measure touching skin entire time)
Patient flexes re-measure
Remember: estimating total thoracic & lumbar ROM (normal is about 5-7cm)

Extension With Tape Measure:


Mark S2 & C7 with tape
Stabilize pelvis, measure distance
Patient extends re-measure
Remember: estimating total thoracic & lumbar ROM (normal is about 3-4cm)

Lateral Flexion With Tape Measure:


Measure tip of middle finger to floor
Patient side bends re-measure
Change in distance should be roughly 21-23cm
Make sure not compensating by rotating; compare both sides & norms
Best used for repeated measures over time rather than compared to norms, 2
degrees to variations in body proportion (ex: arm length)

Lateral Flexion With Goniometer:


Fulcrum: S1
Proximal arm (fixed arm): perpendicular to ground
Distal Arm (moving arm): aligned with C7 (follow C7, not curvature of the spine)

Leg Length Testing:


- True leg length discrepancy: actual shortening/lengthening of skeletal system
between had of femur & ankle
- Functional/Apparent leg length discrepancy: factors other than actual bone length
cause the shortening/lengthening (ex: scoliosis, foot pronation, pelvic obliquity)
- Visual Method: patient supine with knees flexed (look at femur from side & tibia
from front)
- Clear with bridge, then straightening legs out
- Measure true first (ASIS medial malleolus)
- Measure apparent second (Umbilicus medial malleolus)
Manual Muscle Testing
Cervical Spine
A. Extension (combined motion, upper and lower)
Primary muscles: KNOW*
- Splenius Capitus, Longisssimus cervicis, semispinalis cervicis,
- Iliocostalis cervicis, splenius cervicis, upper trapezius
Patient lies prone with head off table (for grades 5,4,3), Arms by side, head off table
Resistance: Occiput
Stabilization: Under chin ready to catch head if necessary
Direction is extension: look up at ceiling
Start with grade 3 lift head up hold it there a few seconds
If full ROM is possible (should see ext. in rest of spine too) apply resistance
If full ROM is not possible put fully onto table
B. Flexion (combined capital and lower cervical)
Primary muscles:
SCMs, anterior scalenes, longus coli (lower), rectus capitus, longus capitus (upper)
- Patient lays supine, head supported by table for all grades
Resistance: applied to forehead (2 fingers), other hand support back of head
Direction is flexion: bring your chin towards your chest
Start with grade 3 see if they can hold it there
If full ROM is possible apply resistance (tell them before you do so)
If full ROM is not possible grade 2, partial range
Deep neck flexors: stabilizers during capitol flexion
- Can be tested with a pressure bladder and measured
- Ex) 10 sec at 10mm/hg for stabilization; 10x for endurance

Manual Muscle Testing Continued: Trunk (do not give resistance, ignore half grades)
Trunk Flexion
- Muscles used: Rectus abdomens (obliques assist)
- Legs extended stabilize at the pelvis (curl up), patient is supine
- Start with grade 3 can hold it up and clear angles
- Clears inferior angles of scapula
- Does not clear inferior angles of scapula
Grade 5
Grade 4
Grade 3
Grade 2
Grade 1
Grade 0

No assist, hand behind head, clear inferior angles


No assist, hands crossed, clear inferior angles
No assist, hands straight forward, clear inf. Angles (shoulders up)
Raise head and palpate abdominals knees bent (shoulders dont clear)
Cough or perform an assisted forward lean (palpate, cough & abs tighten)
Zero (palpate: cough & feel no contraction)

Trunk Extension
Muscles used: multifidi, Longissimus/Iliocostalis/Spinalis thoracis, Iliocostalis lumborum
- Patient prone with hands clasped behind head (grades 5,4,3 off the table to xiphoid
process) use pillow right under pelvis, stabilize at hips with your hands
- Start with grade 3 lift chest all the way up, hold for 3 seconds (arms by side)
- Can rise up hands behind head
- Cannot raise up fully xiphoid still touching table put fully on table try grade 2
Grade 5
Raises up and locks without effort or lag
Grade 4
Raises up but yields slightly
Grade 3
Raises up with arms at side
Grade 2
Partial range of motion arm at side
Grade 1
Trace contraction (palpate back to feel, will feel contraction)
Grade 0
Zero (palpate back to feel, feel no contraction)
Truck Rotation
- Muscles used: Internal & External obliques
- Patient position: Supine, legs straight, stabilize pelvis & hand in back to protect
- Start with grade 3 lift this shoulder toward that side of the room
- Can clear inferior angle of scapula hands behind head, make sure not pulling
on neck
- Cannot clear inferior angle of scapula grade 2 if lifting up at all
Diagonal curl-up perform movements bilaterally
Grade 5
Hands behind headelbow towards opposite knee. Must clear scapula.
Grade 4
Arms crossed
Grade 3
Arms straight out can raise scapula off table
Grade 2
Arms straight unable to clear inferior angle
Grade 1
Trace contraction (not lifting off table but you feel obliques contracting)
Grade 0
Zero (palpate obliques, feel no contraction)

Elbow Range of Motion


Active screen/gross screen first: standing
- Look from front/side Flexion, Extension
Have patient lay supine to do PROM
- Flexion: stabilize shoulder, end feel: firm/soft
- Extension: hand under elbow, end feel: hard
Flexion
Patient position
Supine with towel under upper arm
Fulcrum
Lateral epicondyle
Proximal Arm
Lateral midline of humerus, landmark acromion process
Distal Arm
Lateral midline of the radius, landmark radial styloid
AAOS normal range 150 degrees
End Feel
Soft. Approximation with muscle bulk of biceps. Most common
Firm. Posterior Capsule of Elbow joint or Triceps
Hard. Bony contact between ulnar coronoid process and coronoid
fossa of humerus. (Can only occur is bicep has very little bulk).
Extension
Position and goniometer placement same as for flexion (& supine)
AAOS normal range 0 degrees
End feel
Hard. Contact between olecranon process and olecranon fossa.
Can be firm, Due to tension in biceps or brachialis,
collateral ligaments and anterior joint capsule.
Dont get to 0 degrees? Ex: 150-5 degrees or -5 degrees of elbow extension (start
from flexion)
- Hyperextension: 0 degrees - ? degrees

Elbow Manual Muscle Testing


First take patient through full ROM, if they can grade 3
Then take them to half way & perform resistance:
Break 3+, little give 4, strong 5
Elbow Flexion
Position
Resistance
Stabilization
GM position
Elbow Extension
Position
Resistance
Stabilization
Alternate position
GM position

(biceps brachii, brachialis, brachioradialis)


Patient is sitting with arm close to side of body. Therapist stands
close to side.
Distal forearm proximal to wrist (hold position, dont let me push
you down)
Lateral/anterior arm (by shoulder)
SL or supine (can also do sitting, bring forearm to chest, shoulder
at 90 degrees)
(triceps)
Supine with 90 degrees of shoulder flexion. Neutral pron/sup at
wrist
Distal ulna
Posterior upper arm just proximal to elbow joint
Patient sitting. Examiner resists elbow extension
Sitting with 90 degrees of flexion, full shoulder IR, elbow
supported by examiner

Muscle Length
Biceps brachii
Position
Sitting
Movement Shoulder extension, forearm pronation, extend elbow
Measurement Note whether patient can get to full elbow extension
- Overpressure at wrist & shoulder (compare both sides)
Triceps brachii
Position
Supine or sitting with full shoulder flexion
Movement Elbow flexion while stabilizing shoulder
Measurement Should get to full elbow flexion. Note limitations. (Passive
insufficiency?)
- Overpressure at hand & below elbow (compare both sides)

Shoulder
ROM
- Quick screen fore posture then a gross screening sitting (view from
front & back to watch scapula)
Functional Screen: Flexion, Abduction, Internal Rotation. External Rotation, Extension
Aply scratch test or reach behind back or IR
- Overpressure once on table

Measurement
Procedure
1.
Position and drape the patient
2.
Explain to the patient what the motion is and what you are going to do.
3.
Check passive range of motion and end feel
4.
Proceed slowly and gently. Give the patient confidence
5.
Measure starting position if necessary
6.
Measure ending position (active or passive)
- Always measure both sides
Flexion: 180*
Patient position
Supine
Fulcrum
Close to Acromion process (humeral head)
Proximal Arm
Mid-Axillary line of thorax
Distal Arm
lateral midline of humerus lateral humeral epicondyle
- Lats can limit if tight
- AROM first then passive, make sure no compensation (Ex: arching back)
Extension 60*
Patient Position
Prone with head turned or forehead on towel
Fulcrum
Close to acromion (humeral head)
Proximal Arm
Mid-Axillary line of thorax
Distal Arm
Lateral midline of humerus lateral epicondyle
- Measure AROM, then lift for PROM
- Avoid compensation, stabilize shoulder & lift above elbow, should be firm end
feel
Abduction 180*
Patient Position
Supine close to the edge of the table (differs from book)
Fulcrum
Anterior aspect of acromion process (humeral head)
Proximal Arm
Parallel to midline of the anterior aspect of the sternum
Distal Arm
Medial midline of humerus
- Thumb up to clear, AROM then PROM at elbow

Internal Rotation 70*


Patient Position
Supine with towel under upper arm, elbow just over edge of table.
90 degrees Abduction (if limited/contraindications bring
wherever he can)
Fulcrum
Olecranon process (elbow)
Proximal Arm
Parallel or perpendicular to floor
Distal arm
Ulna. Aligned with Olecranon and ulnar styloid
Note
What carefully for substitution. As soon as humeral head rises
noticeably, motion is complete. (if you push too much, shoulder
will pop out)
- Ask to bring arm forward for IR
External Rotation 90*
Same as for Internal
Ask patient to bring arm back instead of forward

Muscle Length Testing


-

Muscle length must be looked at because it can limit ROM


Take them into the motion opposite of what the muscle does to lengthen muscle
ALWAYS assessed passively with over pressure
There are no norms, comparing sides

Latissimus Dorsi & Teres Major


- Teres major is the synergist, but has no attachment to pelvis
Patient position
Movement

Supine on table. Hips and knees flexed


Flex both upper limbs with low back flat on table. When back
arches, amount of flexion is noted (back pop up & movement is
done, look at one side to compare to other, if it is tight stretch
patient in that position)
- Flex, abduction of UEs & apply overpressure
Pectoralis Major

(remember there are 2 heads & apply overpressure!)

Patient position
Movement

Supine on table. Hips and knees flexed


Sternocostal Head (scaption w/ER), attaches to sternum
Shoulder lateral rotation and flexion about way between frontal
and sagittal planes. Shoulders should achieve full flexion to the
table.
Costoclavicular Head, attaches to clavicle
Horizontal Abduction at 90 degrees of shoulder flexion. Upper
limb should reach the table

Pectoralis Minor

Supine on table with hips and knees flexed.


Assess for asymmetrical shoulder height from table.
Can be measured with a tape measure to compare both sides (table
to shoulder height).
Will be tight with round shoulders, view & gently press on
shoulders to see if they come down closer to table

Scapulothoracic MMT (no grav min!)


Scapular Depression and Adduction (lower trapezius)
P
Prone. Elbow extended. Thumb up. 145 degrees of abduction (a little more than
scaption). Therapist stands at test side inferior to arm.
R
Distal humerus
S
Use other hand to palpate lower trap
Scapular Adduction (middle trap)
P
Prone. Therapist at side and inferior to arm
Arm abducted and externally rotated (thumb toward ceiling)
R
Distal forearm
S
Scapular area (palpating the fibers of middle trapezius)
Note: Look for scapular adduction (are you pulling scaps together), not horizontal
abduction of the humerus.
Scapular Adduction and medial rotation (Rhomboid major/minor)
P
Prone with dorsum of hand placed over the buttock opposite the test side- raises
the arm away from the back (make sure scapula is adducted and IR). (90,90 &
push to ceiling)
R
applied over the scapula (vertebral border) in the direction of abduction and ER
S
through the weight of the trunk assess for substitutions (tipping of scapula
forward through pec minor)
Scapular Abduction (Serratus anterior)
P
Supine. Shoulder flexed to 90, elbow flexed to 90
R
On top of elbow
S
Pec major
Alternate Position
Elbow extended. Patient makes a fist. Resistance applied to top of fist. No stabilization
required unless elbow is weak.
Quick Clinical Test - Wall push up Weakness is demonstrated by winging of the
scapula.

SHOULDER /GH MMT


- Always apply max resistance, but relative to the joint & individual patient
- PROM first to see range & end feel if can pull arm all the way up grade 3
- Then take patient halfway through ROM & stabilize shoulder/upper trap
- 3+ can break, 4 little give, 5 cant budge
- Cant go all the way through PROM GM positioned:
- 3- can PROM in GM position (strength in an issue), 2 full ROM in GM
- 2+ partial ROM against gravity, 2- cant go through full ROM
- 1 trace (touch & feel contraction), 0 no contraction at all
Flexion (anterior deltoid, Coracobrachialis & long head of the biceps)
Position
Sitting. Elbow extended & thumb up.
Resistance
Distal Humerus
Stabilization Distal upper trap
GM position: side lying (cant lift half way, support arm, take through PROM,
grade is less than 3)
Abduction (middle deltoid and supraspinatus)
P
Sitting. Elbow extended, thumb up. Therapist in front of patient.
R
Distal Humerus
S
Distal upper trap
(Follow the same principles as for flexion)
GM position supine (not full ROM, support, arm overhead)
Scaption (deltoid and supraspinatus): Arm elevation in the plane of the scapula.
P
Short Sitting elevate arm to 90 deg, halfway between Abduction and Flexion
R
Distal humerus
S
Distal Upper Trap
Extension (Latissimus Dorsi, Teres Major, Posterior Deltoid)
P
Prone with head turned or forehead on towel
R
Distal Humerus
S
Scapula
GM position: sidelying
Horizontal Adduction (Pec major)
P
Supine. 90 degrees of elbow flexion, full shoulder internal rotation, Therapist
stands on the cranial side of the arm.
R
Distal humerus
S
Pec major
GM position - sitting

External Rotation (teres minor and Infraspinatus)


P
Prone with head turned or forehead on towel. 90 degrees of ABD and 90 degrees
of elbow flexion. Can use a towel or pad under upper arm. Therapist stands
superior to arm.
R
Distal forearm use mild or two-finger resistance (half way)
S
Elbow
GM position arm straight

Internal Rotation (Subscapularis, pec major, lat. dorsi, teres major)


P
Prone with head turned or forehead on towel. Towel under upper arm. Therapist
stands inferior to arm.
R
Distal forearm. Resistance is stronger than for ER.
S
Elbow
GM position arm straight

Wrist and Hand ROM and Muscle Testing LAB


Gross exam: AROM screening
Flexion/Extension
Ulnar/radial deviation
Supination/pronation
Digit abduction/adduction
Thumb flexion/extension
Fist (make full fist)
Opposition (thumb to each finger)
If all can fully be achieved, strength is the issue
Passive Range of Motion Assessment
Supine or sitting

Goniometry
1. Pronation
Position
Fulcrum
Proximal arm
Stationary arm
Expected ROM

Arm at side of body with elbow at 90 degrees, STANDING,


Forearm neutral
proximal ulnar head
dorsal or volar surface of forearm just proximal to styloid process
Perpendicular to floor
0-90 degrees

1. Supination
Position
Fulcrum
Proximal arm
Stationary arm
Expected ROM

Arm at side of body with elbow at 90 degrees, STANDING


Forearm neutral
exact opposite of ulnar head
dorsal or volar surface of forearm just proximal to styloid process
Perpendicular to floor
0-90 degrees

1. Wrist Flexion
Position
Fulcrum
Proximal arm
Stationary arm
Expected ROM
End feel

Sitting with arm supported on table. Wrist just over edge of table.
Lateral Aspect of wrist. Triquetrum (ulnar side)
Olecranon
Lateral midline of 5th MC.
80 degrees
Firm

2. Wrist Extension: same positions & end feel


Expected ROM

70 degrees

3. Radial Deviation
Position
Fulcrum
Proximal arm
Distal arm
End feel
Expected ROM

Same
Capitate
Dorsal Midline of forearm
Third MC
Firm or hard
20 degrees

4. Ulnar Deviation
Position
Same
Fulcrum
Same
Proximal arm
Same
Distal arm
Same
End feel
firm
Expected ROM
30 degrees
*** Wrist Capsular Pattern Equal limitations of flexion and extension

5. MCP Flexion
Position
Sitting. Neutral pronation/supination
Fulcrum
Place axis on the dorsal surface of the MCP joint
Proximal
Dorsal midline of MC
Distal
Dorsal midline of proximal phalanx
End feel
Firm or hard
Expected ROM
90 degrees

6. MCP Extension
Same as for flexion
End feel
Expected Rom

Firm
45 degrees

7. Thumb CMC Flexion


Position
Sitting. Full supination
Fulcrum
Palmer first CMC joint
Proximal
Ventral midline of radius radial styloid
Distal
Ventral midline of first MC
End feel
Soft
Expected ROM
15 degrees

8. Thumb CMC Extension


Same as for Flexion
End feel
Firm
Expected ROM
Not listed. Roughly 25 degrees

9. Thumb CMC Abduction


Position
Sitting. Neutral Pronation/Sup
Fulcrum
Lateral aspect of radial styloid process
Prox
Center of 2nd MC
Distal
Center of 1st MCP joint
End feel
Firm
Expected ROM
70 degrees

10. Thumb MCP Flexion


Position
Sitting. Full Supination
Fulcrum
Dorsal aspect of MCP
Prox
Dorsal midline of MC
Distal
Dorsal midline of prox phalanx
End feel
Hard or firm
Expected ROM
50 degrees

11.

Thumb MCP Extension

Same as MCP flexion


End feel
Firm
Expected ROM
Not listed

12.

Thumb Opposition

Position
Sitting. Full supination
Ruler position Tip of thumb and tip of fifth finger.

13.

PIP and DIP Flexion and Extension

Demonstration only

Muscle Length Testing


Flexor carpi ulnaris, flexor carpi radialis, and palmaris longus

Extensor carpi radialis longus and brevis, extensor carpi ulnaris

Flexor digitorum superficialis

Extensor digitorum and digiti minimi

Manual Muscle Testing


Please note that there is no gross strength screening for the wrist and hand.

1. Wrist Flexion (flexor carpi radialis, flexor carpi ulnaris)


Position:
Stabilization:
Resistance:
GM:

Sitting, full supination


Proximal to wrist
Distal to wrist
Neutral pron/sup

2. Wrist Extension (extensor carpi radialis longus and brevis, extensor carpi
ulnaris)
Position:
Stabilization
Resistance:
GM:

Sitting, full pronation


Prox to wrist
Distal to wrist
Neutral Pronation/supination

3. Wrist Radial Deviation (flexor carpi radialis brevis/longus, extensor


carpi radialis)
Position:
Stabilization
Resistance
GM

Sitting, neutral sup/pron


Prox to wrist
Distal to wrist. Radial side of hand
Neutral pron/sup

4. Wrist Ulnar Deviation (flexor carpi ulnaris and extensor carpi unlnaris)

Position
Stabilization
Resistance
GM

Sitting. Full pronation


Prox to wrist.
Ulnar side of wrist
None. Main test position is GM

Finger MMT
Please note that there are no grades given for finger MMTs. Gravity has very little
effect so you will not be asked to learn GM positions for the following tests. .

1.

PIP Flexion (Flexor digitorum superficialis)

Position
Stabilize
Resistance

2.

Sitting. Full supination


Prox phalanx
Middle Phalanx

DIP Flexion (Flexor digitorum profundus)

Position
Stabilize
Resistance

Same
Middle phalanx
Distal phalanx

3.
MCP Extension (Extensor digitorum, extensor indices, extensor digiti
minimi (depending on finger tested)
Position
Stabilize
Resistance

Sitting. Full pronation. MCP flexion. Finger flexion


Wrist
Prox phalanx

Thumb motions
The thumb is positioned in a rotated position. Therefore flexion, extension, abduction
and adduction may appear counterintuitive when viewed in the anatomical plane.

4.

Thumb Extension (extensor pollicis longus)

Position
Stabilize
Resistance

5.

Thumb Abduction (abductor pollicis longus)

Position
Stabilize
Resistance

6.

Sitting. Neutral pron/sup


Prox phalanx
distal phalanx

Sitting. Neutral.
Hand
Prox phalanx

Thumb Adduction (adductor pollicis)

Position
Stabilize
Resistance

Sitting. Neutral
Hand, digits 2-5
Inner aspect of prox phalanx

Hip and Knee ROM and Muscle Testing Lab


Range of motion screening
Hip: Look at symmetry & full ROM from multiple planes
- Flexion: march leg up (both sides) any pain?
- Extension: lift leg back, very little motion, no leaning forward
- Abduction: leg out to side, toe straight
- Adduction: bring leg out in front, cross over then bring back
*All standing, hold on to table or hold their hand
- IR: bring foot out to side (avoid knee movement)
- ER: bring leg in & up shin towards knee
*Both sitting, some hip flexion can occur with normal range
Knee extension:
- sitting, kick knee up totally straight, look for symmetry & full ROM
Knee flexion:
- standing, hold onto something stable, bend knee back, bring heel towards bottom
Ankle: (performed in short sitting), hold leg, get a stool
- Dorsiflexion (guide with finger)
- Plantarflexion (guide with finger)
- Inversion
- Eversion
- Flexion, Abduction, Extension of 1st MT
Goniometric Measurement:
1. Passive Range of Motion Assessment
Supine (Hip extension can be done in prone or side-lying; Hip adduction can be assessed
by moving both legs together (one adducting the other abducting), say end feel

2. AROM & get measurement


3. give overpressure, obtain PROM measurement (should be 5-10* more)
*Test effected side first!!!
1.
Hip Flexion
Position
Supine (fully relax, lift hip toward belly, bend knee, any pain?)
Fulcrum
GT
Prox arm
Lateral midline of trunk
Distal arm
Lateral femoral epicondyle
AAOS ROM 120 degrees
End Feel
Usually soft, can be firm

2.

Hip Extension (side-lying is cant lay prone)

Position
Goni
AAOS ROM
End feel

Prone (feet off table, stabilize hip, keep leg straight & lift to ceiling)
Same as flexion
20 degrees
Firm

3.
Hip Abduction
Position
Supine (bring leg out to side, support around knee, stabilize pelvis)
Fulcrum
ASIS
Prox Arm
Line between ASISs (straight across stomach), patient can hold goni
Distal arm
Midline of Patella
AAOS ROM 45 degrees
End Feel
Firm
4.
Hip Adduction: Same as abduction
(abduct other leg, bring leg toward other leg, keep knee straight)
AAOS ROM 30
(come closer to that side of table & abduct other leg away)
5.
Hip Internal (Medial) Rotation
Position
Sitting, knee flexed to 90 degrees (stabilize gently at knee, leg to ankle)
Fulcrum
Anterior aspect of patella
Prox arm
Perpendicular to floor
Distal arm
midpoint between malleoli
AAOS ROM 45 degrees
End feel
Firm, do PROM & end feel in supine first!!
6.
Hip External (Lateral) Rotation
Position
Same (stabilize knee, bring leg in toward other foot)
Goni
Same
AAOS ROM 45 degrees
End feel
firm, do PROM & end feel in supine first!!
7.
Knee Flexion (Supine)
Position
Supine, can flex hip also if necessary
Fulcrum
Lateral epicondyle
Prox arm
GT
Distal arm
lateral malleolus
AAOS ROM 135 degrees
End feel
Soft (apply overpressure on tibia)
8.
Knee Extension (Supine)
Position
Supine with towel under ankle, knee straight, quad set (squeeze knee &
push into my hand), do not give resistance (just a cue), Same as knee flexion
AAOS ROM 10 degrees of hyperextension
End feel
Firm (overpressure on femur & support back of calf)

Muscle Length Testing

1. Hip Flexors - Thomas Test psoas & rectus femoris


- will be tight with anterior pelvic tilt
- sitting at edge of table, lie them back & support back, bring both knees toward chest
- drop one leg down & tell pt to pull other leg in as tight as possible
- is leg hitting table or not? Angle of knee should be 90, positive psoas if tight
- COMPARE BOTH SIDES!
2. Rectus Femoris Thomas test. Watch for knee extension
- rule rectus out by extending the leg (can help but dont hold it up), back is flat
- if it is rectus that is tight thigh should go down, if not psoas is tight
- if rectus is issue turn over to prone for elys test
3. Ely - Prone Knee Flexion
- stabilize hip, bend knee if angle is 90 or more, it is a positive test
- can measure flexibility with goni to compare both sides, but not measuring the true
angle in this position (due to passive insufficiency)
4. TFL Ober test:
- side-lying, bend knee & support hip
- lift pt into abduction & extension (body in neutral so hips don't roll back)
- let go, should fall back slowly..if hanging in air positive test (of TFL)
- then extend knee & redo to figure out if ITB is involved (pos IT band)
5. Hamstrings SLR (normally 70-80 degrees)/ 90/90
- supine, SLR with other knee straight, compare both sides & apply overpressure
(positive test tightness of proximal
- then position pt at 90,90 and attempt to extend knee
(positive test tightness of distal hamstring )
- can compare visually or measure with goni (same landmarks as knee flexion), but will
not be measuring TRUE joint, always unaffected side first

Manual Muscle Testing


Gross Strength Screening (sitting, supine)
Flexion, extension, abduction, adduction, IR/ER
Specific muscle testing
Hip Flexion Iliopsoas
Position
Sitting. Hands flat on table (march)
Resistance
Distal Femur (don't let me push you down)
Stabilization Posterior trunk/back
GM
Sidelying (on opposite side)
Hip Extension
Hamstrings and Glut Max
Position
Prone (watch for compensation, push up against my hand)
Resistance
Distal femur
Stabilization Lateral pelvis
GM
Sidelying (on opposite side)
Hip Extension with knee flexion Glut Max (isolates)
Position
Prone. Knee flexed to 90 degrees
Resistance
Distal femur
Stabilization Lateral pelvis
GM
Sidelying
Hip Abduction
Glut medius and minimus SLR
Position
Sidelying. Slight bend in lower leg.
Resistance
Distal femur, lateral aspect
Stabilization Lateral pelvis
GM
Supine
Hip Adduction SLR
Position
Sidelying. Top limb either flexed in front or behind lower limb
Resistance
Distal femur, medial aspect
Stabilization Lateral Pelvis
GM
Supine
Hip External Rotation

Obturators, Gemellae, Piriformis, Quadratus femoris,


Glut Max
Position
Sitting (bring foot towards other)
Resistance
Medial ankle
Stabilization Lateral Knee
GM
Supine. Limb straight (rotate toe in)

Hip Internal Rotation


Glut medius and minimus and TFL
Position
Sitting
Resistance
Lateral ankle
Stabilization Medial knee
GM
Supine. Limb straight (rotate toe out)
Knee Extension
Quadriceps Femoris
Position
Sitting. Therapist on chair or standing (chair is preferable).
Resistance
Distal Tibia
Stabilization Distal Femur
(kick straight out, now half way)
GM
Sidelying
Knee Flexion
Position
Resistance
Stabilization
GM

Hamstrings
Prone
Distal Posterior Tibia
Distal Femur
Sidelying

Goniometric Measurements
- do PROM, get end feel, then AROM, then PROM measurements
- do unaffected side first!
Passive Range of Motion Screening.
- Of which ankle movement is deficient (short sitting or long with towel under knee)
- Hindfoot inversion & eversion performed in prone
Talocrural Dorsiflexion
Position
Sitting with legs over edge or long sitting with knees bent and ankle off
table.
Fulcrum
lateral malleolus or lateral calcaneus
Prox arm
Fibular head
Distal arm
Parallel to 5th MT (above, in same plane)
AAOS ROM 20 degrees
End Feel
firm
Talocrural Plantarflexion
Same as dorsiflexion
AAOS ROM 50 degrees
End feel
Firm
Forefoot Inversion (talocrural joint)
Position
Same (bring toes toward midline & up)
Fulcrum
Anterior ankle midway between malleoli
Prox Arm
Tibial tuberosity
Distal Arm
2nd MT
AAOS ROM 35 degrees
End feel
Firm

Forefoot eversion
Position
Same
Alignment
Same
AAOS ROM 15 degrees
End feel
Firm or hard
Hindfoot Inversion
Position
Prone with feet off of table
Fulcrum
Posterior ankle, midway between malleoli
Prox arm
Posterior midline, lower leg
Distal arm
Posterior midline of calcaneous
AAOS ROM 0-4 naturally, 4-32 degrees actively
End feel
Firm
Hindfoot eversion
Position
Same
Alignment
Same
AAOS ROM 5 degrees
End feel
Hard or firm
1st MTP Extension (use hand goni, on bottom of foot)
Fulcrum
lateral aspect of first MT joint
Prox arm
1st MT
Distal arm
proximal phalanx
AAOS ROM 70 degrees
End feel
firm
1st MTP Flexion (use hand goni, on top of foot)
Position
Same
Alignment
Same
AAOS ROM 45 degrees
End feel
Firm

Muscle length testing


Gastroc: supine with knee straight
Soleus: supine with knee flexed (towel/bolster)
Function:

Full range of DF is required to descend steps (21-36 degrees)Manual Muscle Testing


No + or for the ankle!!
Gross strength Screening
Dorsiflexion with inversion Tibialis Anterior
Position
Short sitting - Therapist sits on stool
Resistance
Distal foot
Stabilization
Proximal to ankle
Alternate Knee flexed to 90 degrees. Patient sitting
Inversion in plantar flexion Tibialis Posterior
Position
Same as previous except ankle in plantar flexion
Resistance
Medial/Distal foot
Stabilization
Proximal to ankle, lateral aspect
Alternate
True AG position is sidelying
Eversion Peroneous Longus and brevis
Position
Short sitting - Therapist on stool. Ankle in plantarflexion
Resistance
Distal/Lateral foot
Stabilization
Proximal to ankle, medial aspect
Alternate
True AG position is sidelying
Plantar Flexion Gastroc/Soleus
10 calf raises
Poor +
range
Fair More than
Fair
1 rep
Far +
2-3 reps
G
4-6 reps
G+
7-9 reps
N
10 reps
Demonstrate non WB in prone
Soleus knee flexed to 90* - pt PF toward ceiling
Gastroc knee extended
Great toe tested in supine
Hallux and toe MP and IP flexion flexor hallicus brevis/longus
Hallux and toe MP and IP extension extensor hallicus longus/brevis
Hallux and toe DIP and PIP flexion as per book

Subtalar Neutral Assessment


- part of gross screen if you get ankle case study
Normal STN = 4 degrees of varus
In prone, feet hanging off table
- make 3 lines
- grasp lateral foot with one hand
- grasp talus (in between two malleoli) with other
- move back & forth until you fill talus is neutral
- angle of 3 pen marks should show a hindfoot varus ~4degrees