Shoulder Flexion 3 PDF

Manual Muscle Testing
of the Shoulder
PHTH 224
Evaluation, Testing and Measurements

Sem 2 - Ms. I. Devreux 1
Objectives of the Lecture
 To know the muscles active in shoulder flexion,

extension, abduction and adduction and their
anatomical basis.
 To be aware and able to measure the ROM for these

movements.
 To be able to test the strength of the movements from a

theoretical and practical aspect.

SHOULDER FLEXION
TO 90°
Evaluation and Measurements

PHTH 223

•Deltoid Anterior
Shoulder Flexion Movement to 90°
•Coracobrachialis
1. Deltoid Anterior Muscle: •Pectoralis Major
Action: (accessory)
 Flexes and medially rotates the
shoulder joint.
 Acts as stabilizer when abduction of
shoulder is performed by the deltoid
middle fibers.
Origin: anterior border & superior surface

of the lateral 1/3 of the clavicle.
Insertion: Deltoid tuberosity of humerus

2. Coracobrachialis muscle:
 Action: Flexes and adducts the
shoulder
 Origin: apex of coracoid process of

scapula.
 Insertion: antero-medial surface of

middle shaft of humerus, opposite to
deltoid tuberosity.
 Nerve: C6, C7.

 Accessory Muscles:
-Pectoralis Major (clavicular
fibers)
-Biceps Brachii.
 ROM= 0° to 90°.
 Limitation of ROM: by
ankylose ( stiffness) of the
shoulder joint.

Shoulder Flexion Movement to 90°: MMT Procedure
Grade FAIR Strength( 3):
 Pt. sits with elbow slightly

flexed.
 Therapist stands behind the pt.’s

affected shoulder. One hand is
placed over the shoulder to fix
the scapula.
 Command: « Pull your arm up

in front of you and your palm
toward the floor ( to 90°)
…relax.
Shoulder FlexionMovement to 90°: MMT Procedure
Grade 4-5 : « Good and Normal Strength »
 Patient is sitting as in Gr. 3.
 Therapist is behind, Proximal hand

stabilizes the scapula, distal hand
gives resistance above the elbow
joint.
 Gr. 4: Moderate resistance is given

opposite the line of motion.
 Gr.5: Maximum resistance + Hold
position is kept at the end of the
range.
 Command: Pull your arm up in front
of you and your palm to the floor +
resist (for gr. 5: hold) at the end of
the motion( to 90°). Evaluation, Testing and Measurements
Shoulder Flexion Movement to 90°:
Deltoid Anterior - Note
1. The pt. is requested to keep the
forearm in pronation to avoid
substitution by the biceps brachii when
testing the elbow in extension.
2. To isolate the coraco-brachialis muscle,

the motion is performed with complete
elbow flexion and supinated forearm.
(Shoulder flexion will then be with a
slight lateral rotation).
Biceps Brachii assists but with limitation
because the movement ( flex+ sup. )
will place the m. in a too short position.
Shoulder Movement to 90°:
Grade 2: Poor Strength:
Pt. is in sidelying with affected arm

(over) supported on a smooth
board( or by therapist) and
elbow is slightly flexed.
 Therapist is behind the affected

shoulder to stabilize the scapula.
The distal hand stabilizes the
board( or supports the arm).
 Command: Pull your arm in front

of you( to 90°)… relax.
Shoulder Flexion Movement to 90°:
Grade 1 and 0: Trace & Zero
Strength:
 Pt. Position: Side or supine

lying.
 Therapist palpates on the

anterior aspect of the shoulder
joint with proximal hand.
 The therapist will fix the

scapula with one hand and the
other palpates.

Shoulder Flexion Movement to 90°: Note
Effect of Weakness:
 Weakness of these muscles will decrease

the strength of shoulder flexion.
 Weakness of the coracobrachialis will

impaire function for movements that need
complete elbow flexion and supination as for
combing the hair.

Shoulder Extension
1. Lattissimus Dorsi
2. Teres Major
Origin:
 Spinous processes of last 6
vertebrae.
 Last 3 or 4 ribs.
 Posterior 1/3 of external lip
of iliac crest.
 Part of inferior angle of the
scapula.
 Insertion: Intertubercular
groove of humerus.

Shoulder Extension:
 Accessory Muscles:
 Triceps ( Long Head)
 Teres Minor
 Range of Motion :
 From 0° to 50° beyond the
midline.
 Nerve: Thoracodorsal nerve

C6, C7, C8, C5 for the
Deltoid) → Tetraplegia after
hyperextension of neck
Shoulder extension: Latissimus Dorsi
Action of Latissimus Dorsi:
 With the origin fixed:
 medial rotation of the shoulder

 adduction and extension of shoulder
joint.
 it depresses the shoulder girdle
 assists in lat. flexion of the trunk.
 With the insertion fixed, it assists in

tilting the pelvis anteriorly and
laterally.

Shoulder Extension: Latissimus Dorsi
 If acting bilaterally, the muscle assists in :
 Hyperextension of the spine
 Anterior tilting of the pelvis.
 In flexing the spine depending on the axes of
motion.
 This m. is very important for: climbing,

walking with crutches, hoisting the body
up on parallel bars in which the m. acts to
lift the body toward the fixed arm.

Activities
 Forcefull swimming, rowing,
chopping are largely
dependent on the strength
of this muscle.
 Shoulder adductors &

medial rotators are
important but the latissimus
dorsi is the most important
one.
 The Latissimus Dorsi may

act as accessory muscle in
respiration.
Shoulder extension: Teres Major
 Origin: Dorsal surfaces of
inferior angle & lower third of
lat. border of scapula.
 Insertion: crest of lesser

tubercle of humerus.
 Action: Medially rotates,

adducts & extends shoulder
joint.

Shoulder extension: Deltoid
Deltoid: ( Posterior Fibers)
 Origin: Inferior lip of posterior
border of spine scapula.
 Insertion: Deltoid tuberosity of

humerus.
 Action: Extends and laterally

rotates the shoulder joint.
 Acts as stabilizer when medial

fibers of deltoid are performing
abduction of the shoulder.
Shoulder extension: Test Procedure
Grade 3: Fair Strength:
 Pt. Is in prone lying with arm
along body side.
 Therapist stands beside the tabel

and fix the scapula with her
proximal hand placed over the
shoulder.
 Command: « Pull your arm up

with palm up…relax.

Shoulder extensionGrades 4 and 5:
 Same positions as in Gr. 3 .

 Therapist applies the
resistance with the distal hand
above the elbow joint.
 Resistance is moderate for gr.
4 and maximal for gr. 5 + hold
at the end of the ROM.
 Command as in gr.3 + hold for

gr. 5 (Pull up arm with palm up)

Shoulder extension
Grade 2 (Poor strength):
 Pt. in sidelying with the
affected arm over & resting
on a smooth board or
supported by therapist in
forearm pronation.
 Therapist stands in front of

the patient. Proximal hand is
placed over the shoulder to
stabilize the scapula.
 Command: « Pull your arm

backwards… relax)
Shoulder extension
Grade 1 & 0: Trace & Zero
grade:
 Pt. In sidelying or prone.
 Therapist is in at the back,
 prox. hand stabilizes the
scapula.
 distal hand palpates fibers
of the teres major.
 Palpation on the lower part of
the axillary border of the
scapula and fibers of
latissimus dorsi slightly below.
Shoulder extension: Note
 Motion should take place
primarily at the gleno humeral
joint.
 Patient should not be allowed

to tip the scapula forward in an
effort to complete the range.

Shoulder extension: Weakness
 Weakness of latissimus Dorsi:
weak adduction of the arm toward
the body or the body toward the
arm.
 Reduced strength of shoulder
extension & lateral trunk flexion is
diminished.
 Weakness of Teres Major:

Diminished strength of medial
rotation and extension of humerus.
 Weakness of Deltoid ( post. fibers):

Diminished strength of extension of
humerus.
New MOVEMENT:
shoulder abduction

SHOULDER ABDUCTION TO 90°
 ROM: 0° to 90°.
 2 muscles:
 Deltoid
( middle fibers)
 Supraspinatus
 Accessory ms. :
 Deltoid anterior and
posterior fibers act as
stabilizers
 The ROM may be limited

by ankylose of the
shoulder joint Evaluation, Testing and Measurements
SHOULDER ABDUCTION TO 90°
Deltoid « Middle Fibers »:

 Origin: Lateral margin of
superior surface of acromion.
 Insertion: Deltoid tuberosity of

humerus.
 Nerve : C5, C6.
Action:
Abducts the shoulder joint.

SHOULDER ABDUCTION TO 90°:
Supraspinatus:
 Origin: Medial 2/3 of supraspinatus
fossa of scapula.
 Insertion:
 Sup. facet of greater tubercle of
humerus.
 Shoulder joint capsule.
 Nerve : C4, C5, C6.
Action:
 Abducts the shoulder.
 Stabilizes the head of humerus in
the glenoid cavity during
movements of this joint.
SHOULDER ABDUCTION TO 90°: Test procedure
Grade 3 « Fair strength »:
 Pt. sits over the edge of the table,
arm at side in mid position between
lateral & medial rot., elbow flexed at
a few degrees.
 Therapist stands behind the pt. with

proximal hand on the shoulder to
stbilize scapula.
 Command: « With palm down ,raise

your arm up & out to 90° ---Relax »
! Action without lat. rotation to avoid

substitution by biceps brachii.
SHOULDER ABDUCTION TO 90°:Test procedure
Grades 4 & 5:
 Pt. sits over the edge of the table.
 Therapist is behind the pt., prox.
hand stabilizes scapula & distal
hand is placed proximal to elbow
joint to give resistance ( by
pressing down moderately for gr. 4
and maximally for gr. 5 + hold at
the end of range.
 Command : » with palm down raise

your arm + hold for gr. 5 at the
end--- relax. »
Grade 2 : « Poor strength »
 Pt. Is in supine lying, arm beside
the body in mid position between
medial and lateral rotation.
 Therapist position and grasp:

beside the table, proximal hand is
placed on the shoulder to
stabilize the scapula.
 Command: « with palm down,

pull your arm out to 90°---relax. »
Grade 1 & 0: Trace & zero strength
 Pt. Position in supine.
 Therapist grasp the forearm to

give a sense of motion to the pt.,
proximal hand palpates the
middle fibers of the deltoid on
lateral surface of the upper third
of arm.
 Command: « try to pull your arm

out ( to 90°) ---relax.

SHOULDER ABDUCTION TO 90°:Effects of weakness
 Weakness of Deltoid middle fibers:
inability to lift the arm in abduction
against gravity.
 If paralysis of deltoid +
supraspinatus, the humerus tends
to subluxate downward if arm is
unsupported:
1 inch separation
of the head of
the humerus &
the glenoid cavity.

 If axillary nerve is
involved: deltoid is weak
& supraspinatus is not
affected.
 Supraspinatus weakness
or rupture decreases the
shoulder joint stability
allowing the head of
humerus to change its
relationship with glenoid
cavity.

New Movement:

SHOULDER ADDUCTION
 Latissimus dorsi:
 as shoulder extensors.
 Teres Major : as sh. extensor.
 Pectoralis Major:
Action:
 For Upper fibers:Flexes the sh.
jt. & horiz. adduct the humerus
toward the opposite side.
 For Lower fibers: Depress the

sh. girdle by the attachment on
the humerus.
 Horizontally adductEvaluation,
the humerusTesting and Measurements
toward the opposite iliac Semcrest.
2 - Ms. I. Devreux 39
Shoulder Adduction
Pectoralis Major:
Origin:
 Anterior surface of sternal ½ of
clavicle.
 Anterior surface of sternum.
 Cartilage of first 6th or 7th ribs.
Insertion: Lateral lip of

intertubercular groove of
humerus.
Nerve supply: C5, C6, C7, C8, T1

SHOULDER ADDUCTION
Accessory muscle:
Subscapularis.  Tests: as for shoulder
extension & medial
Range of motion: rotators as most of
them have triple
 Pure adduction of the
action ( in prone).
shoulder joint is from
90° of abduction to
the 0° position.  Pectoralis major is
tested as for
horizontal adduction.

New Movement

Shoulder Horizontal Abduction
Deltoid muscle: (posterior fibers)

 ROM: 135°
 The ROM can be limited by :
 Tension of ant. fibers of capsule
of glenohumeral joint.
 Tension of pectoralis major &

deltoid anterior fibers.

Shoulder Horizontal Abduction: Test Procedure gr.3 – Fair
 Pt. is in prone lying position;

shoulder abducted to 90°, upper
arm resting on the table &
forearm hanging vertically over
the edge.
 Therapist stands beside the

table, prox. hand is on the
shoulder& distal hand stabilizes
on the lateral border of the
scapula.
 Command: « Pull your upper

arm up….Relax ». Evaluation, Testing and Measurements
Shoulder Horizontal Abduction:
Testing Procedure grade 4-5
 Pt. In prone as in gr. 3.
 Therapist proximal hand is on
the shoulder, distal hand gives
resistance proximal to elbow
joint.
 Gr4: resistance is moderate by

pressing the upper arm down.
 Gr.5: Maximum resistance is

applied throughout the motion
+ hold at the end of ROM.
Command: Pull your upper arm
up---- (hold for gr.5)---relax.
Shoulder Horizontal Abduction
Testing procedure for grade 2 – Poor Strength
 Patient is sitting on a stool, arm
supported on a table in a 90° flexion
position.
 Therapist stands behind, proximal

hand is placed on the shoulder,
distal hand is on the lateral border of
the scapula to stabilize it.
 Command: « Move your arm

backward-----Relax ».

Shoulder Horizontal Abduction:Testing for gr. 1 – 0
 Pt. is in sitting as for gr. 2.
 Therapist stands in front of
the patient, the proximal
hand is placed on shoulder
from the back of the pt.
 The distal hand palpates
the fibers of the deltoid
(posterior portion) on
posterior aspect of shoulder
joint.
 Command: « Try to move
your arm backwards ».
Effects of Weakness
 Weakness of the deltoid

muscle (Posterior fibers)
will result in inability to
perform horizontal
abduction of the shoulder
against gravity.

Shoulder Horizontal Adduction
Pectoralis Major: as in shoulder
adduction.
 Accessory muscle: Deltoid
anterior fibers.
 ROM : + or - 135°
 ROM can be limited by:

 Tension of the shoulder
extensor muscles (Lattisimus
Dorsi, Teres Major)
 Contact of arm with the chest.
Shoulder Horizontal Adduction:
Testing Procedure for Grade 3- Fair Strength
 Patient is in backlying
position, arm abducted to
90°.
 Therapist stands near the
edge of table,
prox. hand is placed under
the shoulder to stabilize the
scapula.
 Command: « Raise your

arm up to vertical position ».
Testing Procedure for Grade 4 -5- Good/ Normal
 Pt. is in supine, arm at 90°
abduction.
 Therapist’s distal hand

grasps the upper arm prox.
to elbow joint for resistance.
 Moderate( for gr.4) and

maximal + hold (for gr. 5) is
applied opposing the line of
raising.
 Command: » Raise your arm

up to the vertical position ---
(hold-gr.5) ---Relax. Evaluation, Testing and Measurements
Testing Procedure for Grade 2- Poor Strength
 Pt. Position:
 Sitting in a stool, arm resting on

the table in a position of 90° abd.
 Therapist stands behind the

patient , proximal hand is placed
on the shoulder to stabilize the
trunk.
 *Command: »Pull your arm

forward---relax »
Note:Horizontal Adduction
Sternal and clavicular portions of
pectoralis major may be isolated to
some degree.
In gr. 4 – 5 resistance is in a
direction opposite to the line of pull
of the muscle fibers:
 Sternal & lower portion: upward &
outward.
 Clavicular & upper portion:
downward & outward.
 For gr. 3 the arm is placed above
90° abd. for testing the lower
portion, & below 90° for testing the
upper portion while in supine.
 The pt. is asked to pull his arm to
the vertical position for each
direction of m. fibers being tested. 53
 Effects of weakness:
 Upper fibers: decreased ability to draw the arm in

horizontal adduction accross the chest, making it difficult
to touch the hand to the opposite shoulder.
 It also decreases strength of shoulder flexion and medial

rotation.

Weakness of the lower fibers:
 Weakness decreases the strength of medial
rotation of the shoulder & add. obliquely
toward the opposite hip.
 There is loss of continuity of ms. action of the

pectoralis major to the external oblique on the
opposite side with the result that chopping or
striking movements are difficult.
 From supine, if the arm is placed diagonally

overhead, he will find it difficult to lift the arm
from the table.
 He will also have difficulty holding any large

or heavy object in both hands at or near waist
level.
New Movement
 External Rotation of the Shoulder

External Rotation
 Infraspinatus muscle:
1. Origin: medial 2/3 of infraspinous
fossa of scapula.
2. Insertion: middle facet of greater
tubercule of humerus
3. Shoulder joint capsule.
 Nerve: suprascapular:C4, C5, C6
Action:
 Laterally rotates the shoulder joint.
 Stabilizes the head of humerus in the
glenoid cavity during movements of
this joint.
External Rotation
Teres Minor Muscle:
 Origin: upper 2/3 dorsal surface of
lateral border of scapula.
 Insertion: lowest facet of greater
tubercule of humerus & shoulder
jt. capsule.
 Nerve C5 C6
 Action: laterally rotates sh. joint &
stabilizes the head of humerus.
 Accessory muscle: Deltoid

posterior fibers.
 ROM = 90° Evaluation, Testing and Measurements
External Rotation: ROM
 ROM is approximatively 90°.
Limitation of ROM is due to:
 Tension of the superior portion

of capsular (glenohumeral)
ligament and coraco-humeral
ligament.
 Tension of the medial rotator
muscles of the shoulder
(antagonists).
External Rotation: Grade 3: Fair strength
 Pt. is in prone lying.

Shoulder is abducted to 90°; upper
arm is supported on table &
hanging vertically over the edge.
 Therapist stabilizes the scapula,

distal hand is placed over the arm
above the elbow to prevent
abduction.
 Command: « Pull your hand up &

toward your head ---relax»
External Rotation: Grade 4-5 Testing
 Position as in gr. 3, but distal

hand is over the wrist to give
resistance.
 For gr. 4 : moderate resistance

while for gr. 5 maximal
resistance & hold at the end of
ROM.

External Rotation: Grade 2 ; Poor strength
 Prone lying with the affected arm

entirely over the edge in medially
rotated position. The palm is in
the direction of the foot of the
table.
 Therapist is stabilizing the
scapula by holding over & under
the shoulder.
 Command: « Turn your whole

arm so that your palm & the
inside of your elbow is facing you
---relax »
External Rotation: Gr. 1 & 0 strength.
 Pt. Is in prone as in gr. 2.

 Therapist is palpating the ms.
contraction of Teres Minor on the
axillary border of scapula &
 Palpate the Infraspinatus over the

body of the scapula below the
spine of the scapula.
 Command: « Try to turn your arm

so that your palm & inside elbow
faces you » Evaluation, Testing and Measurements
External Rotation: Weakness
 Effects of weakness of these
muscles will cause a medial
rotation of the humerus.
 Lateral rotation in anti-gravity
positions is difficult or
impossible.
Note:
 For grading a weak lateral
rotator group against gravity,
the prone position can be used
but the supine position is
preferred to eliminate the
necessity of maximal trapezius
fixation & decrease the
assistance of deltoid posterior.
Internal Rotation
New Movement
Internal Rotation
 Muscles:
 Subscapularis
 Pectoralis Major
 Latissimus Dorsi
 Teres Major
 Accessory: Deltoid (Anterior fibers)
 ROM: aproximatively 90°

 ROM is limited :
 due to capsular ligament.
 Lateral rotator muscles of the
shoulder.
Internal Rotation : testing gr. 3 – Fair strength
 Pt. s in prone with shoulder abd. to
90°, upper arm is supported on the
table & forearm hanging vertically
over the edge.
 Ph.Th. stands beside the table,

proximal hand & forearm is placed
on shoulder & scapula to stabilize it
but allowing freedom for the
shoulder rotation.
 Pull your hand back & up keeping

your upper arm on the table---
relax. » Evaluation, Testing and Measurements
Internal Rotation : Testing gr.4-5 – Good-Normal
strength
 Pt. Is in prone as in gr. 3.

 Distal hand of therapist gives
resistance on the pt.’s wrist.
 Gr. 4: moderate resistance by
pressing down.
 Gr. 5: Maximum resistance +
hold at end of ROM.
 Command: Pull your hand back &

up keeping your upper arm on
the table + hold at end of ROM.
Internal Rotation : Testing gr.2 – Poor strength
 Pt. Position in prone, with entire

arm hanging over the edge of the
table in lateral rotation (palm &
interior of elbow facing the
patient).
 Therapist grasps as for gr.3 on

the scapula but allowing
movements.
 Command: « Turn your whole

arm in so that your palm & the
interior of your elbow face me---
relax. »
Internal Rotation : Testing gr.1-0 – Trace & Zero Strength
 Position of therapist and patient as

for Gr. 3.
 The distal hand palpates m.
contraction of:
 Subscapularis: deep in the axilla
near insertion.
 Latissimus Dorsi: palpated below
the lower part of the axillary
border of the scapula.
 Pectoralis Major: on the anterior
aspect of the thorax ( sternal &
clavicular portions).
Internal Rotation :Effects of Weakness
 Shoulder ext. rotators are also strong shoulder

adductor muscles,
 The ability to perform medial rotation and

adduction is decreased by the weakness of
these muscles.

Elbow Flexion: Biceps Brachii, Brachialis
Muscles: Biceps Brachii:

 Origin:
 Short Head: Apex of coracoid
process (scapula).
 Long Head: Supraglenoid
tubercle of scapula.
 Insertion: Tuberosity of
Radius and aponeurosis of
Biceps Brachii.
 Nerve: C5 C6 Evaluation, Testing and Measurements

Action:
 Flexes the shoulder joint & long
head assists in abduction if
humerus is laterally rotated.
 With origin fixed; it flexes the

elbow by moving the arm toward
the humerus & supinates
forearm.
 With insertion fixed, it flexes the

elbow jt. moving the humerus
toward the forearm as in pull-up
or chinning exercises.Evaluation, Testing and Measurements
 Brachialis:
1. Origin: Distal ½ of ant. surface
of humerus.
2. Insertion: tuberosity of coronoid
process of ulna.
3. Nerve: C5, C6
4. Action: With the origin fixed, it
flexes the elbow moving the
forearm toward the humerus.
5. With the insertion fixed, it flexes
the elbow joint moving the
humerus toward the forearm as
in pull up or chinning exercises.
Elbow Flexion: Biceps Brachii, Brachialis, Brachoradialis
 Brachioradialis:
 Origin: proximal 2/3 of lateral
supracondylar ridge of humerus.
 Insertion: lateral side of base of
styloid process of radius.
 Nerve C5 C6.
 Action:
 Flexes the elbow jt.,
 assists in pronating to
midposition
 and supination to midposition.
Elbow Flexion: Biceps Brachii, Brachialis, Brachioradialis
 Accessory ms. : flexor ms. of the

wrist & fingers (arising from medial
epicondyle of humerus).
 (Always test with fingers and wrist

in a relaxed position
 ROM: 0° to 145° - 160°.

 Limited ROM :
 Contact of m. mass on volar
aspect of arm & forearm.
 Contact of coronoid process
with coronoid fossa of
humerus. Evaluation, Testing and Measurements
Elbow Flexion Test procedures:
To isolate brachioradialis from the biceps & brachialis muscle.
 Brachioradialis works at its best when the flexion of the
elbow is with forearm in mid position.
 Biceps brachii: when forearm is in supination.
 Brachialis : as inserted on the ulna, supination or pronation

does not affect the action of the muscle.
 All the following procedures can be done

 in supination for Biceps brachii & brachialis &
 in mid position for brachioradialis.

Elbow Flexion: Grade 3- Fair strength
 Pt. is sitting with the arms along side of

the body, forearm in Sup. (biceps,
brachialis) or in midposition for the
brachioradialis.
 Therapist is behind the pt. , proximal

hand is on shoulder, distal hand
grasps the arm over the elbow. Both
grasps stabilize the patient’s upper
arm.
 Command: « Bend your elbow---

relax »

Elbow Flexion: Grade 4-5; Good to Normal strength
 Pt. its as in grade 3.

 Therapist is in front of the patient &
proximal hand grasps the upper arm
to stabilize it, distal hand applies
resistance at wrist joint level.
 Command: « Bend your elbow----

hold(gr.5)---relax.
 Moderate resistance for gr. 4 &

maximum resistance for grade 5
;directly opposite the line of motion +
hold.

Elbow Flexion: Grade 2; Poor strength
 Pt. Is in supine lying with shoulder at

90° abd. + lateral rotation.
 Alternate: pt. in sitting on a low stool
or kneeling on floor & arm in 90°
abd. on table.
 Forearm in supination: for Biceps
Brachii, brachialis.
 Forearm in midposition for
brachioradialis testing.
 Therapist is near the affected arm ,
proximal grasps the upper arm to
stabilize it.
 Command: » Bend your elbow---
Relax » Evaluation, Testing and Measurements
Elbow Flexion: Grade 1-0; Trace & Zero Strength
 Patient in supine or sitting as in

gr.2.
 Therapist : proximal hand
stabilizes the upper arm, distal
hand palpates the tendon of:
 Biceps Brachii on the ante

cubital space.
 Brachioradialis on the
anterolateral aspect of the
elbow.
 Command: « Try to bend your

elbow---relax ». Evaluation, Testing and Measurements
Elbow Flexion: Effect of weakness
Biceps Brachii &
Brachialis:  Substitution:
 Weakness:
 If musculocutaneous nerve
 Decreased ability to flex lesion, pt. will pronate the
the forearm against gravity forearm before he/ she flexes
especially when the using:
forearm is in supination.  brachioradialis,
 extensor carpi radialis
 Marked interference in ADL longus,
such as feeding, combing  pronator teres
hair.  & wrist flexor muscles.
Elbow Flexion: Effect of weakness
Brachioradialis
 Weakness : decreased strength of elbow

flexion, & supination or pronation to the
midline.

 Action: extends the elbow
Elbow Extension + long head may assist in
Triceps Brachii: shoulder add.&
 Origin: extension.
 Long head on infraglenoid
tubercule of scapula.
 Short head on lat. & post.
Surface of proximal ½ of body of
humerus, lateral intermuscular
sceptum.
 Medial Head: distal 2/3 of medial
& post. surfaces of humerus
below the radial groove.
 Insertion: posterior surface of

olecranon process of ulna.
 Nerve: C6, C7, C8, T1 Evaluation, Testing and Measurements
Elbow Extension
Anconeus:
 Origin: Lateral epicondyle of
humerus, post. surface.
 Insertion: lateral side of the

olecranon process.; upper ¼ of post.
surface of ulna.
 Nerve: C7 C8
 Action: elbow extension + stabilizes

the ulna during pronation.
Elbow Extension ROM: 0° to 145°-160°.
 Acessory muscle: Extensor
muscles of the wrist and
fingers rising from the lateral
condyle of the humerus.
ROM can be limited by:

 Tension of the anterior radial
and ulnar collateral ligaments
of the elbow jt.
 Tension of the flexor muscles
of the forearm.
 Contact of olecranon process
with olecranon fossa on
posterior aspect of humerus.
Elbow Extension
 Grade 3: Fair strength.
 Pt. Is in supine with shoulder
flexed to 90° & elbow flexed.
 Therapist stands beside the table

at shoulder level; Proximal hand
fixes the upper arm by grasping
just above the elbow joint.
 Command: » Extend your elbow ---

relax » or « move your arm
upwards ».
Elbow Extension: Testing Gr. 4-5; Good to Normal Str.
 Pt. is in supine as in gr.3
 Therapist stabilizes the upper arm

above the elbow jt. & distal hand
applies resistance on post. surface
of the wrist.
 Resistance: Moderate for gr.4.

 Maximum resistance + hold for gr. 5.
 Command: « Move your arm

upwards ---Hold (gr. 5) at end of
ROM ---Relax ».
Elbow Extension: Testing Gr.2 ;Poor strength
 Pt. is sitting on a low stool with
arm supported on the table,  Command: » Move your arm
shoulder in 90° abduction & away from you ».
elbow flexion.
 Or
 Pt. in supine lying with shoulder
abducted to 90° & laterally
rotated + elbow flexed.
 Therapist is behind the pt. ,

proximal hand stabilizes the
upper arm by grasping above
the elbow joint.
 Note: in sitting, the shoulder

girdle needs to be also
stabilized to avoid shoulder
protraction.
Elbow Extension: Testing Gr.1-0 ;Trace to Zero strength
 Pt. & Therapsit Position is as in gr.
2.
 Distal hand of the therapist may

palpate the muscle contraction on
the superior surface of the arm
just above the olecranon.
 Command : »Try to move your

arm away from you. »

Elbow Extension: Effects of Weakness
 ↓ ability to extend the elbow against gravity.
 Interference with ADL as in reaching upward to a

high shelve.
 Loss of ability to throw objects or push with the

extended elbow.
 Unability to use crutches or cane as one cannot

extend his elbow & transfer weight to his hand.
Elbow Extension: Note
 Grades 3,4,5 can also be tested in prone position in
addition to supine.
 In prone + horiz. abduction, the long head of the triceps is

shortened over both the elbow and the shoulder joint.
 In supine + shoulder flexion, the long head of the triceps is
shortened over the elbow jt. while elongated over the
shoulder jt.
 Therefore in prone, the triceps withstands less pressure than
when tested in supine. It is made less effective in the prone
position by being shortened fully over both joints.
Elbow extension: Note ( cont.)
While the triceps & anconeus act together in elbow
extension, we can differentiate the 2 muscles.
 By palpation: the belly of the anconeus is below

the elbow joint.
 By the nerve involvement: the radial nerve
responsible of the anconeus arises near the mid
humeral level & is quite long → a lesion can
involve only this branch & leave the triceps
unaffected.
 Paralysis of the anconeus materially reduces the
strength of elbow extension.

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Manual Muscle Testing

Evaluation, Testing and Measurements

 To know the muscles active in shoulder flexion,

 To be aware and able to measure the ROM for these

 To be able to test the strength of the movements from a

Evaluation, Testing and Measurements

Evaluation and Measurements

Evaluation, Testing and Measurements

Origin: anterior border & superior surface

Insertion: Deltoid tuberosity of humerus

 Origin: apex of coracoid process of

 Insertion: antero-medial surface of

 Nerve: C6, C7.

Evaluation, Testing and Measurements

 Pt. sits with elbow slightly

 Therapist stands behind the pt.’s

 Command: « Pull your arm up

 Therapist is behind, Proximal hand

 Gr. 4: Moderate resistance is given

2. To isolate the coraco-brachialis muscle,

Pt. is in sidelying with affected arm

 Therapist is behind the affected

 Command: Pull your arm in front

 Pt. Position: Side or supine

 Therapist palpates on the

 The therapist will fix the

Evaluation, Testing and Measurements

 Weakness of these muscles will decrease

 Weakness of the coracobrachialis will

Evaluation, Testing and Measurements

Evaluation, Testing and Measurements

 Nerve: Thoracodorsal nerve

 With the origin fixed:

 medial rotation of the shoulder

 With the insertion fixed, it assists in

Evaluation, Testing and Measurements

 This m. is very important for: climbing,

Evaluation, Testing and Measurements

 Shoulder adductors &

 The Latissimus Dorsi may

 Insertion: crest of lesser

 Action: Medially rotates,

Evaluation, Testing and Measurements

 Insertion: Deltoid tuberosity of

 Action: Extends and laterally

 Acts as stabilizer when medial

 Therapist stands beside the tabel

 Command: « Pull your arm up

Evaluation, Testing and Measurements

 Same positions as in Gr. 3 .

 Command as in gr.3 + hold for

Evaluation, Testing and Measurements

 Therapist stands in front of

 Command: « Pull your arm

 Patient should not be allowed

Evaluation, Testing and Measurements

 Weakness of Teres Major:

 Weakness of Deltoid ( post. fibers):

Evaluation, Testing and Measurements

 The ROM may be limited

Deltoid « Middle Fibers »:

 Insertion: Deltoid tuberosity of