SHOULDER FLEXION
(Anterior Deltoid and Coracobrachial*)
Table 4-6 S H O U L D E R F L E X I O N
I.D. Muscle Origin Insertion
133 Deltoid (anterior)
Clavicle (anterior superior border Humerus (deltoid tuberosity on
139 Coracobrachialis of lateral 1 /3 of shaft) shaft)
Scapula (coracoid process at Humerus (shaft, medial surface
apex) at middle 1/3)
Others Pectoralis major (upper)
131 Deltoid (middle)
133 Serratus anterior (via upwardly rotating scapula and preventing scapular adduction)
128
Grade 5 (Normal) and Grade 4 (Good) Instructions to Patient: "Raise your arm forward to
shoulder height. Hold it. Don't let me push it down."
Position of Patient: Short sitting with arms at sides,
elbow slightly flexed, forearm pronated. Grading
Position of Therapist: Stand at test side. Hand giv- Grade 5 (Normal): H o l d s end position ( 9 0 ° ) against
ing resistance is contoured over the distal humerus maximal resistance.
just above the elbow. The other hand may stabilize
the shoulder (Figure 4 - 4 4 ) . Grade 4 (Good): H o l d s end position against strong
to moderate resistance.
Test: Patient flexes shoulder to 90° without rotation
or horizontal movement (Figure 4 - 4 4 ) . The scapula
should be allowed to abduct and upwardly rotate.
FIGURE 4-44 *The coracobrachialis muscle cannot be isolated, nor is it readily
palpable. It has no unique function. It is included here because
classically it is considered a shoulder flexor and adductor.
Chapter 4 / Testing the Muscles of the Upper Extremity 87
SHOULDER FLEXION
(Anterior Deltoid and Coracobrachial*)
Grade 3 (Fair) Grade 2 (Poor), Grade 1 (Trace),
and Grade 0 (Zero)
Position of Patient: Short sitting, arm at side with
elbow slightly flexed and forearm pronated. Position of Patient: Short sitting with arm at side
and elbow slightly flexed.
Position of Therapist: Stand at test side.
Position of Therapist: Stand at test side. Fingers
Test: Patient flexes shoulder to 90° (Figure 4 - 4 5 ) . used for palpation are placed over the superior and
anterior surfaces of the deltoid over the shoulder joint
Instructions to Patient: "Raise your arm forward to (Figure 4-46).
shoulder height."
Test: Patient attempts to flex shoulder to 90°.
Grading
Instructions to Patient: "Try to raise your arm."
Grade 3 (Fair): Completes test range ( 9 0 ° ) but
tolerates no resistance. Grading
Grade 2 (Poor): Completes partial range of motion as
this is against gravity.
Grade 1 (Trace): Examiner feels or sees contractile
activity in the anterior deltoid, but no motion occurs.
Grade 0 (Zero): No contractile activity.
FIGURE 4-45 FIGURE 4-46
*The coracobrachialis muscle cannot be isolated, nor is it readily
palpable. It has no unique function. It is included here because
classically it is considered a shoulder flexor and adductor.
88 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER FLEXION
(Anterior Deltoid and Coracobrachial*)
Alternate Test for Grades 2, 1, and 0 Helpful Hint
If for any reason the patient is unable to sit, the test Although the coracobrachialis is a minor contrib-
can be conducted in the side-lying position (test side utor to shoulder flexion, it is deep-lying and may
up). In this posture, the examiner cradles the test be difficult or impossible to palpate within a rea-
arm at the elbow before asking the patient to flex the sonable range of comfort for the patient.
shoulder. For Grade 2 (Poor), the patient must com-
plete full range of motion.
Substitutions
• In the absence of a deltoid the patient may at-
tempt to flex the shoulder with the biceps
brachii by first externally rotating the shoulder
(Figure 4 - 4 7 ) . To avoid this, the arm should be
kept in the midposition between internal and
external rotation.
• Attempted substitution by the upper trapezius
results in shoulder elevation.
• Attempted substitution by the pectoralis major
results in horizontal adduction.
• The patient may lean backward or try to ele-
vate the shoulder girdle to assist in flexion.
FIGURE 4-47
*The coracobrachialis muscle cannot be isolated, nor is it readily
palpable. It has no unique function. It is included here because
classically it is considered a shoulder flexor and adductor.
Chapter 4 / Testing the Muscles of the Upper Extremity 89
SHOULDER EXTENSION
(Latissimus dorsi, Teres major, * Posterior Deltoid)
FIGURE 4-49
POSTERIOR
FIGURE 4-48
FIGURE 4-50
*The role of the teres major is often disputed as a shoulder ex-
tensor and EMG studies vary, but it has long been considered to
move the humerus posteriorly.
90 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER EXTENSION
(Latissimus dorsi, Teres major, * Posterior Deltoid)
Table 4-7 S H O U L D E R E X T E N S I O N
I.D. Muscle Origin Insertion
130 Latissimus dorsi Humerus (intertubercular sulcus,
T6-T12, L1-L5, and sacral floor)
133 Deltoid (posterior) vertebrae (spinous processes) Deep fascia of arm
138 Teres major Supraspinous ligaments
Other Triceps brachii (long head) Ribs 9-12 (by slips interdigitating Humerus (deltoid tuberosity on
142 with obliquus abdominis midshaft via humeral tendon)
externus) Humerus (intertubercular sulcus,
Ilium (crest, posterior) medial lip)
Thoracolumbar fascia
Scapula (spine on lower lip of
lateral and posterior borders)
Scapula (dorsal surface of inferior
angle)
Grade 5 (Normal) and Grade 4 (Good) Test: Patient raises arm off the table, keeping the el-
bow straight (Figure 4 - 5 2 ) .
There are three tests for Grades 5 and 4 that should
be used routinely. The first is the traditional way of Instructions to Patient: "Lift your arm as high as
testing shoulder extension in the prone position. The you can. Hold it. Don't let me push it down."
other two tests are used to isolate the latissimus
dorsi to the extent possible and to simulate a more Grading
functional movement.
Grade 5 (Normal): Completes available range and
Test 1: Generic Shoulder Extension holds against maximal resistance.
Position of Patient: Prone with arms at sides and Grade 4 (Good): Completes available range but yields
shoulder internally rotated (palm up) (Figure 4 - 5 1 ) . against strong resistance.
Position of Therapist: Stand at test side. Hand used
for resistance is contoured over the posterior arm just
above the elbow.
FIGURE 4-51 FIGURE 4-52
Chapter 4 / Testing the Muscles of the Upper Extremity 91
SHOULDER EXTENSION
(Latissimus dorsi, Teres major, * Posterior Deltoid)
Grade 5 (Normal) and Grade 4 (Good) Continued
Test 2: To Isolate Latissimus Dorsi Test 3: To Isolate Latissimus Dorsi
Position of Patient: Prone with head turned to test Position of Patient: Short sitting, with hands flat on
side; arms are at sides and shoulder is internally rotat- table adjacent to hips (Figure 4 - 5 4 ) .
ed (palm up). Test shoulder is "hiked" to the level
of the chin. If the patient's arms are too short to assume this
position, provide a push-up block for each hand.
Position of Therapist: Stand at test side. Grasp Position of Therapist: Stand behind patient. Fingers
forearm above patient's wrist with both hands are used to palpate fibers of the latissimus dorsi on
(Figure 4-53). the lateral aspects of the thoracic wall (bilaterally)
just above the waist (Figure 4 - 5 4 ) . (In this test the
Test: Patient depresses arm caudally and in so doing sternal head of the pectoralis major is equally active.)
approximates the rib cage to the pelvis.
Test: Patient pushes down on hands (or blocks) and
Instructions to Patient: "Reach toward your feet. lifts buttocks from table (Figure 4 - 5 4 ) .
Hold it. Don't let me push your arm upward toward
your head." Instructions to Patient: "Lift your bottom off the
table."
Grading
Grading
Grade 5 (Normal): Patient completes available range
against maximal resistance. If the therapist is unable Grade 5 (Normal): Patient is able to lift buttocks
to push the arm upward using both hands for resis- clear of table.
tance, test the patient in the sitting position as
described in Test 3. Grade 4 (Good): T h e r e is no Grade 4 in this se-
quence because the prone test (Test 2) determines a
Grade 4 (Good): Patient completes available range of grade of less than 5.
motion, but the shoulder yields at end point against
strong resistance.
FIGURE 4-53 FIGURE 4-54
"The role of the teres major is often disputed as a shoulder ex-
tensor and EMC studies vary, but it has long been considered to
move the humerus posteriorly.
92 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER EXTENSION
(Latissimus dorsi, Teres major, * Posterior Deltoid)
Grade 3 (Fair) and Grade 2 (Poor) Grade 1 (Trace) and Grade 0 (Zero)
Position of Patient: Prone with head turned to one Position of Patient: Prone with arms at sides and
side. Arms at sides; test arm is internally rotated shoulder internally rotated (palm up).
(palm up) (Figure 4 - 5 5 ) .
Position of Therapist: Stand at test side. Fingers
Position of Therapist: Stand at test side. for palpation (latissimus) are placed on the side of
the thoracic wall (Figure 4 - 5 6 ) below and lateral to the
Test: Test 1 (generic extension): Patient raises inferior angle of the scapula.
arm off table (Figure 4 - 5 5 ) . Test 2 (isolation of
latissimus): Patient pushes arm toward feet (not shown). Palpate over the posterior shoulder just superior to
the axilla for posterior deltoid fibers. Palpate the
Instructions to Patient: Test 1: "Lift your arm as teres major on the lateral border of the scapula just
high as you can." Test 2 (latissimus): "Reach down below the axilla. The teres major is the lower of the
toward your feet." two muscles that enter the axilla at this point; it
forms the lower posterior rim of the axilla.
Grading
Test and Instructions to Patient: Patient attempts
Grade 3 (Fair): Completes available range of m o t i o n to lift arm from table on request.
with no manual resistance.
Grading
Grade 2 (Poor): Completes partial range of m o t i o n .
Grade 1 (Trace): Palpable contractile activity in any
of the participating muscles but no movement of the
shoulder.
Grade 0 (Zero): No contractile response in partici-
pating muscles.
FIGURE 4-55
FIGURE 4-56
*The role of the teres major is often disputed as a shoulder ex-
tensor and E M G studies vary, but it has long been considered to
move the humerus posteriorly.
Chapter 4 / Testing the Muscles of the Upper Extremity 93
SHOULDER SCAPTION
(Deltoid and Supraspinatus)
Table 4-8 SCAPTION Origin Insertion
I.D. Muscle
133 Deltoid Clavicle (shaft; anterior-superior Humerus (deltoid tuberosity via
border, lateral 1/3) humeral tendon)
Anterior fibers Scapula (crest of spine and
Middle fibers acromion, lateral superior Humerus (greater tubercle,
margin) highest facet)
135 Supraspinatus Articular capsule of
Scapula (supraspinous fossa) glenohumeral joint
Supraspinatus fascia
This recently minted motion is arm elevation in the flexion and shoulder abduction.2 This movement,
plane of the scapula, that is, 30° to 4 5 ° anterior to called scaption, is more functional than cither for-
the coronal plane about halfway between shoulder ward flexion or abduction.
Grade 5 (Normal) to Grade 0 (Zero) Instructions to Patient: "Raise your arm to shoul-
der height halfway between straight-ahead and out to
Position of Patient (All Grades): Short sitting. the side. Hold it. Don't let me push your arm
down." (Demonstrate this motion to the patient.)
Position of Therapist: Stand in front of and slightly
to the test side of patient. Hand used for resistance is Grading
contoured over the arm above the elbow (Grades 5
and 4 only). Grade 5 (Normal): Completes available range of
motion and holds against maximal resistance.
Test: Patient elevates arm halfway between flexion
and abduction (30° to 4 5 ° anterior to coronal plane) Grade 4 (Good): Completes available range and
(Figure 4-57). holds against strong resistance, but there will be some
yielding at the end of the range.
Grade 3 (Fair): Completes available range but toler-
ates no resistance other than the weight of the arm.
Grade 2 (Poor): Moves only through partial range of
motion. The therapist's fingers for palpation are posi-
tioned on the anterior and medial aspect of the
shoulder (for Grades 2 and below).
Grade 1 (Trace) and Grade 0 (Zero): Palpable or
visible contractile activity for Grade 1; no activity
detected for Grade 0.
FIGURE 4-57
94 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER ABDUCTION
(Middle Deltoid and Supraspinatus)
LATERAL LATERAL FIGURE 4-60
FIGURE 4-58 FIGURE 4-59
FIGURE 4-61
Chapter 4 / Testing the Muscles of the Upper Extremity 95
SHOULDER ABDUCTION
(Middle Deltoid and Supraspinatus)
Table 4-9 S H O U L D E R A B D U C T I O N
I.D. Muscle Origin Insertion
133 Deltoid (middle fibers)
Scapula (acromion, lateral Humerus (deltoid tuberosity on
135 Supraspinatus margin, superior surface, and shaft via humeral tendon)
crest of spine)
Humerus (greater tubercle,
Scapula (supraspinous fossa, highest facet)
medial 2/3) Articular capsule of
Supraspinatus fascia glenohumeral joint
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)
Preliminary Evaluation: E x a m i n e r should check for Instructions to Patient: " L i f t your arm out to the
full range of shoulder motion in all planes and side to shoulder level. H o l d it. D o n ' t let me push it
should observe scapula for stability and smoothness down."
of movement. (Refer to test for scapular abduction
and upward rotation.) Grading
Position of Patient: S h o r t sitting with arm at side Grade 5 (Normal): H o l d s end test p o s i t i o n against
and elbow slightly flexed. maximal downward resistance.
Position of Therapist: Stand behind patient. Hand Grade 4 (Good): H o l d s end test p o s i t i o n against
giving resistance is contoured over arm just above strong to moderate downward resistance.
elbow (Figure 4 - 6 2 ) .
Grade 3 (Fair): C o m p l e t e s range of m o t i o n to 9 0 °
Test: Patient abducts arm to 90°. with no manual resistance (Figure 4 - 6 3 ) .
FIGURE 4-62 FIGURE 4-63
96 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER ABDUCTION
(Middle Deltoid and Supraspinatus)
Grade 2 (Poor) Alternate Test for Grade 2
Position of Patient: Short sitting with arm at side Position of Patient: Supine. Arm at side supported
and slight elbow flexion. on table (Figure 4 - 6 5 ) .
Position of Therapist: Stand behind patient to pal- Position of Therapist: Stand at test side of patient.
pate muscles on test side. Palpate the deltoid (Figure (Figure 4 - 6 5 shows therapist on opposite side to avoid
4 - 6 4 ) lateral to the acromial process on the superior obstructing test procedure illustrated.) Hand used for
aspect of the shoulder. The supraspinatus can be pal- palpation is positioned as described for Grade 2 test.
pated by placing the fingers deep under the
trapezius in the supraspinous fossa of the scapula. Test: Patient attempts to abduct shoulder by sliding
arm on table without rotating it (see Figure 4 - 6 5 ) .
Test: Patient attempts to abduct arm.
Instructions to Patient: "Take your arm out to the
Instructions to Patient: " T r y to lift your arm out side."
to the side."
Grading
Grade 2 (Poor): Completes partial range of m o t i o n for
sitting test and full range for supine test.
FIGURE 4-64
FIGURE 4-65
Chapter 4 / Testing the Muscles of the Upper Extremity 97
SHOULDER ABDUCTION
(Middle Deltoid and Supraspinatus)
Grade 1 (Trace) and Grade 0 (Zero) Alternate Test for Grade 1
and Grade 0 (Supine)
Position of Patient: Short sitting.
Position of Patient: Supine with arm at side and
Position of Therapist: Stand behind and to the side elbow slightly flexed.
of patient. Therapist cradles test arm with the shoul-
der in about 90° of abduction, providing limb sup- Position of Therapist: Stand at side of table at a
port at the elbow (Figure 4 - 6 6 ) . place where the deltoid can be reached. Palpate the
deltoid on the lateral surface of the upper one third
Test: Patient tries to maintain the arm in abduction. of the arm (Figure 4 - 6 7 ) .
Instructions to Patient: "Try to hold your arm in Grading
this position."
Grade 1 (Trace): Palpable or visible contraction of
deltoid with no movement.
Grade 0 (Zero): No contractile activity.
FIGURE 4-66
FIGURE 4-67
Helpful Hints Substitution by Biceps Brachii
• Turning the face to the opposite side and ex- When a patient uses the biceps to substitute, the
tending the neck will put the trapezius on shoulder will externally rotate and the elbow will
slack and make the supraspinatus more accessi- flex. T h e arm will be raised but not by the action
ble for palpation. of the abductor muscles. To avoid this substitu-
tion, begin the test with the arm in a few degrees
• The deltoid and supraspinatus work in tan- of elbow flexion, but do not allow active contrac-
dem, and when one is active in abduction the tion of the biceps during the test.
other also will be active. Only when supraspina-
tus weakness is suspected is it necessary
to palpate.
• Do not allow shoulder elevation or lateral flex-
ion of the trunk to the opposite side because
these movements can create an illusion of ab-
duction.
98 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER HORIZONTAL ABDUCTION
(Posterior Deltoid)
FIGURE 4-69
POSTERIOR
FIGURE 4-68
Table 4-10 S H O U L D E R H O R I Z O N T A L A B D U C T I O N
I.D. Muscle Origin Insertion
133 Deltoid (posterior fibers)
Scapula (spine on lower lip of Humerus (deltoid tuberosity via
crest) humeral tendon)
Others Infraspinatus
136 Teres minor
137
Chapter 4 / Testing the Muscles of the Upper Extremity 99
SHOULDER HORIZONTAL ABDUCTION
(Posterior Deltoid)
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)
Position of Patient: Prone. Shoulder abducted to Grading
90° and forearm off edge of table with elbow flexed.
Grade 5 (Normal): Completes range and holds end
Position of Therapist: Stand at test side. Hand giv- position against maximal resistance.
ing resistance is contoured over posterior arm just
above the elbow (Figure 4 - 7 0 ) . Grade 4 (Good): Completes range and holds end
position against strong to moderate resistance.
Test: Patient horizontally abducts shoulder against
maximal resistance. Grade 3 (Fair): Completes range of m o t i o n with no
manual resistance (Figure 4 - 7 1 ) .
Instructions to Patient: "Lift your elbow up toward
the ceiling. Hold it. Don't let me push it down."
FIGURE 4-70
FIGURE 4-71
100 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER HORIZONTAL ABDUCTION
(Posterior Deltoid)
Grade 2 (Poor), Grade 1 (Trace), Alternate Test for Grades 2, 1, and 0
Grade 0 (Zero)
Position of Patient: Short sitting with arm sup-
Position of Patient: Short sitting over end or side ported on table (smooth surface) in 9 0 ° of abduc-
of table. tion; elbow partially flexed.
Position of Therapist: Stand at test side. Support Position of Therapist: Stand behind patient.
forearm under distal surface (Figure 4 - 7 2 ) and pal- Stabilize by contouring one hand over the superior
pate over the posterior surface of the shoulder just aspect of the shoulder and the other over the scapula
superior to the axilla. (Figure 4 - 7 3 ) . Palpate the fibers of the posterior
deltoid below and lateral to the spine of the scapula
and on the posterior aspect of the proximal arm
adjacent to the axilla.
Test: Patient slides (or tries to move) the arm across
the table in horizontal abduction.
Instructions to Patient: "Slide your arm backward."
Grading
Grade 2 (Poor): Moves through full range of mo-
tion.
Grade 1 (Trace): Palpable contraction; no motion.
Grade 0 (Zero): No contractile activity.
FIGURE 4-72
FIGURE 4-73
Helpful Hint Substitution by Triceps Brachii
(Long Head)
If the scapular muscles are weak, the examiner must
manually stabilize the scapula to avoid scapular Maintain the elbow in flexion to avoid substitution
abduction. by the long head of the triceps.
Chapter 4 / Testing the Muscles of the Upper Extremity 101
SHOULDER HORIZONTAL ADDUCTION
(Pectoralis major)
FIGURE 4-74 FIGURE 4-75
FIGURE 4-76
102 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER HORIZONTAL ADDUCTION
(Pectoralis major)
Table 4- 1 1 S H O U L D E R H O R I Z O N T A L A D D U C T I O N
I.D. Muscle Origin Insertion
131 Pectoralis major
Clavicle (sternal 1/2 of anterior Humerus (intertubercular sulcus,
Clavicular part surface) lateral lip)
Sternum (anterior surface down Both parts converge on a
Sternal part to rib 6) bilaminar common tendon
Ribs 2-7 (costal cartilages)
Aponeurosis of obliquus externus
abdominis
Other Deltoid (anterior fibers)
133
Preliminary Examination Grade 5 (Normal) and Grade 4 (Good)
The examiner begins with the patient supine and Position of Patient
checks the range of motion and then tests both Whole Muscle: Supine. Shoulder abducted to 9 0 ° ;
heads of the pectoralis major simultaneously. The pa- elbow flexed to 90° (Figure 4 - 7 7 ) .
tient is asked to move the arm in horizontal adduc-
tion, keeping it parallel to the floor without rotation. Clavicular Head: Patient begins test with shoulder
in 60° of abduction with elbow flexed. Patient then
If the arm moves across the body in a diagonal is asked to horizontally adduct the shoulder.
motion, test the sternal and clavicular heads of the
muscle separately. Testing both heads of the pec- Sternal Head: Patient begins test with shoulder in
toralis major separately should be routine in any about 120° of abduction with elbow flexed.
patient with cervical spinal cord injury because of
their different nerve root innervation.
FIGURE 4-77
Chapter 4 / Testing the Muscles of the Upper Extremity 1 0 3
SHOULDER HORIZONTAL ADDUCTION
(Pectoralis major)
Grade 5 (Normal) and Grade 4 (Good) Continued
Position of Therapist: Stand at side of shoulder to Palpate the clavicular fibers of the pectoralis major
be tested. Hand used for resistance is contoured up under the medial half of the clavicle (Figure 4 - 7 9 ) .
around the forearm just proximal to the wrist. The Palpate the sternal fibers on the chest wall at the
other hand is used to check the activity of the pec- lower anterior border of the axilla (Figure 4 - 8 0 ) .
toralis major on the upper aspect of the chest just
medial to the shoulder joint (Figure 4 - 7 8 ) . (Palpation T e s t : W h e n the whole muscle is tested, the patient
is not needed in a Grade 5 test, but it is prudent to horizontally adducts the shoulder through the avail-
assess activity in the muscle being tested.) able range of motion.
FIGURE 4-78 FIGURE 4-79
FIGURE 4-80
104 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER HORIZONTAL ADDUCTION
(Pectoralis major)
Grade 5 (Normal) and Grade 3 (Fair)
Grade 4 (Good) Continued
Position of Patient: Supine. Shoulder at 90° of
To test the clavicular head, the patient's motion abduction and elbow at 90° of flexion.
begins at 60° of abduction and moves up and in
across the body. The examiner applies resistance Position of Therapist: Same as for Grade 5.
above the wrist in a downward direction (toward
floor) and outward (i.e., opposite to the direction of Test
the fibers of the clavicular head, which moves the Both Heads: Patient horizontally adducts extremity
arm diagonally up and inward) (see Figure 4 - 7 9 ) . across chest in a straight pattern with no diagonal
motion (Figure 4-81).
To test the sternal head, the m o t i o n begins at
120° of shoulder abduction and moves diagonally Clavicular Head: Direction of m o t i o n by the patient
down and in toward the patient's opposite hip. is diagonally up and inward.
Resistance is given above the wrist in an up and out-
ward direction (i.e., opposite to the motion of the Sternal Head: Direction of m o t i o n is diagonally
sternal head, which is diagonally down and inward) down and inward.
(see Figure 4 - 8 0 ) .
Instructions to Patient: Same as for the Grade 5
Instructions to Patient (Normal) test, but no resistance is offered.
Both Heads: " M o v e your arm across your chest. H o l d
it. Don't let me pull it back." Grading
Clavicular Head: " M o v e your arm up and i n . " Grade 3 (Fair): Patient completes available range of
motion in all three tests with no resistance other
Sternal Head: " M o v e your arm down and i n . " than the weight of the extremity.
Grading
Grade 5 (Normal): Completes range of m o t i o n and
takes maximal resistance.
Grade 4 (Good): Completes range of motion and
takes strong to moderate resistance, but muscle
exhibits some "give" at end of range.
FIGURE 4-81
Chapter 4 / Testing the Muscles of the Upper Extremity 105
SHOULDER HORIZONTAL ADDUCTION
(Pectoralis major)
Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)
Position of Patient: Supine. Arm is supported in Position of Therapist: Stand at side of shoulder to
90° of abduction with elbow flexed to 90°. be tested or behind the sitting patient. When the
patient is supine, support the full length of the forearm
Alternate Position: Patient is seated with test arm and hold the limb at the wrist (see Figure 4 - 8 0 ) .
supported on table (at level of axilla) with arm in
90° of abduction (or in scaption) and elbow slightly For both tests, palpate the pectoralis major muscle
flexed (Figure 4 - 8 2 ) . Friction of the table surface on the anterior aspect of the chest medial to the shoulder
should be minimized. joint (see Figure 4-78.)
Test: Patient attempts to horizontally adduct the
shoulder. The use of the alternate test position, in
which the arm moves across the table, precludes indi-
vidual testing for the two heads.
Instructions to Patient: "Try to move your arm
across your chest." In seated position: "Move your
arm forward."
Grading
Grade 2 (Poor): Patient horizontally adducts shoul-
der through available range of motion with the
weight of the arm supported by the examiner or
the table.
Grade 1 (Trace): Palpable contractile activity.
Grade 0 (Zero): No contractile activity.
FIGURE 4-82
Helpful Hint
This test requires resistance on the forearm, which
in turn requires that the elbow flexors be strong.
If they are weak, provide resistance on the arm
just proximal to the elbow.
106 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER EXTERNAL ROTATION
(Infraspinatus and Teres minor)
FIGURE 4-84
DORSAL
FIGURE 4-83
FIGURE 4-85
Chapter 4 / Testing the Muscles of the Upper Extremity 107
SHOULDER EXTERNAL ROTATION
(Infraspinatus and Teres minor)
Table 4-12 S H O U L D E R EXTET RNAL ROTATION
I.D. Muscle Origin Insertion
136 Infraspinatus
Scapula (infraspinous fossa, Humerus (greater tubercle,
137 Teres minor medial 2/3) middle facet)
Infraspinous fascia
Humerus (greater tubercle,
Scapula (lateral border, superior lowest facet)
2/3) Humerus (shaft, distal to lowest
facet)
Capsule of glenohumeral joint
Other Deltoid (posterior)
133
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)
Position of Patient: Prone with head turned toward Instructions to Patient: "Raise your arm to the level
test side. Shoulder abducted to 9 0 ° with arm fully of the table. Hold it. Don't let me push it down."
supported on table; forearm hanging vertically over Therapist may need to demonstrate the desired motion.
edge of table. Place a folded towel under the arm at
the edge of the table if it has a sharp edge. Grading
Alternate Position: Short sitting with elbow flexed Grade 5 (Normal): Completes available range of
to 90°. The amount of resistance tolerated in this motion and holds firmly against two-finger resistance.
position may be much greater for Grades 5 and 4.
Grade 4 (Good): Completes available range, but the
Position of Therapist: Stand at test side at level of muscle at end range yields or gives way.
patient's waist (Figure 4 - 8 6 ) . Two fingers of one hand
are used to give resistance at the wrist for Grades 5 Grade 3 (Fair): Completes available range of motion
and 4. The other hand supports the elbow to pro- but is unable to take any manual resistance
vide some counterpressure at the end of the range. (Figure 4-87).
Test: Patient moves forearm upward through the
range of external rotation.
FIGURE 4-86 FIGURE 4-87
108 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER EXTERNAL ROTATION
(Infraspinatus and Teres minor)
Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)
Position of Patient: Prone with head turned to test Test: Patient attempts to externally rotate the shoul-
side, trunk at edge of table. The entire limb hangs der. Alternatively, place the patient's arm in external
down loosely from the shoulder in neutral rotation, rotation and ask the patient to hold the end position
palm facing table (Figure 4 - 8 8 ) . (Figure 4-89).
Position of Therapist: Stand or sit on a low stool at Instructions to Patient: "Turn your palm outward."
test side of patient at shoulder level. Palpate the
infraspinatus over the body of the scapula below Grading
the spine in the infraspinous fossa (see Figure 4 - 8 7 ) .
Palpate the teres minor on the inferior margin of the Grade 2 (Poor): Completes available range (i.e., palm
axilla and along the axillary border of the scapula faces forward) in this gravity-eliminated position.
(see Figure 4 - 8 8 ) .
Grade 1 (Trace): Palpation of either or both muscles
reveals contractile activity but no motion.
Grade 0 (Zero): No palpable or visible activity.
FIGURE 4-88 FIGURE 4-89
Helpful Hints • The therapist must be careful to discern whether
supination occurs instead of the requested external
• Resistance in tests of shoulder rotation should be rotation during the testing of Grade 2 and Grade
administered gradually and slowly, with great 1 muscles because this motion can be mistaken
care taken to prevent injury, which can occur for lateral rotation.
readily because the shoulder lacks inherent sta-
bility. This is particularly important for the el-
derly patient.
Chapter 4 / Testing the Muscles of the Upper Extremity 109
SHOULDER INTERNAL ROTATION
(Subscapularis)
FIGURE 4-91
ANTERIOR
FIGURE 4-90
FIGURE 4-92
1 1 0 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER INTERNAL ROTATION
(Subscapularis)
Table 4-13 S H O U L D E R INTE R N A L R O T A T I O N
I.D. Muscle Origin Insertion
Humerus (lesser tubercle)
134 Subscapularis Scapula (fills fossa on costal Capsule of glenohumeral joint
131 Pectoralis major surface) (anterior)
Intermuscular septa
Clavicular part Aponeurosis of subscapularis Humerus (intertubercular sulcus,
Sternal part lateral lip)
Clavicle (sternal half of anterior Both parts converge on a
130 Latissimus dorsi surface) bilaminar common tendon
Sternum (anterior surface down
138 Teres major to rib 6) Humerus (floor of intertubercular
Ribs 2-7 costal cartilages sulcus)
Aponeurosis of obliquus externus Deep fascia of arm
abdominis
Humerus (intertubercular sulcus,
T6-T12; L1-L5 and sacral medial lip)
vertebrae (spinous processes)
Supraspinous ligaments
Ribs 9-12 (by slips which
interdigitate with obliquus
externus abdominus)
Ilium (crest, posterior)
Thoracolumbar fascia
Scapula (dorsal surface of inferior
angle)
Other Deltoid (anterior)
133
Chapter 4 / Testing the Muscles of the Upper Extremity 111
SHOULDER INTERNAL ROTATION
(Subscapularis)
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)
Position of Patient: Prone with head turned toward Instructions to Patient: "Move your forearm up
test side. Shoulder is abducted to 90° with folded and back. Hold it. Don't let me push it down."
towel placed under distal arm and forearm hang- Demonstrate the desired motion to the patient.
ing vertically over edge of table. Short sitting is a
common alternate position. Grading
Position of Therapist: Stand at test side. Hand giv- Grade 5 (Normal): Completes available range and
ing resistance is placed on the volar side of the fore- holds firmly against strong resistance.
arm just above the wrist. The other hand provides
counterforce at the elbow (Figure 4 - 9 3 ) . The resis- Grade 4 (Good): Completes available range, but
tance hand applies resistance in a downward and there is a "spongy" feeling against strong resistance.
forward direction; the counterforce is applied backward
and slightly upward. Stabilize the scapular region if Grade 3 (Fair): Completes available range with no
muscles are weak. manual resistance (Figure 4 - 9 4 ) .
Test: Patient moves arm through available range of
internal rotation (backward and upward).
FIGURE 4-93 FIGURE 4-94
112 Chapter 4 / Testing the Muscles of the Upper Extremity
SHOULDER INTERNAL ROTATION
(Subscapularis)
Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)
Position of Patient: Prone with head turned toward Instructions to Patient: "Turn your arm so that the
test side. Patient must be near the edge of the table palm faces away from the table" (not shown).
on test side so that entire arm can hang down freely Grading
over the edge (Figure 4 - 9 5 ) . Arm is in neutral with
palm facing the table. Grade 2 (Poor): Completes available range.
Position of Therapist: Stand at test side or sit on Grade 1 (Trace): Palpable contraction occurs.
low stool. Hand used for palpation must find the
tendon of the subscapularis deep in the central area Grade 0 (Zero): No palpable contraction.
of the axilla (Figure 4 - 9 6 ) . Therapist may have to sta-
bilize test arm at the shoulder.
Test: Patient internally rotates arm with thumb lead-
ing so that the palm faces out or away from the
table.
FIGURE 4-95 FIGURE 4-96
Helpful Hints • The hand of the examiner may substitute for a
towel roll under the distal arm, the purpose be-
• The therapist should be wary of pronation in ing to protect the patient from the discomfort of
this test. Forearm pronation is rather easily mis- moving against a hard table and to keep the arm
taken for internal rotation. horizontal to the floor.
• Internal rotation is a stronger motion than ex- • The prone position is preferred to the supine or
ternal rotation. This is largely a factor of differ- sitting position in tests for Grades 2, 1, and 0
ing muscle mass. because a weak patient has a tendency to use
trunk rotation as a substitute.
• If you cannot palpate the subscapularis, try the
pectoralis major, which, as a surface muscle, is
more readily felt.
Chapter 4 / Testing the Muscles of the Upper Extremity 113
ELBOW FLEXION
(Biceps, Brachialis, and Brachioradialis)
FIGURE 4-99
FIGURE 4-97 ANTERIOR
FIGURE 4-98
FIGURE 4-100 FIGURE 4-101
114 Chapter 4 / Testing the Muscles of the Upper Extremity
(Biceps, ELBOW FLEXION
Brachialis, and Brachioradialis)
Table 4-14 E L B O W F L E X I O N
I.D. Muscle Origin Insertion
140 Biceps brachii
Scapula (coracoid process, apex) Radius (radial tuberosity)
Short head Scapula (supraglenoid tubercle) Bicipital aponeurosis
Long head Capsule of glenohumeral joint and
glenoid labrum Ulna (tuberosity and coronoid
141 Brachialis process)
Humerus (shaft anterior, distal 1/2) Radius (distal end just proximal
143 Brachioradialis Intermuscular septa (medial) to styloid process)
Humerus (lateral supracondylar ridge,
proximal 2/3)
Lateral intermuscular septum
Others Pronator teres (See also Plate 4, page 127.)
146 Extensor carpi radialis longus
148 Flexor carpi radialis
151 Flexor carpi ulnaris
153
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)
Position of Patient: Short sitting with arms at sides.
The following are the positions of choice, but it is
doubtful whether the individual muscles can be sepa-
rated when strong effort is used. The brachialis in
particular is independent of forearm position.
Biceps brachii: forearm in supination (Figure 4 - 1 0 2 )
Brachialis: forearm in pronation (Figure 4 - 1 0 3 )
Brachioradialis: forearm in midposition between
pronation and supination (Figure 4 - 1 0 4 )
FIGURE 4-103
FIGURE 4-102 FIGURE 4-104
Chapter 4 / Testing the Muscles of the Upper Extremity 1 1 5
ELBOW FLEXION
(Biceps, Brachialis, and Brachioradialis)
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair) Continued
Position of Therapist: Stand in front of patient Grade 2 (Poor)
toward the test side. Hand giving resistance is con-
toured over the flexor surface of the forearm proxi- Position of Patient
mal to the wrist (see Figure 4 - 1 0 2 ) . T h e other hand All Elbow Flexors: S h o r t sitting with arm abducted
applies counterforce by cupping the palm over the to 90° and supported by examiner (Figure 4 - 1 0 6 ) .
anterior superior surface of the shoulder. Forearm is supinated (biceps), pronated (brachialis),
and in midposition (brachioradialis).
No resistance is given in a Grade 3 test, but
the test elbow is cupped by the examiner's hand Alternate Position for Patients Unable to Sit:
(Figure 4 - 1 0 5 , biceps illustrated at end range). Supine. Elbow is flexed to about 45° with forearm
supinated (for biceps) (Figure 4 - 1 0 6 ) , pronated (for
Test (All Three Forearm Positions): Patient flexes brachialis), and in midposition (for brachioradialis)
elbow through range of motion. (Figure 4-107) (biceps illustrated).
Instructions to Patient (All Three Tests)
Grades 5 and 4: " B e n d your elbow. H o l d it. D o n ' t
let me pull it down."
Grade 3: " B e n d your elbow."
Grading
Grade 5 (Normal): Completes available range and
holds firmly against maximal resistance.
Grade 4 (Good): Completes available range against
strong to moderate resistance, but the end point may
not be firm.
Grade 3 (Fair): Completes available range with each
forearm position with no manual resistance.
FIGURE 4-106
FIGURE 4-105 FIGURE 4-107
116 Chapter 4 / Testing the Muscles of the Upper Extremity
(Biceps, ELBOW FLEXION
Brachialis, and Brachioradialis)
Grade 5 (Normal), Grade 4 (Good), Grade 1 (Trace) and Grade 0 (Zero)
and Grade 3 (Fair) Continued
P o s i t i o n s o f P a t i e n t a n d T h e r a p i s t : Supine for all
Position of Therapist three muscles with therapist standing at test side (see
All Three Flexors: Stand in front of patient and sup- Figure 4 - 1 0 8 ) . All other aspects are the same as for
port abducted arm under the elbow and wrist if nec- the Grade 2 test.
essary (see Figure 4 - 1 0 6 ) . Palpate the tendon of the
biceps in the antecubital space (see Figure 4 - 1 0 7 ) . On Test: Patient attempts to bend elbow with hand
the arm, the muscle fibers may be felt on the anterior supinated, pronated, and in midposition.
surface of the middle two thirds with the short head
lying medial to the long head. Grading
Palpate the brachialis in the distal arm medial to Grade 1 (Trace): Examiner can palpate a contractile
the tendon of the biceps. Palpate the brachioradialis response in each of the three muscles for which a
on the proximal volar surface of the forearm, where Trace grade is given.
it forms the lateral border of the cubital fossa
(Figure 4-108). Grade 0 (Zero): No palpable contractile activity.
Test: Patient attempts to flex the elbow.
Instructions to Patient: "Try to bend your elbow."
Grading
Grade 2 (Poor): Completes range of m o t i o n (in each
of the muscles tested).
FIGURE 4-108 Helpful Hints
• The patient's wrist flexor muscles should re-
main relaxed throughout the test because
strongly contracting wrist flexors may assist in
elbow flexion.
• If the sitting position is contraindicated for any
reason, all tests for these muscles may be per-
formed in the supine position, but in that case
manual resistance should be part of the Grade
3 test (gravity compensation).
Chapter 4 / Testing the Muscles of the Upper Extremity 117
ELBOW EXTENSION
(Triceps brachii)
POSTERIOR
FIGURE 4-109
FIGURE 4-110 FIGURE 4-111
118 Chapter 4 / Testing the Muscles of the Upper Extremity
ELBOW EXTENSION
(Triceps brachii)
Table 4-15 E L B O W E X T E N SI O N Origin Insertion
I.D. Muscle All heads have a common
142 Triceps brachii Scapula (infraglenoid tuberosity tendon to:
and capsule of glenohumeral Ulna (olecranon process, upper
Long head joint) surface)
Humerus (shaft, oblique ridge, Blends with antebrachial fascia
Lateral head posterior surface) Capsule of elbow joint
Lateral intermuscular septum
Medial head Humerus (shaft: entire length of (See also Plate 4, page 127.)
posterior surface)
Medial and lateral intermuscular
septa
Other Anconeus
144
Chapter 4 / Testing the Muscles of the Upper Extremity 1 1 9
ELBOW EXTENSION
(Triceps brachii)
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)
Position of Patient: Prone on table. The patient Instructions to Patient: "Straighten your elbow.
starts the test with the arm in 9 0 ° of abduction and Hold it. D o n ' t let me bend i t . " Do not allow hyper-
the forearm flexed and hanging vertically over the extension.
side of the table (Figure 4 - 1 1 2 ) .
Grading
Position of Therapist: For the prone patient, the
therapist provides support just above the elbow. The Grade 5 (Normal): Completes available range and
other hand is used to apply downward resistance on holds firmly against maximal resistance.
the dorsal surface of the forearm (Figure 4 - 1 1 3 illus-
trates end position). Grade 4 (Good): Completes available range against
strong resistance, but there is a "give" to the resis-
Test: Patient extends elbow to end of available range tance at the end range.
or until the forearm is horizontal to the floor.
Grade 3 (Fair): Completes available range with no
manual resistance (Figure 4 - 1 1 4 ) .
FIGURE 4-112 FIGURE 4-114
FIGURE 4-113
120 Chapter 4 / Testing the Muscles of the Upper Extremity
ELBOW EXTENSION
(Triceps brachii)
Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)
Position of Patient: Short sitting. The arm is ab- Grading
ducted to 90° with the shoulder in neutral rotation
and the elbow flexed to about 4 5 ° . The entire limb Grade 2 (Poor): Completes available range in the
is horizontal to the floor (Figure 4 - 1 1 5 ) . absence of gravity.
Position of Therapist: Stand at test side of patient. Grade 1 (Trace): Examiner can feel tension in the
For the Grade 2 test, support the limb at the elbow. triceps tendon just proximal to the olecranon (see
For a Grade 1 or 0 test, support the limb under the Figure 4 - 1 1 6 ) or contractile activity in the muscle
forearm and palpate the triceps on the posterior sur- fibers on the posterior surface of the arm.
face of the arm just proximal to the olecranon process
(Figure 4-116). Grade 0 (Zero): No evidence of any muscle activity.
Test: Patient attempts to extend the elbow.
Instructions to Patient: "Try to straighten your
elbow."
FIGURE 4-115 FIGURE 4-116
Chapter 4 / Testing the Muscles of the Upper Extremity 121
ELBOW EXTENSION Helpful Hints
(Triceps brachii) • The therapist should confirm that muscle activ-
ity is seen and felt (i.e., triceps activity is actu-
Substitutions ally present) because patients can become very
adept at substituting. In fact, patients fre-
• Via external rotation. When the patient is sit- quently are taught substitution and encouraged to
ting with the arm abducted, elbow extension use it as a functional movement, but are not
can be accomplished with a Grade 0 triceps allowed to do so for the purpose of testing.
(Figure 4 - 1 1 7 ) . This can occur when the patient
externally rotates the shoulder, thus dropping • Give resistance in Grade 5 and Grade 4 tests with
the arm below the forearm. As a result, the el- the elbow slightly flexed to avoid enabling the
bow literally falls into extension. patient to "lock" the elbow joint by hyperex-
tending it.
• Via horizontal adduction. This substitution can
accomplish elbow extension and is done pur- • While elbow extension is tested in the prone
posefully by patients with a cervical cord injury position, there must be awareness that with the
and a Grade 0 triceps. With the distal seg- shoulder horizontally abducted the two-joint
ment fixed (as when the examiner stabilizes the muscle is less effective, and the test grade may
hand or wrist), the patient horizontally adducts be lower than it should be.1
the arm, and the thrust pulls the elbow into
extension (Figure 4 - 1 1 8 ) . The therapist, there- • An alternate position for Grades 5, 4, and 3 is
fore, should provide support at the elbow for with the patient short sitting. The examiner
testing purposes rather than at the wrist. stands behind the patient, supporting the arm
in 90° of abduction just above the flexed el-
bow (Figure 4 - 1 1 9 ) . The patient straightens the
elbow against the resistance given at the wrist.
FIGURE 4-117
FIGURE 4-119
FIGURE 4-118
122 Chapter 4 / Testing the Muscles of the Upper Extremity
FOREARM SUPINATION
(Supinator and Biceps brachii)
FIGURE 4-121
ANTERIOR
FIGURE 4-120
FIGURE 4-122
Chapter 4 / Testing the Muscles of the Upper Extremity 123
FOREARM SUPINATION
(Supinator and Biceps brachii)
Table 4-16 F O R E A R M S U P I N A T I O N
I.D. Muscle Origin Insertion
145 Supinator Radius (shaft, lateral aspect of
Humerus (lateral epicondyle) proximal 1/3)
140 Biceps brachii Ulna (supinator crest)
Short head Radial collateral ligament of Radius (radial tuberosity)
Long head elbow joint Bicipital aponeurosis
Annular ligament of radioulnar (See also Plate 4, page 127.)
joint
Aponeurosis of supinator
Scapula (coracoid apex)
Scapula (supraglenoid tubercle)
Capsule of glenohumeral joint
and glenoid labrum
Grade 5 (Normal), Grade 4 (Good), and ade 3 (Fair)
Position of Patient: Short sitting; arm at side and Test: Patient begins in pronation and supinates the
elbow flexed to 90°; forearm in pronation (Figure forearm until the palm faces the ceiling. Therapist re-
4 - 1 2 3 , showing end range). Alternatively, patient sists motion in the direction of pronation. (No resis-
may sit at a table. tance is given for Grade 3.)
Position of Therapist: Stand at side or in front Alternate Test: Grasp patient's hand as if shaking
of patient. One hand supports the elbow (see Figure hands; cradle the elbow and resist via the hand grip
4 - 1 2 3 ) . For resistance, grasp the forearm on (Figure 4 - 1 2 4 ) . This test is used if the patient has
the volar surface at the wrist. Grade 5 or 4 wrist and hand strength. If wrist flex-
ion is painful, give resistance at the wrist a more diffi-
cult level, but less painful.
FIGURE 4-123 FIGURE 4-124
124 Chapter 4 / Testing the Muscles of the Upper Extremity
FOREARM SUPINATION
(Supinator and Biceps brachii)
Grade 5 (Normal), Grade 4 (Good), Grade 2 (Poor)
and Grade 3 (Fair) Continued
Position of Patient: Short sitting with shoulder
Instructions to Patient: "Turn your palm up. Hold flexed between 4 5 ° and 9 0 ° and elbow flexed to 9 0 ° .
it. Don't let me turn it down. Keep your wrist and Forearm in neutral.
fingers relaxed."
Position of Therapist: Support the test arm by cup-
For Grade 3: "Turn your palm up." ping the hand under the elbow.
Grading Test: Patient supinates forearm (Figure 4 - 1 2 6 ) through
partial range of motion.
Grade 5 (Normal): Completes full available range of
motion and holds against maximal resistance. Instructions to Patient: "Turn your palm toward
your face."
Grade 4 (Good): Completes full range of motion against
strong to moderate resistance. Grading
Grade 3 (Fair): Completes available range of motion Grade 2 (Poor): Completes a full range of motion.
without resistance (Figure 4 - 1 2 5 , showing end range).
FIGURE 4-125 FIGURE 4-126
Chapter 4 / Testing the Muscles of the Upper Extremity 125
FOREARM SUPINATION
(Supinator and Biceps brachii)
Grade 1 (Trace) and Grade 0 (Zero) Substitutions
Position of Patient: Short sitting. Arm and elbow • Patient may externally rotate and adduct the
are flexed as for the Grade 3 test. arm across the body (Figure 4 - 1 2 8 ) as forearm
supination is attempted. When this occurs, the
Position of Therapist: Support the forearm just dis- forearm rolls into supination with no activity
tal to the elbow. Palpate the supinator distal to the of the supinator muscle.
head of the radius on the dorsal aspect of the fore-
arm (Figure 4 - 1 2 7 ) . • Patient should be instructed to keep the wrist
and fingers as relaxed as possible to avoid sub-
Test: Patient attempts to supinate the forearm. stitution by the wrist extensors.
Instructions to Patient: "Try to turn your palm so
it faces the ceiling."
Grading
Grade 1 (Trace): Slight contractile activity but no limb
movement.
Grade 0 (Zero): No contractile activity.
FIGURE 4-128
FIGURE 4-127
126 Chapter 4 / Testing the Muscles of the Upper Extremity
PLATE 4
Chapter 4 / Testing the Muscles of the Upper Extremity 127
FOREARM PRONATION
(Pronator teres and Pronator quadratus)
FIGURE 4-130
PALMAR
FIGURE 4-129
FIGURE 4-131
128 Chapter 4 / Testing the Muscles of the Upper Extremity
FOREARM PRONATION
(Pronator teres and Pronator quadratus)
Table 4-17 F O R E A R M P R O N ATION
I.D. Muscle Origin Insertion
146 Pronator teres Radius (midshaft, lateral surface)
Humerus (shaft proximal to
Humeral head medial epicondyle) Radius (shaft, anterior surface
Common tendon of origin of distally; also area above ulnar
Ulnar head flexor muscles notch)
Intermuscular septum (See also Plate 4, page 127.)
Antebrachial fascia
Ulna (coronoid process, medial)
Joins humeral head in common
tendon
147 Pronator quadratus Ulna (oblique ridge on distal 1/4
of anterior surface)
Muscle aponeurosis
Other Flexor carpi radialis
151
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)
Position of Patient: Short sitting or may sit at a test may be used if the patient has Normal or Good
table. Arm at side with elbow flexed to 9 0 ° and fore- wrist and hand strength.
arm in supination.
Instructions to Patient: "Turn your palm down.
Position of Therapist: Standing at side or in front Hold it. Don't let me turn it up. Keep your wrist
of patient. Support the elbow (Figure 4-132, showing and fingers relaxed."
end range). Hand used for resistance grasps the fore-
arm over the dorsal surface at the wrist. Grading
Test: Patient pronates the forearm until the palm Grade 5 (Normal): Completes available range of
faces downward. Therapist resists motion at the wrist motion and holds against maximal resistance.
in the direction of supination for Grades 4 and 5.
(No resistance is given for Grade 3.) Grade 4 (Good): C o m p l e t e s all available range
against strong to moderate resistance.
Alternate Test: Grasp patient's hand as if to shake
hands, cradling the elbow with the other hand and Grade 3 (Fair): Completes available range without
resisting pronation via the hand grip. This alternate resistance (Figure 4 - 1 3 3 , showing end range).
FIGURE 4-132 FIGURE 4-133
Chapter 4 / Testing the Muscles of the Upper Extremity
129
FOREARM PRONATION
(Pronator teres and Pronator quadratus)
Grade 2 (Poor) Grade 1 (Trace) and Grade 0 (Zero)
Position of Patient: Short sitting with shoulder Position of Patient: Short sitting. Arm is positioned
flexed between 4 5 ° and 9 0 ° and elbow flexed to 90°. as for the Grade 3 test.
Forearm in neutral (not illustrated).
Position of Therapist: Support the forearm just dis-
Position of Therapist: Support the test arm by cup- tal to the elbow. The fingers of the other hand are
ping the hand under the elbow. used to palpate the pronator teres over the upper
third of the volar surface of the forearm on a diago-
Test: Patient pronates forearm. nal line from the medial condyle of the humerus to the
lateral border of the radius (Figure 4 - 1 3 5 ) .
Instructions to Patient: "Turn your palm facing
outward away from your face." Test: Patient attempts to pronate the forearm.
Grading Instructions to Patient: "Try to turn your palm
down."
Grade 2 (Poor): Complete range of motion (Figure
4-134, showing end range). Grading
Grade 1 (Trace): Visible or palpable contractile activ-
ity with no motion of the part.
Grade 0 (Zero): No contractile activity.
FIGURE 4-134
FIGURE 4-135
130 Chapter 4 / Testing the Muscles of the Upper Extremity
Substitution FOREARM PRONATION
Patient may internally rotate the shoulder or (Pronator teres and Pronator quadratus)
abduct it during attempts at pronation (Figure
4 - 1 3 6 ) . When this occurs, the forearm rolls into Helpful Hint
pronation without the benefit of activity by the
pronator muscles. Patient should be instructed to keep the wrist and
fingers relaxed to avoid substitution by the flexor
carpi radialis and the finger flexors.
FIGURE 4-136
Chapter 4 / Testing the Muscles of the Upper Extremity 131
WRIST FLEXION carpi ulnaris)
(Flexor carpi radialis and Flexor
FIGURE 4-139
FIGURE 4-137 PALMAR
FIGURE 4-138
FIGURE 4-140
132 Chapter 4 / Testing the Muscles of the Upper Extremity
WRIST FLEXION
(Flexor carpi radialis and Flexor carpi ulnaris)
Table 4-18 W R I S T F L E X I O N Origin Insertion
I.D. Muscle 2nd and 3rd metacarpals
151 Flexor carpi radialis Humerus (medial epicondyle via (base, palmar surface)
common flexor tendon) Pisiform bone
153 Flexor carpi ulnaris Antebrachial fascia Hamate bone
Two heads Intermuscular septum 5th metacarpal, base
Humeral head (medial (See also Plate 4, page 127.)
epicondyle via common flexor
tendon)
Ulnar head (olecranon, medial
margin; shaft, proximal 2/3
posterior via an aponeurosis)
Intermuscular septum
Others Palmaris longus
152 Flexor digitorum superficialis
156 Flexor digitorum profundus
157 Abductor pollicis longus
166 Flexor pollicis longus
169
Grade 5 (Normal) and Grade 4 (Good) To Test Both Wrist Flexors: T h e examiner applies re-
sistance to the palm of the test hand with the thumb
Position of Patient (All Tests): Short sitting. circling around to the dorsal surface (Figure 4 - 1 4 2 ) .
Forearm is supported on its dorsal surface on a table. Resistance is given evenly across the hand in a
To start, forearm is supinated (Figure 4 - 1 4 1 ) . Wrist is straight-down direction into wrist extension.
in neutral position or slightly extended.
To Test the Flexor carpi radialis: Resistance is
Position of Therapist: One hand supports the pa- focused over the 2nd metacarpal (radial side of
tient's forearm under the wrist (Figure 4 - 1 4 1 ) . the hand) in the direction of extension and ulnar de-
viation.
Test: Patient flexes the wrist, keeping the digits and
thumb relaxed.
FIGURE 4-141 FIGURE 4-142
Chapter 4 / Testing the Muscles of the Upper Extremity 133
WRIST FLEXION
(Flexor carpi radialis and Flexor carpi ulnaris)
Grade 5 (Normal) and Grade 4 Grade 3 (Fair)
Good Continued
Position of Patient: Starting position with forearm
To Test the Flexor carpi ulnaris: Resistance is supinated and wrist neutral as in Grade 5 and 4 tests.
focused over the 5th metacarpal (ulnar side of
the hand) in the direction of extension and radial Position of Therapist: Support the patient's forearm
deviation. under the wrist.
Instructions to Patient (All Tests): "Bend your Test
wrist. Hold it. Don't let me pull it down. Keep For Both Wrist Flexors: Patient flexes the wrist
your fingers relaxed." straight up without resistance and without radial or
ulnar deviation.
Grading
For Flexor carpi radialis: Patient flexes the wrist
Grade 5 (Normal): Completes available range of in radial deviation (Figure 4 - 1 4 3 ) .
wrist flexion and holds against maximal resistance.
For Flexor carpi ulnaris: Patient flexes the wrist in
Grade 4 (Good): Completes available range and ulnar deviation (Figure 4 - 1 4 4 ) .
holds against strong to moderate resistance.
FIGURE 4-143
FIGURE 4-144
134 Chapter 4 / Testing the Muscles of the Upper Extremity
(Flexor carpi WRIST FLEXION
radialis and Flexor carpi ulnaris)
Grade 3 (Fair) Continued Grade 2 (Poor)
Instructions to Patient wrist. Keep it Position of Patient: Short sitting with elbow sup-
ported on table. Forearm in midposition with hand
For Both Wrist Flexors: " B e n d your resting on ulnar side (Figure 4 - 1 4 5 ) .
straight with your fingers relaxed."
Position of Therapist: Support patient's forearm
For Flexor carpi radialis: " B e n d your wrist leading proximal to the wrist.
with the thumb side."
Test: Patient flexes wrist with the ulnar surface glid-
For Flexor carpi ulnaris: " B e n d your wrist leading ing across or not touching the table (Figure 4 - 1 4 5 ) .
with the little finger." To test the two wrist flexors separately, hold the fore-
arm so that the wrist does not lie on the table and
Grading ask the patient to perform the flexion motion while
the wrist is in ulnar and then radial deviation.
Grade 3 (Fair) (All Tests): Completes available
range without resistance. Instructions to Patient: "Bend your wrist, keeping
your fingers relaxed."
Grading
Grade 2 (Poor): Completes available range of wrist
flexion without assistance of gravity.
FIGURE 4-145
Chapter 4 / Testing the Muscles of the Upper Extremity 135
WRIST FLEXION
(Flexor carpi radialis and Flexor carpi ulnaris)
Grade 1 (Trace) and Grade 0 (Zero) Test: Patient attempts to flex the wrist.
Position of Patient: Supinated forearm supported Instructions to Patient: "Try to bend your wrist.
on table. Relax. Bend it again." Patient should be asked to
repeat the test so the examiner can feel the tendons
Position of Therapist: Support the wrist in flexion; during both relaxation and contraction.
the index finger of the other hand is used to palpate
the appropriate tendons. Grading
Palpate the tendons of the flexor carpi radialis Grade 1 (Trace): O n e or both tendons may exhibit
(Figure 4 - 1 4 6 ) and the flexor carpi ulnaris (Figure visible or palpable contractile activity, but the part
4 - 1 4 7 ) in separate tests. does not move.
The flexor carpi radialis lies on the lateral palmar Grade 0 (Zero): No contractile activity.
aspect of the wrist (Figure 4 - 1 4 6 ) lateral to the
palmaris longus, if the patient has one!
The tendon of the flexor carpi ulnaris (Figure
4 - 1 4 7 ) lies on the medial palmar aspect of the wrist.
FIGURE 4-146 FIGURE 4-147
136 Chapter 4 / Testing the Muscles of the Upper Extremity