TRUNK EXTENSION
Longissimus thoracis
lliocostalis thoracis
Spinalis thoracis
Semispinalis thoracis
Multifidus
lliocostalis lumborum
All m u s c l e s are bilateral
and segmental
Innervation is variable
along thoracic, lumbar,
and even cervical spine
FIGURE 3-2
POSTERIOR
FIGURE 3-1
36 Chapter 3/ Testing the Muscles of the Trunk
Thoracic spine: 0° to 0°
Lumbar spine: 0° to 25°
Table 3-1 T R U N K EXTENSION Origin Insertion
I.D. Muscle Ribs 6 up to 1 (angles)
89 Iliocostals thoracis Ribs 12 up to 7 (angles) C7 vertebra (transverse processes)
90 Iliocostals lumborum Ribs 6-12 (angles)
Tendon of erector spinae
91 Longissimus thoracis (anterior surface) T1-T12 vertebrae (transverse
Thoracolumbar fascia processes)
92 Spinalis thoracis (often Iliac crest (external lip) Ribs 2-12 (between angles and
indistinct) Sacrum (posterior surface) tubercles)
T1 -T4 vertebrae (or to T8,
93 Semispinalis thoracis Tendon of erector spinae spinous processes)
94 Multifidi Thoracolumbar fascia Blends with semispinalis thoracis
L1-L5 vertebrae (transverse C6-T4 vertebrae (spinous
95, 96 Rotatores thoracis and processes) processes)
lumborum (11 pairs) Spinous processes of higher
Common tendon of erector vertebra (may span 2-4
97, 98 Interspinals thoracis spinae vertebrae before inserting)
and lumborum T11-L2 vertebrae (spinous
processes) Next highest vertebra (lower
99 Intertransversarii thoracis border of lamina)
and lumborum T6-T10 vertebrae (transverse See Origin
processes)
100 Quadratus lumborum See Origin
Sacrum (posterior)
Erector spinae (aponeurosis) 12th rib (lower border)
Ilium (PSIS) and crest L1 -L4 vertebrae (transverse
Sacroiliac ligaments processes)
L1-L5 vertebrae (mamillary T12 vertebra (body)
processes)
T1-T12 vertebrae (transverse
processes)
C4-C7 vertebrae (articular
processes)
Thoracic and lumbar vertebrae
(transverse processes; variable in
lumbar area)
Thoracis: (3 pairs) between spinous
processes of contiguous
vertebrae (T1-T2; T2-T3; T11-T12)
Lumborum: (4 pairs) lie between
the 5 lumbar vertebrae; run
between spinous processes
Thoracis: (3 pairs) between
transverse processes of
contiguous vertebrae T10-T12
and L1
Lumborum: medial muscles;
accessory process of superior
vertebra to mamillary process of
vertebra below
Lateral muscles: fill space
between transverse processes of
adjacent vertebrae
Ilium (crest and inner lip)
Iliolumbar ligament
Other Gluteus maximus
182 (provides stable base
for trunk extension by
stabilizing pelvis)
Chapter 3 / Testing the Muscles of the Trunk 37
TRUNK EXTENSION
LUMBAR SPINE Grading
Grade 5 (Normal) and Grade 4 (Good) Grade 5 (Normal) and Grade 4 (Good): T h e exam-
iner distinguishes between Grade 5 and Grade 4
The Grade 5 and Grade 4 tests for spine extension muscles by the nature of the response (see Figures
are different for the lumbar and thoracic spines. Begin- 3-3 and 3-4). T h e Grade 5 muscle holds like a lock;
ning at Grade 3, the tests for both levels are combined. the Grade 4 muscle yields slightly because of an elastic
quality at the end point. The patient with Normal
Position of Patient: Prone with hands clasped be- back extensor muscles can quickly come to the end
hind head. position and hold that position without evidence of
significant effort. The patient with Grade 4 back ex-
Position of Therapist: Standing so as to stabilize tensors can come to the end position but may waver
the lower extremities just above the anldes if the pa- or display some signs of effort.
tient has Normal hip strength (Figure 3-3).
Alternate Position: Therapist stabilizes the lower ex-
tremities using body weight and both arms placed
across the pelvis if the patient has hip extension
weakness. It is very difficult to stabilize the pelvis ad-
equately in the presence of significant hip weakness
(Figure 3-4).
Test: Patient extends the lumbar spine until the en-
tire thorax is raised from the table (clears umbilicus).
Instructions to Patient: "Raise your head, shoul-
ders, and chest off the table. Come up as high as
you can."
FIGURE 3-3 FIGURE 3-4
38 Chapter 3 / Testing the Muscles of the Trunk
TRUNK EXTENSION
THORACIC SPINE LUMBAR AND THORACIC SPINE
Grade 5 (Normal) and Grade 4 (Good) Grade 3 (Fair)
Position of Patient: Prone with head and upper Position of Patient: Prone with arms at sides.
trunk extending off the table from about the nipple
line (Figure 3-5). Position of Therapist: Standing at side of table.
Lower extremities are stabilized just above the ankles.
Position of Therapist: Standing so as to stabilize
the lower limbs at the ankle. Test: Patient extends spine, raising body from the
table so that the umbilicus clears the table
Test: Patient extends thoracic spine to the hori- (Figure 3-7).
zontal.
Instructions to Patient: "Raise your head, arms,
Instructions to Patient: "Raise your head, shoul- and chest from the table as high as you can."
ders, and chest to table level."
Grading
Grading
Grade 3 (Fair): Patient c o m p l e t e s the range of
Grade 5 (Normal): Patient is able to raise the u p p e r motion.
trunk quickly from its forward flexed position to the
horizontal (or beyond) with ease and no sign of ex-
ertion (Figure 3-6).
Grade 4 (Good): Patient is able to raise the trunk to
the horizontal level but does it somewhat laboriously.
FIGURE 3-7
FIGURE 3-5
FIGURE 3-6
Chapter 3 / Testing the Muscles of the Trunk 39
TRUNK EXTENSION
Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)
These tests are identical to the Grade 3 test ex- Grading
cept that the examiner must palpate the lumbar and Grade 2 (Poor): Patient c o m p l e t e s partial range of
thoracic (Figures 3-8 and 3-9) spine extensor muscle motion.
masses adjacent to both sides of the spine. The indi- Grade 1 (Trace): C o n t r a c t i l e activity is detectable
but no movement.
vidual muscles cannot be isolated.
Grade 0 (Zero): No contractile activity.
FIGURE 3-8 FIGURE 3-9
Helpful Hints • The position of the arms (clasped behind the
head) provides added resistance for Grades 5 and
• Tests for hip extension and neck extension 4; the weight of the head and arms essentially
should precede tests for trunk extension. substitutes for manual resistance by the examiner.
When the spine extensors are weak and the
hip extensors are strong, the patient will be • If the patient is a complete paraplegic, the test
unable to raise the upper trunk from the should be done on a mat table. Position the sub-
table. Instead, the pelvis will tilt posteriorly while ject with both legs and pelvis off the mat. This
the lumbar spine moves into flexion (low back allows the pelvis and limbs to contribute to stabi-
flattens). lization, and the examiner holding the lower
When the back extensors are strong and the trunk has a chance to provide the necessary sup-
hip extensors are weak, the patient can hyperex- port. (If a mat table is not available, an assistant
tend the low back (increased lordosis) but will be will be required, and the lower body may rest on
unable to raise the trunk without very strong sta- a chair.)
bilization of the pelvis by the examiner.
• If the neck extensors are weak, the examiner may
need to support the head as the patient raises the
trunk.
40 Chapter 3 / Testing the Muscles of the Trunk
ELEVATION OF THE PELVIS
Quadratus To:
lumborum Quadratus lumborum
T12-L3
FIGURE 3-11
POSTERIOR Approximates pelvis to lower
FIGURE 3-10 ribs; range not precise
Table 3-2 E L E V A T I O N O F T H E P E L V I S
I.D. Muscle Origin Insertion
100 Quadratus lumborum
Ilium (crest and inner lip) Rib 12 (lower border)
Iliolumbar ligament L1-L4 vertebrae (transverse
processes, apex)
110 Obliquus externus Ribs 5-12 T12 vertebra (body;
abdominis (interdigitating on external and occasionally)
inferior surfaces)
Iliac crest (outer border)
111 Obliquus internus Iliac crest (anterior 2/3 of Linea alba
abdominis intermediate line) Aponeurosis from 9th costal
Thoracolumbar fascia cartilage to ASIS; both sides
Inguinal ligament (lateral 2/3 of meet at midline to form linea
upper aspect) alba
Pubic symphysis (upper border)
Ribs 9-12 (inferior border and
cartilages by digitations that
appear continuous with internal
intercostals)
Ribs 7-9 (cartilages)
Aponeurosis to linea alba
Others Latissimus dorsi (arms fixed)
130 lliocostalis lumborum
90
Chapter 3 / Testing the Muscles of the Trunk 41
ELEVATION OF THE PELVIS
Grade 5 (Normal) and Grade 4 (Good) Grade 3 (Fair) and Grade 2 (Poor)
Position of Patient: Supine or prone with hip and Position of Patient: Supine or prone. Hip in exten-
lumbar spine in extension. The patient grasps edges sion; lumbar spine neutral or extended.
of the table to provide stabilization during resistance
(not illustrated). P o s i t i o n of T h e r a p i s t : Standing at foot of table fac-
ing patient. One hand supports the leg just above
Position of T h e r a p i s t : Standing at foot of table fac- the ankle; the other is under the knee so the limb is
ing patient. Therapist grasps test limb with both slightly off the table to decrease friction (Figure 3-13).
hands just above the ankle and pulls caudally with a
smooth, even pull (Figure 3-12). Resistance is given as Test: Patient hikes the pelvis unilaterally to bring the
in traction. rim of the pelvis closer to the inferior ribs.
Test: Patient hikes the pelvis on one side, thereby Instructions to Patient: "Bring your pelvis up to
approximating the pelvic rim to the inferior margin your ribs."
of the rib cage.
Grading
Instructions to Patient: "Hike your pelvis to bring
it up to your ribs. Hold it. D o n ' t let me pull your Grade 3 (Fair): Patient c o m p l e t e s available range of
leg down." motion.
Grading Grade 2 (Poor): Patient c o m p l e t e s partial range of
motion.
Grade 5 (Normal): T h i s m o t i o n , certainly n o t attrib-
utable solely to the quadratus lumborum, is one that
tolerates a huge amount of resistance that is not
readily broken when the muscles involved are
Normal (5).
Grade 4 (Good): Patient tolerates very s t r o n g resist-
ance. Testing this movement requires more than a bit
of clinical judgment.
FIGURE 3-13
FIGURE 3-12
42 Chapter 3 / Testing the Muscles of the Trunk
ELEVATION OF THE PELVIS
Grade 1 (Trace) and Grade 0 (Zero) Substitution
These grades should be avoided in the cause of clini- The patient may attempt to substitute with trunk
cal accuracy. T h e principal muscle to which pelvis lateral flexion, primarily using the abdominal
elevation is attributed lies deep to the paraspinal muscles. The spinal extensors may be used with-
muscle mass and can rarely be palpated. In per- out the quadratus lumborum. In neither case
sons who have extensive truncal atrophy or severe can manual testing detect an inactive Quadratus
inanition, paraspinal muscle activity may be palpat- lumborum.
ed, and possibly, but not necessarily convincingly, the
quadratus lumborum can be palpated.
Chapter 3 / Testing the Muscles of the Trunk 43
TRUNK FLEXION To:
Rectus abdominus
Rectus T7-T12
abdominis
FIGURE 3-15
ANTERIOR Origin 0° to 80°
FIGURE 3-14
Table 21-3 T R U N K F L E X I O N Pubis Insertion
I D . Muscle Lateral fibers (tubercle on crest Ribs 5-7 (costal cartilages)
113 Rectus abdominis and pecten pubis) Sternum (xiphoid ligaments)
(paired muscle) Medial fibers (ligamentous
covering of symphysis to attach Iliac crest (outer border)
110 Obliquus externus to contralateral muscle) Linea alba
abdominis Aponeurosis from 9th costal
Ribs 5-12 (interdigitating on cartilage to ASIS; both sides
external and inferior surfaces) meet at midline to form linea alba
Ribs 9-12 (inferior border and
111 Obliquus internus Iliac crest (anterior 2/3 of cartilages by digitations that
abdominis intermediate line) appear continuous with internal
Thoracolumbar fascia intercostals)
Inguinal ligament (lateral 2/3 of Ribs 7-9 (cartilages)
upper aspect) Aponeurosis to linea alba
Others Psoas major
174 Psoas minor
175
44 Chapter 3 / Testing the Muscles of the Trunk
TRUNK FLEXION
Trunk flexion has multiple elements that include both thoracic and lumbar motion. Measurement is difficult at
best and may be done in a variety of ways with considerable variability in results.
Tests for neck flexion should precede tests for trunk flexion. This will permit allowances to be made for
neck weakness (should it exist), and support can be provided as required.
Grade 5 (Normal) A curl-up is emphasized, and trunk is curled until
scapulae clear table (Figure 3-17).
Position of Patient: Supine with hands clasped be-
hind head (Figure 3-16). Instructions to Patient: "Tuck your chin and bring
your head, shoulders, and arms off the table, as in a
Position of Therapist: Standing at side of table at sit-up."
level of patient's chest to be able to ascertain
whether scapulae clear table during test (see Figure Grading
3-16). For a patient with no other muscle weakness,
the therapist does not need to touch the patient. If, Grade 5 (Normal): Patient c o m p l e t e s range of m o -
however, the patient has weak hip flexors, the exam- tion until inferior angles of scapulae are off the table.
iner should stabilize the pelvis by leaning across the (Weight of the arms serves as resistance.)
patient on the forearms (Figure 3-17).
Test: Patient flexes trunk through range of motion.
FIGURE 3-16 FIGURE 3-17
Chapter 3 / Testing the Muscles of the Trunk 45
TRUNK FLEXION
Grade 4 (Good) Grade 3 (Fair)
Position of Patient: Supine with arms crossed over Position of Patient: Supine with arms outstretched
chest (Figure 3-18). in full extension above plane of body (Figure 3-19).
Test: Other than patient's position, all other aspects T e s t : O t h e r than patient's position, all other aspects
of the test are the same as for Grade 5. of the test are the same as for Grade 5. Patient flexes
trunk until inferior angles of scapulae are off the
Grading table. Position of the outstretched arms "neutralizes"
resistance by bringing the weight of the arms closer
Grade 4 (Good): Patient c o m p l e t e s r a n g e of m o t i o n to the center of gravity.
and raises trunk until scapulae are off the table.
Resistance of arms is reduced in the cross-chest posi- Instructions to Patient: "Raise your head, shoul-
tion. ders, and arms off the table."
Grading
Grade 3 (Fair): Patient c o m p l e t e s range of m o t i o n
and flexes trunk until inferior angles of scapulae are
off the table.
FIGURE 3-18
FIGURE 3-19
46 Chapter 3 / Testing the Muscles of the Trunk
TRUNK FLEXION
Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)
Testing trunk flexion is rather clear cut for Grades 5, Position of Therapist: Standing at side of table.
4, and 3. When testing Grade 2 and below, the The hand used for palpation is placed at the midline
results may be ambiguous, but observation and of the thorax over the linea alba, and the four fingers
palpation are critical for defendable results. Sequen- of both hands are used to palpate the rectus abdo-
tially from 2 to 0, the patient will be asked to raise minis (Figure 3-20).
the head (Grade 2), do an assisted forward lean
(Grade 1), or cough (Grade 1). Test and Instructions to Patient: The examiner
tests for Grades 2, 1, and 0 in a variety of ways to
If the abdominal muscles are weak, reverse action make certain that muscle contractile activity that may
of the hip flexors may cause lumbar lordosis. When be present is not missed.
this occurs, the patient should be positioned with
the hips flexed with feet flat on the table to disallow
the hip flexors to contribute to the test motion.
Position of Patient: Supine with arms at sides.
Knees flexed.
FIGURE 3-20
Chapter 3 / Testing the Muscles of the Trunk 47
TRUNK FLEXION
Grading Sequence 3: C o u g h ( F i g u r e 3 - 2 3 ) : Ask the patient to
cough. If the patient can cough to any degree and
Sequence 1: H e a d raise ( F i g u r e 3 - 2 1 ) : A s k the patient depression of the rib cage occurs, the Grade is 2 (Poor).
to lift the head from the table. If the scapulae do not (If the patient coughs, regardless of its effectiveness,
clear the table, the Grade is 2 (Poor). If the patient the abdominal muscles are automatically brought into
cannot lift the head, p r o c e e d to S e q u e n c e 2. play.) If the patient cannot cough but there is pal-
pable rectus abdominis activity, the Grade is 1 (Trace).
Sequence 2: Assisted f o r w a r d lean ( F i g u r e 3 - 2 2 ) : T h e Lack of any demonstrable activity is Grade 0 (Zero).
examiner cradles the upper trunk and head off the
table and asks the patient to lean forward. If there is
depression of the rib cage, the Grade is 2 (Poor). If
there is no depression of the rib cage but visible or
palpable contraction occurs, the Grade assigned
should be 1 (Trace). If there is no activity, the Grade
is 0; proceed to Sequence 3.
FIGURE 3-21. Sequence 1. FIGURE 3-23. Sequence 3.
FIGURE 3-22. Sequence 2.
Helpful Hints
• In all tests observe any deviations of the um-
bilicus. (This is not to be confused with the re-
sponse to light stroking, which elicits superficial
reflex activity.) In response to muscle testing, if
there is a difference in the segments of the
rectus abdominis, the umbilicus will deviate
toward the stronger part (i.e., cranially if the
upper parts are stronger, caudally if the lower
parts are stronger).
• If the extensor muscles of the lumbar spine are
weak, contraction of the abdominal muscles can
cause posterior tilt of the pelvis. If this situation
exists, tension of the hip flexor muscles would
be useful to stabilize the pelvis; therefore the
examiner should position the patient in hip
extension.
48 Chapter 3 / Testing the Muscles of the Trunk
TRUNK ROTATION
To: To:
Obliquus Obliquus
internus externus
abdominis abdominis
(bilateral) (bilateral)
T7-L1 T7-T12
Obliquus Obliquus (Ilioinguinal and
internus externus Iliohypogastric nn.)
abdominis abdominis L1
FIGURE 3-25
ANTERIOR 0° to 45°
FIGURE 3-24
Table 3-4 T R U N K R O T A T I O N Origin Insertion
I.D. Muscle Ribs 5-12 (interdigitating on Iliac crest (outer border)
external and inferior surfaces) Thoracolumbar fascia
110 Obliquus externus Linea alba
abdominis Aponeurosis from 9th costal
cartilage to ASIS; both sides
111 Obliquus internus Iliac crest (anterior 2/3 of meet at midline to form linea
abdominis intermediate line) alba
Thoracolumbar fascia Pubic symphysis (upper border)
Inguinal ligament (lateral 2/3 of
upper aspect) Ribs 9-12 (inferior border and
cartilages by digitations that
appear continuous with internal
intercostals)
Aponeurosis of transverse
abdominis to crest of pecten
pubis to form falx inguinalis
Inguinal ligament
Linea alba
Ribs 7-9 (cartilages)
Other
Deep back muscles
(one side)
Chapter 3 / Testing the Muscles of the Trunk 49
TRUNK ROTATION
Grade 5 (Normal) Instructions to Patient: "Lift your head and shoul-
ders from the table, taking your right elbow toward
Position of Patient: Supine with hands clasped be- your left k n e e . " T h e n , "Lift your head and shoulders
hind head. from the table, taking your left elbow toward your
right knee."
Position of Therapist: Standing at patient's waist
level. Grading
Test: Patient flexes trunk and rotates to one side. Grade 5 (Normal): T h e scapula c o r r e s p o n d i n g to
This movement is then repeated on the opposite side the side of the external oblique function must clear
so that the muscles on both sides can be examined. the table for a Normal grade.
Right elbow to left knee tests the right external
obliques and the left internal obliques (Figure 3-26).
Left elbow to right knee tests the left external
obliques and the right internal obliques (Figure 3-27).
When the patient rotates to one side, the internal
oblique muscle is palpated on the side toward the
turn; the external oblique muscle is palpated on
the side away from the direction of turning.
Substitution
If the pectoralis major is active (inappropriately)
in this test of trunk rotation at any grade, the
shoulder will shrug or be raised from the table,
and there is limited rotation of the trunk.
FIGURE 3-26 FIGURE 3-27
50 Chapter 3 / Testing the Muscles of the Trunk
TRUNK ROTATION
Grade 4 (Good) Grade 3 (Fair)
Position of Patient: Supine with arms crossed over Position of Patient: Supine with arms outstretched
chest. above plane of body.
T e s t : Other than patient's position, all other aspects Test: Position of therapist and instructions are the
of the test are the same as for Grade 5. The test is same as for Grade 5. The test is done first to the left
done first to one side (Figure 3-28) and then to the (Figure 3-30) and then to the right (Figure 3-31).
other (Figure 3-29).
Grading
Grade 3 (Fair): Patient is able to raise the scapula
off the table. The therapist may use one hand to
check for scapular clearance (see Figure 3-31).
FIGURE 3-28 FIGURE 3-30
FIGURE 3-29
FIGURE 3-31
Chapter 3 / Testing the Muscles of the Trunk 51
TRUNK ROTATION
Grade 2 (Poor) At the same time, the internal oblique muscle on
the opposite side of the trunk is palpated. The inter-
Position of Patient: Supine with arms outstretched nal oblique muscle lies under the external oblique,
above plane of body. and its fibers run in the opposite diagonal direction.
Position of Therapist: Standing at level of patient's Examiners may remember this palpation procedure
waist. Therapist palpates the external oblique first on better if they think of positioning their two hands as
one side and then on the other, with one hand if both hands were to be in the pants' pockets or
placed on the lateral part of the anterior abdominal grasping the abdomen in pain. (The external
wall distal to the rib cage (Figure 3-32). Continue to obliques run from out to in; the internal obliques
palpate the muscle distally in the direction of its run from in to out.)
fibers until reaching the anterior superior iliac spine
(ASIS). Instructions to Patient: "Lift your head and reach
toward your right knee." (Repeat to left side for the
opposite muscle.)
Test: Patient attempts to raise body and turn toward
the right. Repeat toward left side.
Grading
Grade 2 (Poor): Patient is unable to clear the inferior
angle of the scapula from the table on the side of the
external oblique being tested. The examiner must,
however, be able to observe depression of the rib
cage during the test activity.
FIGURE 3-32
52 Chapter 3 / Testing the Muscles of the Trunk
TRUNK ROTATION
Grade 1 (Trace) and Grade 0 (Zero) One hand palpates the internal obliques on the
side toward which the patient turns (not illustrated)
Position of Patient: Supine with arms at sides. Hips and the external obliques on the side away from the
flexed with feet flat on table. direction of turning (see Figure 3-33). The therapist
assists the patient to raise the head and shoulders
Position of Therapist: Head is supported as patient slightly and turn to one side. This procedure is used
attempts to turn to one side (Figure 3-33). (Turn to when abdominal muscle weakness is profound.
the other side in a subsequent test.) Under normal
conditions, the abdominal muscles stabilize the trunk I n s t r u c t i o n s to P a t i e n t : " T r y to lift up and turn to
when the head is lifted. In patients with abdominal your right." (Repeat for turn to the left.)
weakness, the supported head permits the patient to
recruit abdominal muscle activity without having to Test: Patient attempts to flex trunk and turn to
overcome the entire weight of the head. either side.
Grading
Grade 1 (Trace): T h e e x a m i n e r can see or palpate
muscular contraction.
Grade 0 (Zero): No r e s p o n s e f r o m the o b l i q u u s in-
ternus or externus muscles.
FIGURE 3-33
Helpful Hints • If the hip flexor muscles are weak, the examiner
must stabilize the pelvis.
• In all tests observe any deviation of the umbili-
cus, which will move toward the strongest quad- • To cause the abdominals to come into action
rant when there is unequal strength in the automatically, the examiner may resist a downward
opposing oblique muscles. diagonal motion of the arm or a downward and
outward movement of the lower limb.
• Flaring of the rib cage denotes weakness of the
external oblique muscles.
Chapter 3 / Testing the Muscles of the Trunk 53
QUIET INSPIRATION Intercostales
externi
DIAPHRAGM Intercostales
FIGURE 3-34 interni
Transversus
abdominis
FIGURE 3-35
FIGURE 3-36*
* Arrow indicates level of cross section. FIGURE 3-37
54 Chapter 3 / Testing the Muscles of the Trunk
QUIET INSPIRATION
FIGURE 3-38
Normal range of motion of
the chest wall during quiet
inspiration is about 0.75 inch,
with gender variations.
Normal chest expansion in
forced inspiration varies from
2.0 to 2.5 inches at the level
of the xiphoid.'
Chapter 3 / Testing the Muscles of the Trunk 55
QUIET INSPIRATION
Table 3-5 M U S C L E S O F Q U I E T I N S P I R A T I O N
I.D. Muscle Origin Insertion
Fibers all converge on central
101 Diaphragm (formed tendon of diaphragm; middle
of 3 parts from the of central tendon is
circumference of below and partially blended with
thoracic outlet) pericardium
Sternal Xiphoid process (posterior) Ribs 2-12 (upper margins of rib
Costal below; last two end in free ends
Ribs 7-12 (internal surfaces of of the costal cartilages)
Lumbar costal cartilages and ribs on External intercostal membrane
each side) Upper border of rib below
102 Intercostales externi Interdigitates with transversus Fibers run obliquely to
(11 pairs) abdominis external intercostals
Medial and lateral arcuate Rib below (upper margin)
ligaments (aponeurotic arches) Fibers run in same pattern as
L1-L2 (left crus, bodies) internal intercostals
L1-L3 (right crus, bodies) Rib below vertebra of origin
(external surface)
Ribs 1-11 (lower borders and 1st rib (scalene tubercle)
tubercles; costal cartilages)
1st rib (superior surface)
103 Intercostales interni Sternum (anterior)
(11 pairs) Ribs 1-11 (ridge on inner surface) 2nd rib (outer surface)
104 Costal cartilages of same rib
107 Intercostales intimi Internal intercostal membrane
80 (innermost intercostals)
81 Often absent Ribs 1-11 (costal groove)
Levator costarum
82 (12 pairs) C7-T11 vertebrae (transverse
Other Scalenus anterior processes, tip)
Scalenus medius C3-C6 vertebrae (transverse
processes, anterior tubercles)
Scalenus posterior
C2 (axis)-C7 vertebrae
(transverse processes, posterior
tubercles)
CI (atlas) sometimes
C4-C6 vertebrae (transverse
processes posterior tubercle,
variable)
Pectoralis major (arms fixed)
QUIET INSPIRATION diaphragm is active. The rise on both sides of the
linea alba should be symmetrical. During quiet inspi-
Diaphragm and Intercostals ration, epigastric rise reflects the movement of the
diaphragm descending over one intercostal space.2,3
Preliminary Examination In deeper inspiratory efforts, the diaphragm may
move across three or more intercostal spaces.
Uncover the patient's chest and abdominal areas so
that the motions of the chest and abdominal walls An elevation and lateral expansion of the rib cage
can be observed. Watch the normal respiration pat- are indicative of intercostal activity during inspiration.
tern, observe differences in the motion of the chest Exertional chest expansion measured at the level of
wall and epigastric area, and note any contraction of the xiphoid process is 2.0 to 2.5 inches (the expan-
the neck muscles and the abdominal muscles. sion may exceed 3.0 inches in more active young
people and athletes).1
Epigastric rise and flaring of the lower margin of
the rib cage during inspiration indicate that the
56 Chapter 3 / Testing the Muscles of the Trunk
QUIET INSPIRATION
THE DIAPHRAGM Grade 3 (Fair): C o m p l e t e s m a x i m a l inspiratory ex-
pansion but cannot tolerate manual resistance.
All Grades (5 to 0)
Grade 2 (Poor): O b s e r v a b l e epigastric rise w i t h o u t
Position of Patient: Supine. completion of full inspiratory expansion.
Position of Therapist: Standing next to patient at Grade 1 (Trace): P a l p a b l e c o n t r a c t i o n is d e t e c t e d
approximately waist level. One hand is placed lightly under the inner surface of the lower ribs, provided
on the abdomen in the epigastric area just below the the abdominal muscles are relaxed (Figure 3-40).
xiphoid process (Figure 3-39). Resistance is given (by Another way to detect minimal epigastric motion is
same hand) in a downward direction. by instructing the patient to " s n i f f with the mouth
closed.
Test: Patient inhales with maximal effort and holds
maximal inspiration. Grade 0 (Zero): No epigastric rise and no p a l p a b l e
contraction of the diaphragm occur.
Instructions to Patient: "Take a deep breath . . .
as much as you can . . . hold it. Push against my Substitution
hand. Don't let me push you d o w n . "
Patient may attempt to substitute for an inade-
Grading quate diaphragm by hyperextending the lumbar
spine in an effort to increase the response to the
Grade 5 (Normal): Patient c o m p l e t e s full inspiratory examiner's manual resistance.4 The abdominal
(epigastric) excursion and holds against maximal re- muscles also may contract, but both motions are
sistance. A Grade 5 diaphragm takes high resistance improper attempts to follow the instruction to
in the range of 100 pounds.4 push up against the examiner's hand.
Grade 4 (Good): C o m p l e t e s m a x i m a l inspiratory ex-
cursion but yields against heavy resistance.
FIGURE 3-39 FIGURE 3-40
Chapter 3 / Testing the Muscles of the Trunk 57
QUIET INSPIRATION
THE INTERCOSTALS Position of Therapist: Standing at side of table.
Tape measure placed lightly around thorax at level of
There is no method of direct assessment of the xiphoid.
strength of the intercostal muscles. An indirect
method measures the difference in magnitude of Test: Patient holds maximal inspiration for measure-
chest excursion between maximal inspiration and the ment and then holds maximal expiration for a second
girth of the chest at the end of full expiration. measurement. (A pneumograph may be used for the
same purpose if one is available.) The difference be-
Grades tween the two measurements is recorded as chest ex-
pansion.
There are no classic 5 to 0 grades given for the in-
tercostal muscles. Instead, a flexible metal or new Instructions to Patient: "Take a big breath in and
cloth tape is used to measure chest expansion. hold it. N o w blow it all o u t and hold i t . "
Position of Patient: Supine on a firm surface. Arms
at sides.
58 Chapter 3 / Testing the Muscles of the Trunk
FORCED EXPIRATION
Coughing often is used as the clinical test for forced Weak Functional: M o d e r a t e i m p a i r m e n t that affects
expiration. An effective c o u g h requires the use of all the degree of active motion or endurance:
muscles of active expiration, in contrast to quiet expi- • Decreased volume and diminished air movement
ration, which is the passive relaxation of the muscles • Appears labored
of inspiration. It must be recognized, however, that a • May take several attempts to clear airway
patient may not have an effective cough because of
inadequate laryngeal control (refer to Chapter 7, Nonfunctional: Severe i m p a i r m e n t :
Muscles of the Larynx) or low vital capacity. • No clearance of airway
• No expulsion of air
Grades • Cough attempt may be nothing more than an
The usual muscle test grades do not apply here, and effort to clear the throat
the following scale to assess cough is used:
Zero: C o u g h is a b s e n t .
Functional: N o r m a l or only slight i m p a i r m e n t :
• Crisp or explosive expulsion of air
• Volume is sharp and clearly audible
• Able to clear airway of secretions
Table 3-6 MUSCLES OF FORC:ED EXPIRATION
I.D. Muscle Origin Insertion
110 Obliquus externus Ribs 5-12 (interdigitating on Iliac crest (outer border)
abdominis external and inferior surfaces) Linea alba
Aponeurosis from 9th costal
111 Obliquus internus Iliac crest (anterior 2/3 of cartilage to ASIS; both sides
abdominis intermediate line) meet at midline to form linea
Thoracolumbar fascia alba
112 Transverse abdominis Inguinal ligament (lateral 2/3 of Pubic symphysis (upper border)
upper aspect)
113 Rectus abdominis Ribs 9-12 (inferior border and
Inguinal ligament (lateral 1/3) cartilages by digitations that
103 Intercostales interni Iliac crest (anterior 2/3, inner lip) appear continuous with internal
130 Latissimus dorsi Thoracolumbar fascia intercostals)
Ribs 7-12 (costal cartilages Ribs 7-9 (cartilages)
Other interdigitate with diaphragm) Aponeurosis to linea alba
106 Transversus thoracis Pubic crest and pecten pubis
Arises via two tendons:
Linea alba (blends with broad
Lateral: pubic crest (tubercle) aponeurosis)
and pecten pubis Pubic crest and pecten pubis
Medial: symphysis pubis (to form falx inguinalis)
(ligamentous covering)
Ribs 5-7 (costal cartilages)
Ribs 1-11 (inner surface)
Sternum (anterior) Costoxiphoid ligaments
Internal intercostal membrane
Ribs 2-12 (upper border of rib
T6-T12 and all lumbar and sacral below rib of origin
vertebrae (spinous processes via
supraspinous ligaments) Humerus (floor of intertubercular
Iliac crest (posterior) sulcus)
Thoracolumbar fascia Deep fascia of arm
Ribs 9-12 (interdigitates with
external abdominal oblique)
Chapter 3 / Testing the Muscles of the Trunk 59
FORCED EXPIRATION
The Functional Anatomy of Coughing
Cough is an essential procedure to maintain airway pa- and laryngeal walls collapse because of the strong com-
tency and to clear the pharynx and bronchial tree when pression of the lungs, causing an invagination so that the
secretions accumulate. A cough may be a reflex or volun- high linear velocity of the airflow moving past and
tary response to irritation anywhere along the airway through these tissues dislodges mucus or foreign particles,
downstream from the nose. thus producing an effective cough.
The cough reflex occurs as a result of stimulation of The three phases of cough—inspiration, compression,
the mucous membranes of the pharynx, larynx, trachea, and forced expiration—are mediated by the muscles of
or bronchial tree. These tissues are so sensitive to light the thorax and abdomen as well as those of the pharynx,
touch that any foreign matter or other irritation initiates larynx, and tongue. The deep inspiratory effort is sup-
the cough reflex. The sensory (afferent) limb of the reflex ported by the diaphragm, intercostals, and arytenoid
carries the impulses set up by the irritation via the glos- abductor muscles (the posterior cricoarytenoids), per-
sopharyngeal and vagus cranial nerves to the fasciculus mitting inhalation of upward of 1.5 liters of air.6 The
solitarius in the medulla, from which the motor impulses palatoglossus and styloglossus elevate the tongue and
(efferent) then move out to the muscles of the pharynx, close off the oropharynx from the nasopharynx.
palate, tongue, and larynx and to the muscles of the ab-
dominal wall and chest and the diaphragm. The reflex re- The compression phase requires the lateral cricoary-
sponse is a deep inspiration (about 2.5 liters of air) fol- tenoid muscles to adduct and close the glottis.
lowed quickly by a forced expiration, during which the
glottis closes momentarily, trapping air in the lungs.3 The The strong expiratory movement is augmented by
diaphragm contracts spasmodically, as do the abdominal strong contractions of the thorax muscles, particularly the
muscles and intercostal muscles. This raises the intratho- latissimus dorsi and the oblique and transverse abdomi-
racic pressure (to above 200 mm H g ) until the vocal nal muscles. The abdominal muscles raise intra-abdominal
cords are forced open, and the explosive outrush of air pressure, forcing the relaxing diaphragm up and drawing
expels mucus and foreign matter. The expiratory airflow the lower ribs down and medially. Elevation of the
at this time may reach a velocity of 75 mph or higher.s diaphragm raises the intrathoracic pressure to about 200 mm
Important to the reflex action is that the bronchial tree H g , and the explosive expulsion phase begins with
forced abduction of the glottis.
REFERENCES
Cited References Donisch EW, Basmajian JV. Electromyography of deep back
muscles in man. Am J Anat 133:25-36, 1972.
1. Carlson B. Normal chest excursion. Phys Ther 53:10-14,
1973. Frownfelter D L . Chest Physical Therapy and Pulmonary
Rehabilitation. Chicago: Year Book, 1987.
2. Wade OL. Movements of the thoracic cage and diaphragm
in respiration. J Physiol (Lond) 124:193-212, 1954. Frownfelter D L . Principles and Practices of Cardiopulmonary
Physical Therapy, 3rd ed. St Louis: CV Mosby, 1996.
3. Stone DJ, Keltz H. Effect of respiratory muscle dysfunction
on pulmonary function. Am Rev Respir Dis 88:621-629, Irwin S, Tecklin JS. Cardiopulmonary Physical Therapy. St Louis:
1964. CV Mosby, 1995.
4. Dail CW. Muscle breathing patterns. Med Art Sci Lehman GJ, McGill SM. Quantification of the differences
10:2-8, 1956. in electromyographic activity magnitude between the
upper and lower portions of the rectus abdominis muscles
5. Guyton A C , Hall J E . Textbook of Medical Physiology, 10th during selected trunk exercises. Phvs Ther 81:1096-1101,
ed. Philadelphia: W.B. Saunders, 2000. 2001.
6. Starr JA. Manual techniques of chest physical therapy and Polkey M I , Harris M L , Hughes PD, et al. The contractile
airway clearance techniques. In Zadai C C . Pulmonary properties of the elderly human diaphragm. Am J Respir
Management in Physical Therapy. New York: Churchill- Crit Care Med 155:1560-1564, 1997.
Livingstone, 1992.
Waters R L , Morris J M . Electrical activity of muscles of the
Other Readings trunk during walking. J Anat 111:191-199, 1972.
Catton WT, Gray JE. Electromyographic study of the action
of the serratus anterior in respiration. J Anat 85:412P,
1951.
60 Chapter 3 / Testing the Muscles of the Trunk
CHAPTER 4
Testing the
Muscles of the
Upper Extremity
Scapular Abduction and Elbow Extension
Upward Rotation Forearm Supination
Forearm Pronation
Scapular Elevation Wrist Flexion
Wrist Extension
Scapular Adduction Finger MP Flexion
Finger PIP and DIP
Scapular Depression and
Adduction Flexion
Finger MP Extension
Scapular Adduction and Finger Abduction
Downward Rotation Finger Adduction
Thumb MP and IP Flexion
Shoulder Flexion Thumb MP and IP
Shoulder Extension Extension
Thumb Abduction
Shoulder Scaption Thumb Adduction
Thumb Opposition
Shoulder Abduction Little Finger Opposition
Shoulder Horizontal
Abduction
Shoulder Horizontal
Adduction
Shoulder External
Rotation
Shoulder Internal
Rotation
Elbow Flexion
PLATE 2
62 Chapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR ABDUCTION AND UPWARD ROTATION
(Serratus anterior)
FIGURE 4-2
FIGURE 4-1
*Arrow indicates level of cross section. FIGURE 4-3*
Chapter 4 / Testing the Muscles of the Upper Extremity 63
SCAPULAR ABDUCTION AND UPWARD ROTATION
(Serratus anterior)
Table 4-1 S C A P U L A R ABDU CTION AND U P W A R D ROTATION
I.D. Muscle Origin Insertion
128 Serratus anterior R i b s 1-8 a n d o f t e n 9 a n d 10 ( b y Scapula (ventral surface of
digitations along a curved line) vertebral border)
Intercostal fascia 1st digitation (superior angle)
Aponeurosis of intercostals 2nd to 4th digitations
(costal surface of entire
Other Pectoralis minor vertebral border)
129 Lower 4th or 5th digitations
(costal surface of inferior angle)
(See also Plate 3, page 85.)
T h e serratus often is graded incorrectly, perhaps be- processes. T h e inferior angle is tucked i n . If the
cause the muscle arrangement and the bony move- i n f e r i o r angle of the scapula is tilted away f r o m
ment are u n l i k e those of axial s t r u c t u r e s . T h e test the rib cage, check for tightness of the pectoralis
procedure here is recommended as sound in that it is m i n o r , weakness of the trapezius, and spinal de-
in keeping w i t h k n o w n kinesiologic and pathokinesi- formity.
ologic principles. T h e scapular muscles, however, do
need further dynamic testing with electromyography T h e most prominent abnormal posture of the
( E M C i ) , magnetic resonance imaging ( M R I ) , and scapula is " w i n g i n g , " in which the vertebral bor-
other modern technology before completely reliable der t i l t s away f r o m the r i b cage, a sign indicative
functional diagnoses can be made. of serratus weakness. Other abnormal postures
are adduction and downward rotation.
T h e supine position, although best for isolating 2. Scapular range of motion. W i t h i n the total arc of
the serratus, is not recommended at any grade level. 180° of shoulder forward flexion, 120° is gleno-
T h e supine position allows too much substitution humeral m o t i o n , and 6 0 ° is scapular motion. T h i s
that may not be noticeable. T h e table gives added
stabilization to the scapula so that it does not
" w i n g " and protraction of the arm may be per-
formed by the pectoralis minor, levator scapulae, or
rhomboids.
Preliminary Examination FIGURE 4-4
Observation of the scapulae, both at rest and during
active and passive shoulder f l e x i o n , is a routine part of
the test. Examine the patient in short sitting posi-
tion with hands in lap.
Palpate the vertebral borders of both scapulae
w i t h the t h u m b s ; place the web of the t h u m b below
the inferior angle; the fingers extend around the axil-
lary borders (Figure 4 - 4 ) .
Specific Elements
1. Position and symmetry of scapula. D e t e r m i n e the
position of the scapulae at rest and whether the
t w o sides are symmetrical.
T h e n o r m a l scapula l i e s close t o the r i b cage
with the vertebral border nearly parallel to and
from 1 to 3 inches lateral to the spinous
64 (Ihapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR ABDUCTION AND UPWARD ROTATION
(Serratus anterior)
Preliminary Examination Continued
is true, however, if the two motions are consid- FIGURE 4-5
ered as isolated functions, but they do not work
as such. It would be more correct to say that the winging), the patient will not be able to flex the
glenohumeral and scapular motions are in syn- arm above 90°. Proceed to tests described for
chrony after 60° and up to 150°. Grades 2, 1, and 0.
Passively raise the test arm in forward flexion The serratus anterior never can be graded
completely above the head to determine scapular higher than the grade given to shoulder flexion. If
mobility. The scapula should start to rotate at the patient has a weak deltoid, the lever for test-
about 60°, although there is considerable individ- ing is gone, and the arm cannot be used to apply
ual variation. Scapular rotation continues until resistance.
about - 2 0 ° to 30° from full flexion. 5. Presence of a weak triceps brachii. If the triceps is
weak, supinate the forearm, or manually assist the
Check that the scapula basically remains in its elbow to maintain its extended position. In either
rest position at ranges of shoulder flexion less case, do not assist humeral flexion.
than 60° (the position is variable among subjects).
If the scapula moves as the glenohumeral joint
moves below 60°, that is, if in this range they
move as a unit, there is limited glenohumeral mo-
tion. Above 60° and to about 150° or 160° in
both active and passive motion, the scapula moves
in concert with the humerus.
3. The serratus always should be tested in shoulder
flexion to minimize the synergy with the trapezius.
If the scapular position at rest is normal, ask the
patient to raise the test arm above the head in the
sagittal plane. If the arm can be raised well above
90° (glenohumeral muscles must be at least Grade
3), observe the direction and amount of scapular
motion that occurs. Normally, the scapula rotates
forward in a motion that is controlled by the
serratus, and if erratic or "discoordinate" motion
occurs, the serratus is most likely weak. The nor-
mal amount of motion of the vertebral border
from the start position is about the breadth of
two fingers (Figure 4 - 5 ) . If the patient is able to
raise the arm with simultaneous rhythmical scapu-
lar upward rotation, proceed with the test se-
quence for Grades 5 and 4.
4. Scapula abnormal position at rest. If the scapula is
positioned abnormally at rest (i.e., adducted or
Chapter 4 / Testing the Muscles of the Upper Extremity 65
SCAPULAR ABDUCTION AND UPWARD ROTATION
(Serratus anterior)
Grade 5 (Normal) and Grade 4 (Good) Grade 3 (Fair)
Position of Patient (All Grades): Short sitting, Positions of Patient and Therapist: Same as for
over end or side of table. Hands on lap. Grade 5 test.
Position of Therapist: Standing at test side of pa- Test: Patient raises the arm to approximately 130° of
tient. Hand giving resistance is on the arm proximal flexion with the elbow extended (Figure 4-7).
to the elbow (Figure 4 - 6 ) . The other hand uses the
web space along with the thumb and index finger to Instructions to Patient: "Raise your arm forward
palpate the edges of the scapula at the inferior angle above your head."
and along the vertebral and axillary borders.
Grading
Test: Patient raises arm to approximately 130° of
flexion with the elbow extended. (Examiner is re- Grade 3 (Fair): Scapula moves through full range of
minded that the arm can be elevated up to 60° motion without winging but can tolerate no resis-
without using the serratus.) The scapula should up- tance other than the weight of the arm.
wardly rotate (glenoid facing up) and abduct without
winging.
Instructions to Patient: "Raise your arm forward
over your head. Keep your elbow straight; hold it!
Don't let me push your arm down."
Grading
Grade 5 (Normal): Scapula maintains its abducted
and rotated position against maximal resistance given
on the arm just above the elbow in a downward
direction.
Grade 4 (Good): Scapular muscles " g i v e " or " y i e l d "
against maximal resistance given on the arm. The
glenohumeral joint is held rigidly in the presence of a
strong deltoid, but the serratus yields, and the
scapula moves in the direction of adduction and
downward rotation.
FIGURE 4-7
FIGURE 4-6
66 Chapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR ABDUCTION AND UPWARD ROTATION
(Serratus anterior)
Alternate Test (Grades 5, 4, and 3) Grade 2 (Poor)
Position of Patient: Short sitting with arm forward Position of Patient: Short sitting with arm flexed
flexed to about 130° and then protracted in that above 90° and supported by examiner.
plane as far as it can move.
Position of Therapist: Standing at test side of pa-
Position of Therapist: Standing at test side of pa- tient. One hand supports the patient's arm at the el-
tient. Hand used for resistance grasps the forearm bow, maintaining it above the horizontal (Figure 4-8).
just above the wrist and gives resistance in a down- The other hand is placed at the inferior angle of the
ward and backward direction. The other hand stabi- scapula with the thumb positioned along the axillary
lizes the trunk just below the scapula on the same border and the fingers along the vertebral border
side; this prevents trunk rotation. (see Figure 4 - 8 ) .
The examiner should select a spot on the wall or Test: Therapist monitors scapular motion by using a
ceiling that can serve as a target for the patient to reach light grasp on the scapula at the inferior angle.
toward in line with about 130° of flexion. Therapist must be sure not to restrict or resist mo-
tion. The scapula is observed to detect winging.
Test: Patient abducts and upwardly rotates the scapula
by protracting and elevating the arm to about 130° of Instructions to Patient: "Hold your arm in this po-
flexion. The patient then holds against maximal sition" (i.e., above 90°). "Tet it relax. Now hold
resistance. your arm up again. Let it relax."
Instructions to Patient: "Bring your arm up, and Grading
reach for the target on the wall."
Grade 2 (Poor): If the scapula abducts and rotates
Grading upward as the patient attempts to hold the arm in
the elevated position, the weakness is in the gleno-
Same as for primary test. humeral muscles. The serratus is awarded a grade of
2. The serratus is graded 2- (Poor-) if the scapula
does not smoothly abduct and upwardly rotate with-
out the weight of the arm or if the scapula moves
toward the vertebral spine.
FIGURE 4-8
Chapter 4 / Testing the Muscles of the Upper Extremity 67
SCAPULAR ABDUCTION AND UPWARD ROTATION
(Serratus anterior)
Grade 1 (Trace) and Grade 0 (Zero) Test: Patient attempts to hold the arm in the test
position.
Position of Patient: Short sitting with arm forward
flexed to above 90° (supported by therapist). Instructions to Patient: "Try to hold your arm in
this position."
Position of Therapist: Standing in front of and slight-
ly to one side of patient. Support the patient's arm Grading
at the elbow, maintaining it above 90° (Figure 4-9).
Use the other hand to palpate the serratus with Grade 1 (Trace): Muscle contraction is palpable.
the tips of the fingers just in front of the inferior
angle along the axillary border (Figure 4 - 9 ) . Grade 0 (Zero): No contractile activity.
FIGURE 4-9
68 Chapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR ELEVATION
(Trapezius, upper fibers)
FIGURE 4-11
POSTERIOR
FIGURE 4-10
FIGURE 4-12
Chapter 4 / Testing the Muscles of the Upper Extremity 69
SCAPULAR ELEVATION
(Trapezius, upper fibers)
Table 4-2 SCAPULAR ELEVATION
I.D. Muscle Origin Insertion
124 Trapezius (upper fibers) Clavicle (posterior border of
Occiput (external protuberance lateral 1/3)
127 Levator scapulae and superior nuchal line, medial
1/3) Scapula (vertebral border
Ligamentum nuchae between superior angle and
C7 vertebrae (spinous process) root of scapular spine)
C1-C4 vertebrae (transverse (See also Plate 3, page 85.)
processes)
Other Rhomboid major
125 Rhomboid minor
126
Grade 5 (Normal) and Grade 4 (Good) Instructions to Patient: "Shrug your shoulders."
OR "Raise your shoulders toward your ears. Hold it.
Position of Patient: Short sitting over end or side Don't let me push them down."
of table. Hands relaxed in lap.
Grading
Position of Therapist: Stand behind patient. Hands
contoured over top of both shoulders to give resis- Grade 5 (Normal): Patient shrugs shoulders through
tance in a downward direction. available range of motion and holds against maximal
resistance (Figure 4 - 1 4 ) .
Test: It is important to examine the patient's shoul-
ders and scapula from a posterior view and to note Grade 4 (Good): Patient shrugs shoulders against
any asymmetry of shoulder height, muscular bulk, or strong to moderate resistance. The shoulder muscles
scapular winging. This kind of asymmetry is common may "give" at the end point.
and can be caused by carrying purses or briefcases
habitually on one side (Figure 4 - 1 3 ) .
Patient elevates ("shrugs") shoulders. In the sit-
ting position, the test is almost always performed on
both sides simultaneously.
FIGURE 4-13 FIGURE 4-14
70 Chapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR ELEVATION
(Trapezius, upper fibers)
Alternate Test Procedure Substitution by Rhomboids
In the sitting position, ask the patient to elevate one In patients with weak shoulder elevators, the
shoulder while the head, with the face turned away, rhomboids may attempt to substitute (whereas
is flexed laterally and down toward the shoulder (oc- normally they assist). In such cases, during unsuc-
ciput leading). The occiput at full range will approxi- cessful attempts to shrug the shoulder the inferior
mate the acromion. The examiner gives resistance at the angle of the scapula will move medially toward
shoulder in the direction of depression and si- the vertebral spine (scapular adduction), and
multaneously against the occiput in the anteromedial downward motion (rotation) also may occur.
direction. If the upper trapezius is weak, the
acromion will not meet the occiput.1
Helpful Hints • In the prone position, the turned head offers a
disadvantage. When the face is turned to either
• If the sitting position for testing is contraindi- side, there is more trapezius activity and less
cated for any reason, the tests for Grade 5 and levator activity on that side.
Grade 4 in the supine position will be quite inac-
curate. If the Grade 3 test is done in the supine • Use the same lever (hand placement for resist-
position, it will at best require manual resistance ance) in all subsequent scapular testing.
because gravity is neutralized.
• If the prone position is not comfortable, the tests
for Grades 2, 1, and 0 may be performed with
the patient supine, but palpation in such cases
will be less than optimal.
72 Chapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR ADDUCTION
(Trapezius, lower fibers)
FIGURE 4-18
FIGURE 4-17
FIGURE 4-19
Chapter 4 / Testing the Muscles of the Upper Extremity 73
SCAPULAR ADDUCTION
(Trapezius, middle fibers)
Table 4-3 S C A P U L A R ADDUCTIO N (RETRACTION)
I.D. Muscle Origin Insertion
Scapula (medial acromial
124 Trapezius (middle fibers) T1-T5 vertebrae (spinous margin and superior lip of crest
125 Rhomboid major processes) on scapular spine)
Supraspinous ligaments Scapula (vertebral border
between root of spine and
T2-T5 vertebrae (spinous inferior angle)
processes and supraspinous
ligaments) (See also Plate 3, page 85.)
Other Rhomboid minor
126 Trapezius (upper and lower)
124 Levator scapulae
127
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)
P o s i t i o n o f P a t i e n t : P r o n e w i t h shoulder a t edge o f 1. W h e n the posterior deltoid is Grade 3 or better:
table. Shoulder is abducted to 90°. E l b o w is flexed T h e hand for resistance is placed over the distal
to a right angle (Figure 4 - 2 0 ) . Head may be turned to end of the h u m e r u s , and resistance is directed
either side for comfort. downward toward the floor (see F i g u r e 4 - 2 0 ) . T h e
w r i s t also may be used for a longer lever, but the
Alternatively, elbow may be fully extended pro- lever selected should be maintained consistently
vided the elbow extensor muscles are s t r o n g enough throughout the test.
to stabilize the elbow on the humerus.
2. W h e n the posterior deltoid is Grade 2 or less:
P o s i t i o n of T h e r a p i s t : Stand at test side close to pa- Resistance is given in a downward direction (to-
t i e n t ' s a r m . S t a b i l i z e the contralateral scapular area to ward floor) with the hand contoured over the
prevent t r u n k r o t a t i o n . T h e r e are t w o ways to give shoulder joint (Figure 4-21). T h i s placement of re-
resistance; one does not require as much strength as sistance requires less adductor muscle strength by
the other. the patient than is needed in the test described in
the preceding paragraph.
FIGURE 4-20 FIGURE 4-21
74 Chapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR ADDUCTION
(Trapezius, middle fibers)
Grade 5 (Normal), Grade 4 (Good), Grade 2 (Poor), Grade 1 (Trace),
and Grade 3 (Fair) Continued and Grade 0 (Zero)
The fingers of the other hand can palpate the Position of Patient and Therapist: Same as for
middle fibers of the trapezius at the spine of the Normal test except that the therapist uses one hand
scapula from the acromion to the vertebral column if to cradle the patient's shoulder and arm, thus sup-
necessary (Figure 4 - 2 2 ) . porting its weight (Figure 4 - 2 3 ) , and the other hand
for palpation.
Test: Patient horizontally abducts arm and adducts
scapula. Test: Same as that for Grades 5 to 3.
Instructions to Patient: "Lift your elbow toward Instructions to Patient: "Try to lift your elbow
the ceiling. Hold it. Don't let me push it down." toward the ceiling."
Grading Grading
Grade 5 (Normal): Completes available scapular ad- Grade 2 (Poor): Completes full range of motion
duction range and holds end position against maxi- without the weight of the arm.
mal resistance.
Grade 1 (Trace) and Grade 0 (Zero): A Grade 1
Grade 4 (Good): Tolerates strong to moderate resis- (Trace) muscle exhibits contractile activity or slight
tance. movement. There will be neither motion nor con-
tractile activity in the Grade 0 (Zero) muscle.
Grade 3 (Fair): Completes available range but with-
out manual resistance (see Figure 4 - 2 2 ) .
FIGURE 4-22 FIGURE 4-23
Chapter 4 / Testing the Muscles of the Upper Extremity 75
SCAPULAR ADDUCTION
(Trapezius, middle fibers)
Alternate Test for Grades 5, 4, and 3 Substitutions
Position of Patient: Prone. Place scapula in full ad- • By the rhomboids: The rhomboids can substitute
duction. Arm is in horizontal abduction (90°) with for the trapezius in adduction of the scapula. They
shoulder externally rotated and elbow fully extended. cannot, however, substitute for the upward
rotation component. When substitution by the
Position of Therapist: Stand near shoulder on test rhomboids occurs, the scapula will adduct and
side. Stabilize the opposite scapular region to avoid rotate downward.
trunk rotation. For Grades 5 and 4, give resis-
tance toward the floor at the distal humerus or at • By the posterior deltoid: If the scapular muscles
the wrist, maintaining consistency of location of are absent and the posterior deltoid acts alone,
resistance. horizontal abduction occurs at the shoulder joint
but there is no scapular adduction.
Instructions to Patient: "Keep your shoulder blade
close to the spine. Don't let me draw it away."
Test: Patient maintains scapular adduction.
Helpful Hint scapula in adduction as the examiner slowly releases
the shoulder support. Observe whether the scapula
When the posterior deltoid muscle is weak, support maintains its adducted position. If it does, it is
the patient's shoulder with the palm of one hand, and Grade 3.
allow the patient's elbow to flex. Passively
move the scapula into adduction via horizontal ab-
duction of the arm. Have the patient hold the
76 Chapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR DEPRESSION AND ADDUCTION
(Trapezius, lower fibers)
FIGURE 4-25
FIGURE 4-24
FIGURE 4-26
Chapter 4 / Testing the Muscles of the Upper Extremity 77
SCAPULAR DEPRESSION AND ADDUCTION
(Trapezius, lower fibers)
Table 4 - 4 S C A P U L A R D E P R E S SI O N A N D A D D U C T I O N
I.D. Muscle Origin Insertion
124 Trapezius (middle and T1-T5 vertebrae (spinous Scapula (spine, medial end and
lower fibers) processes) tubercle at lateral apex via
Supraspinous ligament aponeurosis)
T6-T12 vertebrae (spinous
processes)
Other Latissimus dorsi
130 Pectoralis major
131 Pectoralis minor
129
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)
Position of Patient: Prone with test arm over head to Test: Patient raises arm from the table to at least ear
about 145° of abduction (in line with the fibers of level and holds it strongly against resistance.
the lower trapezius). Forearm is in midposition with Alternatively, preposition the arm in elevation diago-
the thumb pointing toward the ceiling. Head may be nally over the head and ask the patient to hold it
turned to either side for comfort. strongly against resistance.
Position of Therapist: Stand at test side. Hand giv- Instructions to Patient: "Raise your arm from the
ing resistance is contoured over the distal humerus table as high as possible. Hold it. Don't let me push
just proximal to the elbow (Figure 4-27). Resistance it down."
will be given straight downward (toward the floor).
For a less rigorous test, resistance may be given over Grading
the axillary border of the scapula.
Grade 5 (Normal): Completes available range and
Fingertips of the opposite hand palpate (for Grade holds it against maximal resistance. This is a strong
3) below the spine of the scapula and across to the muscle.
thoracic vertebrae, following the muscle as it curves
down to the lower thoracic vertebrae. Grade 4 (Good): Takes strong to moderate resis-
tance.
Grade 3 (Fair): Same procedure is used, but patient
tolerates no manual resistance (Figure 4-28).
FIGURE 4-27 FIGURE 4-28
78 Chapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR DEPRESSION AND ADDUCTION
(Trapezius, lower fibers)
Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)
Position of Patient: Same as for Grade 5. Grading
Position of Therapist: Stand at test side. Support Grade 2 (Poor): Completes full scapular range of
patient's arm under the elbow (Figure 4 - 2 9 ) . motion without the weight of the arm.
Test: Patient attempts to lift the arm from the table. Grade 1 (Trace): Contractile activity can be palpated
If the patient is unable to lift the arm because of a in the triangular area between the root of the spine
weak posterior and middle deltoid, the examiner of the scapula and the lower thoracic vertebra
should lift and support the weight of the arm. ( T 7 - T 1 2 ) , that is, the course of the fibers of the
lower trapezius.
Instructions to Patient: "Try to lift your arm from
the table past your ear." Grade 0 (Zero): No palpable contractile activity.
FIGURE 4-29 Helpful Hints
• If shoulder range of motion is limited in flexion
and abduction, the patient's arm should be po-
sitioned over the side of the table and sup-
ported by the examiner at its maximal range of
elevation as the start position.
• Examiners are reminded of the test principle that
the same lever arm must be used in se-
quential testing (over time) for valid compari-
son of results.
Chapter 4 / Testing the Muscles of the Upper Extremity 79
SCAPULAR ADDUCTION AND DOWNWARD ROTATION
(Rhomboids)
FIGURE 4-31
POSTERIOR
FIGURE 4-30
FIGURE 4-32
80 Chapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR ADDUCTION AND DOWNWARD ROTATION
(Rhomboids)
Table 4-5 S C A P U L A R A D D UC T I O N A N D D O W N W A R D ROTATION
I.D. Muscle Origin Insertion
Scapula (vertebral border
125 Rhomboid major T2-T5 vertebrae (spinous between root of spine and
processes) inferior angle)
126 Rhomboid minor Supraspinous ligaments Scapula (vertebral margin at
root of spine)
C7-T1 vertebrae (spinous
processes) (See also Plate 3, page 85.)
Ligamentum nuchae (lower)
Other Levator scapulae
127
The test for the rhomboid muscles has become the trapezius and the pectoralis minor. Innervated only
focus of some clinical debate. Kendall and co-workers by C5, a test for the rhomboids, correctly conducted,
claim, with good evidence, that these muscles fre- can confirm or rule out a cord lesion at this level. With
quently are underrated; that is, they are too often these issues in mind, the authors present first their
graded at a level less than their performance.1 At method and then, with the generous permission of
issue also is the confusion that can occur in separating Mrs. Kendall, her rhomboid test as another method
the function of the rhomboids from those of other of assessment.
scapular or shoulder muscles, particularly the
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)
Position of Patient: Prone. Head may be turned Position of Therapist: Stand at test side. When
to either side for comfort. Shoulder is internally rotat- the shoulder extensor muscles are Grade 3 or higher,
ed and the arm is adducted across the back with the hand used for resistance is placed on the humerus
the elbow flexed and hand resting on the back just above the elbow, and resistance is given in a
(Figure 4 - 3 3 ) . downward and outward direction (Figure 4 - 3 4 ) .
FIGURE 4-33 FIGURE 4-34
Chapter 4 / Testing the Muscles of the Upper Extremity 81
SCAPULAR ADDUCTION AND DOWNWARD ROTATION
(Rhomboids)
Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair) Continued
When the shoulder extensors are weak, place the Grading
hand for resistance along the axillary border of the
scapula (Figure 4 - 3 5 ) . Resistance is applied in a down- Grade 5 (Normal): Completes available range and
ward and outward direction. holds against maximal resistance (Figure 4 - 3 6 ) . The
fingers will "pop o u t " from under the scapula when
The fingers of the hand used for palpation are strong rhomboids contract.
placed deep under the vertebral border of the scapula.
Test: Patient lifts the hand off the back, maintaining Grade 4 (Good): Completes range and holds against
the arm position across the back at the same time strong to moderate resistance. Fingers usually will
the examiner is applying resistance above the elbow. "pop out."
With strong muscle activity, the therapist's fingers will
" p o p " out from under the edge of the scapular ver- Grade 3 (Fair): Completes range but tolerates no
tebral border (see Figure 4 - 3 3 ) . manual resistance (Figure 4 - 3 7 ) .
Instructions to Patient: "Lift your hand. Hold it.
Don't let me push it down."
FIGURE 4-36
FIGURE 4-35
FIGURE 4-37
82 Chapter 4 / Testing the Muscles of the Upper Extremity
SCAPULAR ADDUCTION AND DOWNWARD ROTATION
(Rhomboids)
Grade 2 (Poor), Grade 1 (Trace), Alternate Test for Grades 2, 1, and 0
and Grade 0 (Zero)
Position of Patient: Prone with shoulder in about
Position of Patient: Short sitting with shoulder in- 45° of abduction and elbow at about 90° of flexion
ternally rotated and arm extended and adducted be- with the hand on the back.
hind back. (Figure 4 - 3 8 ) .
Position of Therapist: Stand at test side and sup-
Position of Therapist: Stand at test side; support port test arm by cradling it under the shoulder
arm by grasping the wrist. The fingertips of one (Figure 4 - 3 9 ) . Fingers used for palpation are placed
hand palpate the muscle under the vertebral border firmly under the vertebral border of the scapula.
of the scapula.
Test: Patient attempts to lift hand from back.
Test: Patient attempts to move hand away from
back. Instructions to Patient: "Try to lift your hand away
from your back." OR "Lift your hand toward the
Instructions to Patient: "Try to move your hand ceiling."
away from your back."
Grading
Grading
Grade 2 (Poor): Completes partial range of scapular
Grade 2 (Poor): Completes range of scapular m o - motion.
tion.
Grades 1 (Trace) and 0 (Zero): A Grade 1 (Trace)
Grades 1 (Trace) and 0 (Zero): A Grade 1 muscle muscle has some palpable contractile activity. A
has palpable contractile activity. A Grade 0 muscle Grade 0 muscle shows no contractile response.
shows no response.
FIGURE 4-39
FIGURE 4-38
Chapter 4 / Testing the Muscles of the Upper Extremity 83
SCAPULAR ADDUCTION AND DOWNWARD ROTATION
(Rhomboids)
Alternate Rhomboid Test After Kendall1 Test: Examiner tests the ability of the patient to hold
the scapula in its position of adduction, elevation,
As a preliminary to the rhomboid test, the shoulder and downward rotation (glenoid down).
adductors should be tested and found sufficiently
strong to allow the arm to be used as a lever. Instructions to Patient: " H o l d your arm as I have
placed it. Do not let me pull your arm forward." OR
Position of Patient: Prone with head turned to side "Hold the position you are in; keep your shoulder
of test. Nontest arm is abducted with elbow flexed. blade against your spine as I try to pull it away."
Test arm is near the edge of the table. Arm Substitution by Middle
(humerus) is fully adducted and held firm to the side Trapezius
of the trunk in external rotation and some extension
with elbow fully flexed. In this position the scapula is The middle fibers of the trapezius can substitute
in adduction, elevation, and downward rotation (gle- for the adduction component of the rhomboids.
noid down). The middle trapezius cannot, however, substitute
for the downward rotation component. When sub-
Position of Therapist: Stand at test side. One hand stitution occurs, the patient's scapula will adduct
used for resistance is cupped around the flexed with no downward rotation (no glenoid down oc-
elbow. The resistance applied by this hand will be in curs). Only palpation can detect this substitution
the direction of scapular abduction and upward rota- for sure.
tion (out and up; Figure 4 - 4 0 ) . The other hand is
used to give resistance simultaneously. It is contoured
over the shoulder joint and gives resistance caudally
in the direction of shoulder depression.
Helpful Hint
When the rhomboid test is performed with the
hand behind the back, never allow the patient to
lead the lifting motion with the elbow because
this will activate the humeral extensors.
FIGURE 4-40
84 Chapter 4 / Testing the Muscles of the Upper Extremity
PLATE 3
Chapter 4 / Testing the Muscles of the Upper Extremity 85
SHOULDER FLEXION
(Anterior Deltoid and Coracobrachial*)
ANTERIOR FIGURE 4-42
FIGURE 4-41
FIGURE 4-43
T h e coracobrachial 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.
86 Chapter 4 / Testing the Muscles of the Upper Extremity