Manual musle testing

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Manual musle testing

  1. 1. Muscle Testing of the Upper and Lower Extremities Physiotherapy Division Dr. Mikhled Maayah
  2. 2. Guide muscle testing• This guide was developed out of a need to assist the therapist in utilizing a standard method of muscle testing in patients at this facility.• It is based on the denials and Worthingham method of muscle testing.• It was originally developed approximately a long time ago as a procedure to assist physiotherapy students who working with the physically disabled.• Since that time it has been utilized by staff, who have given suggestions over a period of years to make it more meaningful and useful to gain proficiency and consistency in muscle testing.
  3. 3. Introduction• The general direction of treatment today is to consider the whole patient in terms of what we do to help him gain maximum recovery and independence.• To accomplish this we must think of him in terms of his status at the beginning of treatment, the prognosis, the plan of treatment and the progress noted under this plan.• It should be a matter of professional pride that we be able to provide accurate and meaningful information, when it is requested of us.
  4. 4. Introduction- continueAs therapists, we consider muscle evaluations from two points of view:• For our use own as guides to planning of specific treatment routines and to determine the success or failure of these routines.• To provide the physicians with whom we work with information which will be helpful to them in: – diagnosis – prescription for treatment – prescription for bracing – determination of progress and prognosis.
  5. 5. Introduction- continue• There are certain specific things which we want to knew. These are: – Is the muscle active? – Is the muscle functional? – How functional is it? – Is spasticity present? – What substitute patterns are present? – What positions the patients assumes at rest? – What positions the patients assumes on activity? – What deformities are present and to what degree? – What stage of motor development has been reached? – What are the specific motor handicaps which keep him developing more rapidly or becoming more independent?
  6. 6. Introduction- continue• In addition, the therapist must be able to convey to the patient what is expected of him in a testing procedure and then be able to record the results of the test in concise way.• Testing by a well trained therapist saves time for the physician and can be great help to him.• Objective testing done at stated intervals serves not only to record progress, or lack of it, but gives us an excellent opportunity to evaluate the technique used.• It also gives information needed to report intelligently to the physician on the status of the patient.
  7. 7. Definition of muscle testA muscle test is an attempt to determine the abilityof a patient to activate skeletal muscle.Available range of motion: this is the passive rangewhich is easily obtained by the examiner withoutfeeling resistance.Example: If passive range measured in elbow flexionis 0 – 90 degree and patient actively moves 0 – 90degree, then he will have moved through completeavailable range of motion.
  8. 8. Muscle test is used as:-• Basis of muscle re-education and exercise.• Determining factor for supportive apparatus.• Aid in determining diagnosis.• Aid in prognosis of a patient.
  9. 9. Requisites for good muscle testing– Knowledge of anatomy as well as functional.– Correct starting position-changes with muscle being tested.– Stabilization of proximal segment and body as a whole.– Area of palpation-knowledge of where and how to palpate.– knowledge of the substitutions muscles (synergic muscles, assisting muscles, direct fixation muscles, indirect fixation muscles and antagonistic muscles).– Recognition of substitution.– Knowledge of normal muscle and muscle groups (action and appearances).– Ability to convey ideas to patient and guide the movement.– Record deformities, limitations in motion, spasticity and tremor, strength within range must be recorded (grade low when in doubt about strength of a muscle).
  10. 10. Terminology• Test Range: is set up for specific test of specify muscle – not necessarily complete ROM.• Easy Test: gravity eliminated test or position that will give you a grade of 0, Trace, Poor -, Poor.• Hard Test: anti-gravity (against), method used to obtain grades from Fair+ to normal.• Palpation: ability of therapist to feel contraction of muscle being tested.• Resistance: applied at the end of ROM, pressure should be applied in a direction as nearly opposite to the line of pull of the muscle or group, as possible.
  11. 11. Muscle grading techniques• Grades are obtained on varies of gravity, gravity eliminated, against gravity, gravity plus manual resistance.• Some grades are obtained by palpation.• Stretch range used for some grades – range beyond neutral position, usually used in rotation.
  12. 12. Grades• The following muscle grades are described in comparison with a normal muscle.• It is important to keep in mind that muscles of normal strength vary in strength tremendously within the body., owing to the size of the muscle and to the work each muscle is normally required to perform.• Normal strength likewise varies between individuals, owing to differences in age and body requirements.• Therefore, in grading muscles above ‘fair’, the degree of objectivity increases with the therapist’s increasing knowledge of normal strength of various age groups and body requirements for that particular muscle, prior to illness or injury.
  13. 13. Grades• Zero (O): No movement of part; contraction cannot be palpated• Trace (T): Contraction can be palpated; no movement of part.• Poor minus (P-): Gravity eliminated, part moves through only a portion of the range of available, not necessarily normal, passive ROM.• Poor (P): Gravity eliminated, part moves through complete available ROM.• Fair: Against gravity, part moves through complete available ROM, but cannot take additional resistance.• Fair Plus (F+): Part moves through complete available ROM against gravity with ‘slight’ resistance (for that muscle) at end of range.• Good (G): Part moves through complete available ROM against gravity and takes “moderately strong” resistance (for that muscle) at end of range.• Normal (N): Part moves through complete available ROM against gravity and takes “strong” resistance (for that muscle) at the end of range.
  14. 14. Recording• All grades below fair are recorded in red for easily identifiable areas of weakness; grades of fair and above are recorded in blue or black ink and dated.• Indicate all muscles not tested during any evaluation by marking “N.T” in the appropriate place.
  15. 15. Outline of technique for administering the manual muscle test• Determine the ROM of joint (joints) passively.• Line up the part with fibers of the muscle to be tested.• Provide adequate stabilization.• Have the patient attempt motion through the test range.• Look at the muscle or movement first.• Palpate at the tendon or muscle belly.• Apply resistance at the end of the range if the muscle is strong enough (Break Test).
  16. 16. Outline of technique for administering the manual muscle test• Resistance should be applied firmly and smoothly in line with direction of the muscle of segment of a muscle being tested.• You may compare the strength of the normal segment with the one being tested to aid in determine the strength grade.• Never give a grade on motion alone. It must possible to palpate the muscle.• Record grade and date and initial the test form.• Normal in relation to muscle testing: normal for are, sex and sounded parts.
  17. 17. Some basic principles1. Take your time.2. Start with a gross observation of function around a joint.3. Patient instruction.4. Be consistent.5. Grading.6. Check yourself.7. Suggested sequence of extremities muscle test.
  18. 18. Some basic principles1. Take your time: – Don’t rush to a conclusion about a grade. – Use plus or minus if patient’s performance is consistent with stated definitions of grades. – If patient’s performance is not consistent with stated definitions, use descriptive terminology, e.g. biceps remains F+ but is taking more resistance than last test.
  19. 19. 2. Start with a gross observation of function around a joint: – Observe the ROM around the joint as it is often a clue to muscle imbalance. – Then observe gross movement around the joint before touching with hands. – Observe muscle atrophy. – Observe and check muscle tone. – The presence of spasticity may negate the value and appropriateness of performing a manual muscle test. – Be aware of sensory deficits as they may affect patient’s ability to follow directions.
  20. 20. 3. Patient instruction: – It is important to give patients all sensory and verbal clues needed for best performance. – This may include: • Demonstrations • Taking part through motion desired • Allowing patient to see part being tested • Allowing practice through muscle re-education techniques (when appropriate) • Using simple instructions.
  21. 21. 4. Be consistent: – Begin by testing the muscle against-gravity, then test in a gravity-eliminated position if muscle is below “Fair”. – Always apply resistance at the end of the motion rather than during the motion. – Resistance is usually applied at the distal end of the part and opposite to the direction of pull.
  22. 22. 5. Grading: – When utilizing the grading system above, examiner must observe proper testing position of the patient for the muscle being tested. – When it is not possible to assume proper testing position, e.g. due to contractures, casts, medical precautions, it is important to determine presence or absence of muscle in question. – In this case, the degree of contraction can be determined as weak or strong, utilizing palpation and observable active motion. – Because some body parts cannot be positioned to work against gravity, the grading of some muscles is modified, as indicated in the procedure to follow. – Recognize that larger muscles would take maximum effort by tester to resist a strong muscle and proportionally less effort for smaller muscles.
  23. 23. The gravity factor in Grading• For other muscles, the gravity free and ant-gravity positions are impractical because gravity may not be an important factor (Finger flexors, toe flexors, forearm pronators and supinators, rotators of the shoulders and hips).• From a mechanical stand-point this is true because the weight of the part is so small in comparison with strength of the muscle.• Foot, hand or their range of motion is much that if the initial position is anti-gravity, the end position is with gravity.• Supinators and pronators could be scored:• Tr : perception of attempted assistance in stretch range
  24. 24. 6. Check yourself on the following factors: – What is the primary action of the muscle being tested? – Is the patient in the proper test position? For example, if patient’s biceps is less than F in a sitting position, have I repositioned for gravity eliminated grading? – Have I stabilized the part proximal to the part on which the muscle acts?
  25. 25. – Have I observed to see that the motion produced is the motion requested, e.g. is there extraneous motion at joints proximal and/or distal to the part being tested?– Have I palpated after observing the motion?– Have I applied resistance in the proper place at the end of motion?– Have I graded, using the proper definition of grades.
  26. 26. 7. Suggested sequence of extremities muscle test• The following suggested sequence first provided to enable the tester to efficiently perform all the tests with the least amount of re-positioning of the patient.• Note that all muscles which can be tested for both above and below F are grouped together.
  27. 27. Suggested sequence of upper extremity muscle testA. UPRIGHT: – Elbow, Forearm, wrist and Hand. – Serratus anterior and pectoral is major (clavicular). – Anterior deltoid – Middle deltoid – Upper trapezius – Latissimus dorsi F+ and above
  28. 28. B. PRONE:• Triceps• External rotators• Internal rotators• Posterior deltoid• Rhomboids• Middle trapezius• Lower trapezius• Latissimus F- and below.
  29. 29. C. Sideling: with weight of arm supported on a smooth board. – Anterior deltoidD. SUPINE – Pectoralis major (sternal) – Triceps (alternate position) support weight. – Elbow flexors (alternate position of arm on smooth Middle deltoid).E. Upright (below Fair): Posterior deltoid Pectoral is major (sternal). External rotators Internal rotators
  30. 30. Suggested sequence of lower extremity muscle test• Turning the patient from one position into another is fatiguing to the patient and wasting for the therapist’s time.• Supine: Toe flexors and extensors, tibialis posterior and anterior, peroneals and triceps.• Side lying: Gluteus medius and minimums adductors, lateral abdominals and tensor fascia lata.• Prone: Hamstrings, gluteus maximums.• Sitting: Quadriceps, internal and external rotators of the hip, iliopsoas, sartorious
  31. 31. Manual Muscle Testing Mikhled Maayah PhD, PTJordan university of science and technology JUST
  32. 32. Neck Manual Muscle Testing
  33. 33. Neck Flexion Sternocleidomatioideus
  34. 34. SternocleidomatioideusOrigin: Anterior and superior manubrium and superior medial third of clavicleInsertion: Lateral aspect of mastoid process and anterior half of superior nuchal lineNerve supply: Axillary N.
  35. 35. Note• Factors Limiting Motion:1- Tension of posterior longitudinal ligament, ligamenta flava, and interspinal and supraspinal ligaments2- Tension of posterior muscles of neck3- Apposition of lower lips of vertebral bodies anteriorly with surfaces of subjacent vertebrae4- Compression of intervertebral fibrocartilages in front• Fixation:1- Contraction of anterior abdominal muscles2-Weight of thorax and upper extremities
  36. 36. Normal & Good• Position: Supine.• Stabilization: Stabilize lower thorax.• Desired Motion: Patient flexes cervical spine through range of motion.• Resistance: Is given on forehead
  37. 37. Note►If there is a difference in strength of the two Sternocleidomastoideus muscles, they may be tested separately by rotation of head to one side and flexion of neck.► Resistance is given above ear.
  38. 38. Fair & Poor• Position: supine.• Stabilization: Stabilize lower thorax.• Desired Motion: Patient flexes cervical spine through full ROM for fair grade and through partial range for poor.
  39. 39. Trace & Zero• The Sternocleidomastoideus muscles maybe palpated on each side of neck as patient attempts to flex.
  40. 40. Muscles contribute to Neck ExtensionSplenius capitis Trapezius (superior fibers) Splenius cervicis Semispinalis capitis
  41. 41. Splenius capitis• Origin: Lower ligament nuchae, spinous processes and supraspinous ligaments T1-3• Insertion: Lateral occiput between superior and inferior nuchal lines• Nerve supply: Greater occipital nerve
  42. 42. Trapezius (superior fibers)• Origin: Base of the skull & posterior ligaments of the neck• Insertion: Posterior aspect of the lateral 3rd of clavicle• N. supply: Greater occipital nerve
  43. 43. Splenius cervicis• Origin: Spinous processes and supraspinous ligaments of T3-T6• Insertion: Posterior tubercles of transverse processes of C1-C3• Action: Neck Extension• Nerve supply:
  44. 44. Semispinalis capitis• Origin: Transverse processes of first 6 or 7 thoracic and 7th cervical vertebrae & Articular processes of fourth, fifth and sixth cervical vertebrae• Insertion: Between superior & inferior nuchal lines of occipital bone• Nerve supply: Greater occipital nerve
  45. 45. Note• Factors Limiting Motion:1-Tension of anterior longitudinal ligament of spine2-Tension of ventral neck muscles3-Approximation of spinous processes• Fixation:1-Contraction of spinal extensor muscles of thorax and depressor muscles of scapulae and clavicles2- Weight of trunk and upper extremities
  46. 46. Normal & Good• Position: Prone with neck in flexion.• Stabilization: Stabilize upper thoracic area and scapulae.• Desired Motion: Patient extends cervical spine through ROM.• Resistance: Is given on occiput. Note: Extensor muscles on right may be tested by rotation of head to right with extension, and vice versa
  47. 47. Fair & Poor• Position: Prone with neck flexed.• Stabilization: Stabilize upper thoracic area and scapulae.• Desired Motion: Patient extends cervical spine through full ROM for fair grade or through partial range for poor
  48. 48. Trace & Zero• Position: Prone• A trace may be determined by observation and palpation of the muscles of the dorsal area of the neck. (Test may be given with head resting on table.)
  49. 49. Note• Be sure patient completes full range of motion of neck extension. Back muscles may contract and lift upper trunk from table, giving the appearance of extension in cervical
  50. 50. Scapular Motions
  51. 51. Muscles contribute toScapular Abduction & Upward Rotation Serratus Anterior
  52. 52. Serratus Anterior• Origin: lateral, anterior surface of the upper 8th- 9th ribs• Insertion: Anterior aspect of the medial vertebral border of the scapula• Action: Shoulder Abduction to 90º• Nerve supply: Long thoracic nerve (C5 – C7)
  53. 53. Note• Factors Limiting Motion:1-Tension of trapezoid ligament (limits forward rotation of scapula upon clavicle).2-Tension of trapezius and Rhomboid major and minor muscles• Fixation:1- In strong scapular abduction, pull of external Obliquus externus abdominus on same side. 2-Weight of thorax
  54. 54. Normal & Good• Position: Supine with arm flexed to 90º with slight abduction, and elbow in extension.• Stabilization & Palpation Point: None• Desired Motion: Patient moves arm upward by abducting the scapula.• Resistance: Is given by grasping around forearm and elbow. Pressure is downward and inward toward table. Alternate Alternate
  55. 55. Fair• Position: Supine with arm flexed to 90º and scapula resting on table.• Stabilization and Palpation: None• Desired Motion: Patient forces arm upward. Scapula should be completely abducted without "winging (If extensor muscles of elbow are weak, elbow may be flexed or forearm may be supported. Alternate
  56. 56. Poor• Position: Sitting with arm flexed to 90º and arm resting on table.• Stabilization: Stabilize thorax.• Desired Motion: Patient moves arm forward by abducting scapula Alternate
  57. 57. Trace & Zero• Examiner lightly forces arm backward to determine presence of a contraction of Serratus anterior.• Scapula should be observed for "winging."• Digitations of Serratus anterior may be palpated on outer surface of ribs for a contraction
  58. 58. Muscles contribute to Scapular Elevation Upper Trapezius Levator scapulae
  59. 59. Upper Trapezius• Origin: Base of the skull & posterior ligaments of the neck• Insertion: Posterior aspect of the lateral 3rd of clavicle• Nerve supply: Accessory nerve (C3 – C4)
  60. 60. Lavetor scapulae• Origin: Transverse process of 1st four cervical• Insertion: Medial border of the scapula• Nerve supply: Dorsal Scapular Nerve (C5)
  61. 61. Note• Factors Limiting Motion:1-Tension of costoclavicular ligament2- Tension of muscles depressing scapula and clavicle: Pectoralis minor, subclavius, and Trapezius (lower fibers).• Fixation: 1-Flexor muscles of cervical spine (for tests done in sitting position). 2-Weight of head (foe tests done in prone position).
  62. 62. Normal & Good• Position: Sitting with arms at sides.• Stabilization: No fixation necessary.• Palpation point: Between lateral neck and acromion.• Desired Motion: Patient raises shoulders as high as possible• Resistance: Is given downward on top of shoulders.
  63. 63. Fair• Position: Sitting with arms at sides.• Desired Motion: Patient elevates shoulders through ROM.
  64. 64. Poor• Position: Prone with shoulders supported by examiner and forehead resting on table.• Desired Motion: Patient moves shoulders toward ears through ROM.
  65. 65. Trace & Zero• Examiner palpates upper fibers of Trapezius parallel to cervical Vertebrae and near their insertion above clavicle.
  66. 66. Note
  67. 67. Muscles contribute to Scapular Adduction Middle Trapezius
  68. 68. Middle Trapezius• Origin: Spinous process of 7th cervical & 1st -3rd thoracic• Insertion: – Medial border of acromion process – Upper border of scapular spine• Nerve supply: XI Accessory nerve (C3 – C4)
  69. 69. Note• Factors Limiting Motion:1-Tension of conoid ligament (limits backward rotation of scapula upon clavicle)2-Tension of Pectoralis major and minor and Serratus anterior muscles.3-Contact of vertebral border of scapula with spinal musculature.• Fixation:• Weight of trunk.
  70. 70. Normal & Good• Position: Prone with arm abducted to 90º and laterally rotated, elbow flexed to a right angle.• Stabilization: Stabilize thorax.• Palpation point: Base of spine of scapula, fibers run horizontally down to vertebra• Desired Motion:• Patient raises arm in horizontal abduction, motion taking place primarily between the scapula and thorax and not at glenohumeral joint.• Scapula is adducted and fixed by middle section of the trapezius.• Resistance: Is given on lateral angle of scapula. (no pressure is placed on the humerus).
  71. 71. Fair• Position: Prone with arm abducted to 90º and laterally rotated, elbow flexed to a right angle.• Stabilization: Stabilize thoracic• Desired Motion: Patient raises arm and adducts scapula
  72. 72. Poor• Position: Sitting with arm resting on table midway between flexion and abduction.• Stabilization: Stabilize thorax• Desired Motion: Patient horizontally abducts arm and adducts scapula.
  73. 73. Trace & Zero• Position: Sitting or Face lying.• Palpation: Middle fibers of Trapezius are palpated between root of spine of scapula and vertebral column to determine presence of a contraction.
  74. 74. Scapular Depression & Adduction Lower Trapezius
  75. 75. Lower Trapezius• Origin: Spinous process of 4th - 12th Thoracic• Insertion: Triangular space at the base of the scapular spine• Nerve supply: Accessory nerve
  76. 76. Note• Factors Limiting Motion:1- Tension of interclavicles ligament and articular disk of sternoclavicular joint.2- Tension of Trapezius (upper fibers), Levator scapular and sternocleidomastoideus (clavicular head).• Fixation:1-Contraction of spinal extensor muscles2- Weight of trunk.
  77. 77. Normal & Good• Position: Prone with forehead resting on table and arm to be tested extended overhead.• Palpation point:• Diagonally down and medially from the base of the spine of scapula.• Desired Motion:• Patient raises arm and fixates scapula strongly with lower part of Trapezius.• Resistance:• Is given on lateral angle of scapula in upward and outward direction. If shoulder flexion is limited, arm may be placed over edge of table.)
  78. 78. Normal & Good ***(Alternate)***• Note:• If Deltoideous is weak, arm is passively raised by examiner.• Patient attempts to assist.• Resistance is given on scapula.
  79. 79. Fair & Poor• Position:• Prone with forehead resting on table and arm overhead.• Desired Motion:• Patient lifts arm from table through full range of motion without upward movement of the scapula or forward sagging of the acromion process for F grade or through partial range for P grade.
  80. 80. Trace & Zero• Examiner palpates fibers of lower part of Trapezius between last thoracic vertebrae and scapula.
  81. 81. Scapular Adduction & Downward Rotation Rhomboid Major Rhomboid Minor
  82. 82. Rhomboid Major• Origin: Spinous process of T 2 –T 7 vertebrae• Insertion: Medial border of scapula inferior to spine• Nerve supply: Dorsal Scapular nerve (C5)
  83. 83. Rhomboid Minor• Origin: Spinous process of C7 –T 1 vertebrae• Insertion: Medial border of scapula superior to spine• Nerve supply: Dorsal Scapular nerve (C5)
  84. 84. Note• Factors Limiting Motion:1-Tension of conoid ligament (limits backward rotation of scapula upon clavicle).2-Tension of Pectoralis major and minor and Serratus anterior muscles3-Contact of vertebral border of scapula with spinal musculature• Fixation: Caution !!!!• Weight of trunk• Substitutions:1-Middle trapezius2-Pectoralis Minor3-Lower trapezius4-Latissimus Dorsi5-Levator Scapula
  85. 85. Normal & Good• Position: Prone with arm medially rotated and adducted across back, with the elbow flexed and hand on buttocks. Shoulders relaxed.• Stabilization: Roll the shoulder forward to pull vertebral border of scapula, to eliminate Pectoralis major.• Palpation Point: Along vertebral border of scapula.• Desired Motion: Patient raises arm and adducts scapula.• Resistance: Is given on vertebral border of scapula in outward and slightly downward direction.
  86. 86. Fair• Position:• Prone with arm medially rotated and adducted across back and shoulders relaxed.• Desired Motion:• Patient raises arm and adducts scapula through range of motion. (If the glenohumeral muscles are weak, slight resistance may be given to the scapula for a fair grade.)
  87. 87. Poor• Position:• Sitting with arm medially rotated and add net ed behind back.• Stabilization:• Stabilize trunk with anterior and posterior pressure to prevent flexion and rotation.• Desired Motion:• Patient adducts scapula through range of motion.
  88. 88. Trace & Zero• Examiner palpates Rhomboid muscles at the angle formed by the vertebral border of the scapula and the lateral fibers of the lower Trapezius.
  89. 89. Testing the Muscles of theUpper Extremity
  90. 90. Shoulder Joint
  91. 91. Shoulder FlexionAnterior Deltoid Ccoracobrachialis
  92. 92. Muscles contribute to Shoulder Flexion Anterior Deltoid• Origin:• Anterior lateral third of the clavicle• Insertion:• Deltoid tuberosity on the lateral humerus• Action:• Shoulder Flexion• Nerve supply:
  93. 93. Muscles contributes to Shoulder Flexion Ccoracobrachialis• Origin:• Coracoid process of the scapula• Insertion:• Middle 1/3 of the medial surface of the humerus• Action:• Shoulder Flexion• Nerve supply:
  94. 94. Normal and Good• Position:• Sitting with arm at side and elbow slightly flexed• Stabilization:• Stabilize scapula.• Palpation Point:• Between lateral portion of clavicle and coracoid process.• Desired motion:• Patient flexes arm to 90º (palm down to prevent lateral rotation with substitution by the Biceps brachii)• Resistance:• Is given above elbow.( Patient should not be allowed to rotate or horizontally adduct or abduct arm)
  95. 95. Fair• The same as Normal and Good techniques but without given resistance
  96. 96. Poor• Position:• Patient sideling with arm at side resting on smooth board (or supported by examiner) and elbow slightly flexed.• Stabilization:• Stabilize scapula.• Palpation Point:• Between lateral portion of clavicle and coracoid process.• Desired motion:• Patient brings arm forward to 90º of flexion
  97. 97. Trace and Zero• Position:• Back lying.• Palpation:• Examiner palpates fibers of anterior portion of Deltoid on anterior aspect of shoulder joint.
  98. 98. Caution!!!!
  99. 99. Notes• Range Of motion: 0-90º• Factors Limiting Motion: None, Rang of motion is incomplete• Fixation:• Contraction Trapezius & Serratus anterior muscles.• Serratus anterior and upper fibers of Trapezius assist in upward rotation of scapula as well as in fixation
  100. 100. Shoulder ExtensionLatissimus dorsi Teres Major Teres Minor
  101. 101. Muscles contribute to Shoulder Extension Latissimus dorsi• Origin:• a- Spines of lower 6 thoracic and lumbar vertebrae• b- Posterior surface of sacrum& Posterior aspect of crest of ileum• c- Lower 3-4 ribs• d- Inferior angle of scapula• Insertion:• Intertubercle groove of humerus• Action: Shoulder Extension• Nerve supply:
  102. 102. Muscles contribute to Shoulder Extension Teres Major• Origin:• Lower 1/3 of the axillary border of the scapula• Insertion:• Medial lip of intertubercular groove of humerus• Action: Shoulder Extension• Nerve supply:
  103. 103. Muscles contribute to Shoulder Extension Teres Minor• Origin:• Posteriorly on upper & middle aspect of lateral border of scapula• Insertion:• Posterior surface of greater tubercle of the humerus• Action: Shoulder Extension• Nerve supply:
  104. 104. Normal & Good• Position:• Prone with arm medially rotated and Adducted (palm up to prevent lateral rotation).• Stabilization:• Stabilize scapula.• Desired Motion:• Patient extends arm through range of motion.• Resistance:• Is given proximal to elbow.
  105. 105. Fair• Position:• Prone with arm at side.• Stabilization:• Stabilize scapula.• Desired Motion:• Patient extends arm through range of motion.
  106. 106. Poor• Position:• Sideling with arm flexed and resting on smooth board (or supported by examiner).• Stabilization:• Stabilize scapula.• Desired Motion:• Patient extends arm in position of medial rotation through range. of motion.
  107. 107. Trace & Zero• Position:• Prone.• Examiner palpates fibers of Teres major on lower part of axillary border of scapula (not shown) and fibers of Latissimus dorsi slightly below.
  108. 108. Note• Range Of motion: 0-50º• Factors Limiting Motion:• 1-Tension of shoulder flexor muscles.• 2-Contact of greater tubercle of humerus with acromion posteriorly.• Fixation:• Contraction of Rhomboideous major and minor and Trapezius muscles.• Weight of trunk
  109. 109. Shoulder Horizontal Abduction ( Deltoid (posterior portion
  110. 110. Muscles contribute to Shoulder Horizontal Abduction Deltoid (posterior portion)• Origin:• Inferior edge of the scapular spine• Insertion:• Deltoid tuberosity on the lateral humerus• Action: Shoulder Horizontal Abduction• Nerve supply:
  111. 111. Normal & Good• Position:• Prone with shoulder abducted to 90º, upper arm resting on table and lower arm hanging vertically over edge.• Stabilize:• scapula in adduction.• Palpation point:• Below the spine of the scapula.• Desired motion:• Horizontal abduction of humerus to the level of the table 90º.• Resistance :• Is given proximal to elbow.• Motion takes place primarily at glenohumeral joint and not between scapula and thorax
  112. 112. Fair• Position:• Prone with shoulder abducted to 90 degrees, upper arm resting on table and lower arm hanging vertically over edge.• Stabilization:• Stabilize scapula.• Desired motion:• Patient abducts upper arm through range of motion
  113. 113. Poor• Position:• Sitting with arm supported in a position of 90º of flexion.• Stabilization:• Stabilize scapula.• Desired Motion:• Patient horizontally abducts arm through range of motion.
  114. 114. Trace & Zero• Muscle fibers of posterior portion of Deltoid are palpated on posterior aspect of shoulder joint.
  115. 115. Note• Factors Limiting Motion:1-Tension of anterior fibers of capsule of glenohumeral joint 2- Tension of Pectoralis major and Deltoid (anterior fibers)• Fixation:• Contraction of Rhomboid major and minor and Trapezius (primarily) middle and lower fibers)• Substitution:• 1- Adduction of scapula with Trapezius. Caution !!!!!• 2- Long head of the triceps.• 3- Teres Major• 4- Latissimus to some extend
  116. 116. Shoulder Horizontal Adduction Upper pectoralis major Lower pectoralis major
  117. 117. Muscles contribute to Shoulder Horizontal Adduction Upper pectoralis major• Origin:• Medial half of anterior surface of clavicle• Insertion:• Intertubercle groove of humerus• Action:• Shoulder Horizontal Adduction• Nerve supply:
  118. 118. Muscles contribute to Shoulder Horizontal Adduction Lower pectoralis major• Origin:• Anterior surface of costal cartilage of first six ribs, adjacent portion of sternum• Insertion:• Intertubercle groove of humerus• Action:• Shoulder Horizontal Adduction• Nerve supply:
  119. 119. Normal & Good• Position:• Supine with arm abducted to 90 degrees.• Stabilization:• Stabilize scapula to prevent abduction of the scapula.• Palpation:• Below and near the origin at sternal end of the clavicle. Palpation• Desired Motion:• Patient adducts arm through range of motion.• Resistance:• Is given proximal to elbow joint.
  120. 120. Fair• Position:• Supine with arm abducted to 90º.• Stabilization:• Stabilize scapula to prevent abduction of the scapula.• Palpation:• Below and near the origin at sternal end of the clavicle.• Desired motion:• Patient adducts arm to vertical position.
  121. 121. Poor• Position:• Sitting with arm resting on table in 90º of abduction.• Stabilization:• Stabilize trunk.• Palpation:• Below and near the origin at sternal end of the clavicle.• Desired motion:• Patient brings arm forward through ROM.
  122. 122. Trace & Zero• Examiner palpates tendon of Pectoralis major near insertion on anterior aspect of upper arm.• Muscle fibers of both sternal and clavicular portions may be observed and palpated on upper anterior aspect of thoracic.
  123. 123. Note• Factor limiting Motion:• Tension of shoulder extensor muscles• Contact of arm with trunk.• Fixation:• In forceful horizontal adduction, contraction of Obliquus externus abdominus muscle on same side.• Substitution:• 1-Anterior portion of deltoid• 2-Coracobrachialis• 3- Short Head of biceps.
  124. 124. Shoulder External Rotation Teres Minor Infraspinatus
  125. 125. Muscles contribute to Shoulder External Rotation Teres Minor• Origin:• Posteriorly on upper & middle aspect of lateral border of scapula• Insertion:• Posterior surface of greater tubercle of the humerus• Action: Shoulder Extension• Nerve supply:
  126. 126. Muscles contribute to Shoulder External Rotation Infraspinatus• Origin:• Posteriorly on upper & middle aspect of lateral border of scapula• Insertion:• Posterior surface of greater tubercle of the humerus• Action: Shoulder Extension• Nerve supply:
  127. 127. Normal & Good• Position:• Prone with shoulder abducted to 90º, upper arm supported on table and lower arm hanging vertically over edge.• Stabilization:• Stabilize scapula with hand and forearm, but allow freedom for rotation.• Palpation point:• None• Desired motion:• Patient swings lower arm forward and up-ward and laterally rotates shoulder through range of motion.• Resistance:• Is given above wrist on forearm.
  128. 128. Fair• Position:• Prone with shoulder abducted to 90º, upper arm supported on table and lower arm hanging vertically over edge.• Stabilization:• Stabilize scapula and place hand against anterior surface of arm to prevent abduction (without interfering with motion).• Palpation:• None• Desired motion:• Patient swings lower arm forward and up-ward and laterally rotates shoulder through ROM.
  129. 129. Poor• Position:• Prone with entire arm over edge table in medially rotated positron.• Stabilization:• Stabilize scapula.• Palpation:• None• Desired Motion:• Patient laterally rotates arm through range of motion. (supination of the forearm should not be allowed to substitute for full range in lateral rotation.)
  130. 130. Trace & Zero• The Teres minor may be palpated on axillary border of scapula, and Infraspinatus over body of scapula below the spine.
  131. 131. Note• Factors Limiting Motion:• a- Tension of superior portion of scapular ligament.• b- Tension of lateral rotator muscles of shoulder.• Fixation:• a- Weight of trunk.• b- Contraction of Trapezius and Rhomboid major and minor muscles to fix scapula• Substitutions:1. Wrist extensors2. Roll the shoulder backwards.
  132. 132. Shoulder Internal RotationSubscapularis U. Pectoralis Major L. Pectoralis Major Latissimus Dorsi
  133. 133. Muscles contribute to Shoulder Internal Rotation Subscapularis• Origin:• Anterior surface of subscapular fossa• Insertion:• Lesser tubercle of the humerus• Action:• Shoulder Internal Rotation• Nerve supply:
  134. 134. Muscles contribute to Shoulder Internal Rotation Upper pectoralis major• Origin:• Medial half of anterior surface of clavicle• Insertion:• Intertubercle groove of humerus• Action:• Shoulder Internal Rotation• Nerve supply:
  135. 135. Muscles contribute to Shoulder Internal Rotation Lower pectoralis major• Origin:• Anterior surface of costal cartilage of first six ribs, adjacent portion of sternum• Insertion:• Intertubercle groove of humerus• Action:• Shoulder Internal Rotation• Nerve supply:
  136. 136. Muscles contribute to Shoulder Internal Rotation Latissimus dorsi• Origin:• a- Spines of lower 6 thoracic and lumbar vertebrae• b- Posterior surface of sacrum& Posterior aspect of crest of ileum• c- Lower 3-4 ribs• d- Inferior angle of scapula• Insertion:• Intertubercle groove of humerus• Action:• Shoulder Internal Rotation• Nerve supply:
  137. 137. Normal & Good• Position:• Prone with shoulder abducted to 90 degrees, upper arm supported on table and lower arm hanging vertically over edge.• Stabilization:• Stabilize scapula with hand and forearm, but allow freedom for rotation.• Palpation:• None• Desired Motion:• Patient swings lower arm backward and up- ward and medially rotates shoulder through range of motion.• Resistance:• Is proximal to wrist on forearm.
  138. 138. Fair• Position:• Prone with shoulder abducted to 90 degrees, upper arm supported on table and lower arm hanging vertically over edge.• Stabilization:• Stabilize scapula.• Palpation:• None• Desired Motion:• Patient swings lower arm backward and up-ward and medially rotates shoulder through range of motion.
  139. 139. Poor• Position:• Prone with arm over edge of table in lateral rotation.• Stabilization:• Stabilize scapula.• Palpation:• None• Desired Motion:• Patient medially rotates arm through range of motion. (Pronation of the forearm should not be allowed to substitute for full range in medial rotation.)
  140. 140. Trace & Zero• Fibers of Subscapularis may be palpated deep in axilla near insertion.
  141. 141. Shoulder Abduction to 90º Middle Deltoid Supraspinatus
  142. 142. Muscles contribute to Shoulder Abduction to 90º Middle Deltoid• Origin:• Acromion process• Insertion:• Deltoid tuberosity on the lateral humerus• Action:• Shoulder Abduction to 90º• Nerve supply:
  143. 143. Muscles contribute to Shoulder Abduction to 90º Supraspinatus• Origin:• Supraspinatus fossa• Insertion:• Greater tubercle of the humerus• Action:• Shoulder Abduction to 90º• Nerve supply:
  144. 144. Note• Factors Limiting Motion:• None: range of motion incomplete.• Fixation:• Contraction of Trapezius and Serratus anterior muscles.• Serratus anterior and upper fibers of trapezius assist in upward rotation of scapula as well as in fixation.
  145. 145. Normal & Good• Position:• Sitting with arm at side in mid-position between medial and lateral rotation.• Elbow flexed a few decrees.• Stabilization:• Stabilize scapula.• Palpation:• Just below the acromion process of the scapula.• Desired Motion:• Patient abducts the humerus to 90º(palm down).• Resistance :• Is given proximal to elbow
  146. 146. Fair• Position:• Sitting with arm at side in midposition between medial and lateral rotation.• Elbow flexed a few degrees.• Stabilization:• Stabilize scapula.• Palpation:• Just below the acromion process.• Desired Motion:• Patient abducts arm to 90º (palm down).
  147. 147. Poor• Position:• Supine with arm at side in midposition between medial and lateral rotation.• Elbow slightly flexed.• Stabilization:• Stabilize scapula over acromion. Alternate• Desired Motion:• Patient abducts arm to 90º without Lateral rotation at shoulder joint
  148. 148. Trace & Zero• Examiner palpates middle section of Deltoid on lateral surface of upper third of arm
  149. 149. Note• Patient may laterally rotate arm and attempt to substitute Biceps brachii during abduction.• Arm should be kept in midposition between medial and lateral rotation.
  150. 150. Note• Range of Motion: 0° TO 90°• Factors Limiting Motion:• Tension of expansions of extensor ten-dons of fingers.• Fixation:• Weight of arm
  151. 151. Shoulder Goniometry
  152. 152. Introduction1. It is the measuring of angles created by the bones of the body at the joints.2. These joints are measured by a goniometer.3. It has a moving arm, stationary arm, and the fulcrum.4. The fulcrum or body is placed over the joint being measured and on it is a scale from 0 to 180°.5. The stationary arm will be aligned with the inactive part of the joint measured, while the moving arm is placed on the part of the limb which is moved in the joint’s motion.6. For example, when measuring knee flexion, the stationary arm will be aligned over the thigh in line with the greater trochanter of the femur.
  153. 153. Introduction - continue7. The fulcrum is aligned over the knee joint or lateral epicondyle of the femur, and the moving arm with the midline of the leg or lateral malleolus.8. Performing these tests is important for many reasons. • The mobility of joints is important for diagnosis and determining the presence or absence of dysfunction.9. In a chronic condition, goniometry can measure the progression of the disorder. • An example of this is the progression of rheumatoid arthritis.10. Furthermore, joint motion measurement can evaluate improvements or lack of progression during rehabilitation.11. This not only provides motivation for the patient when there are improvements, but also can decipher if modifications need to be made if treatment is not effective.
  154. 154. FlexionPatient Instructions:• Once the goniometer is aligned properly ask the patient to lift the arm up just as if they were raising their hand to ask a question.• Be sure that the patient keeps the palm of their hand facing in toward their body.
  155. 155. Starting Position • Patient is supine with arm at side and the palm of the hand facing the body. • The fulcrum of the goniometer is placed over the acromion process. • The stationary and moving arms are aligned with the midline of the humerus and lateral epicondyle.
  156. 156. Ending Position • The moving arm remains in line with the lateral epicondyle and midline of the humerus. • The examiner supporting the patient’s extremity. • The stationary arm should remain in its starting position, only now it should be in line with the lateral midline of the thorax. • Normal ROM for glenohumeral flexion is 160 to 180º; in the picture the patient is in 180º of flexion.
  157. 157. Extension• Patient Instructions:• Ask the patient to simply lift their arm off the table as far as they can.
  158. 158. Starting Position • Patient is prone with arm at side; make sure the head is facing away from the shoulder being tested. • Elbow bent slightly and the palm facing in toward the body. • The fulcrum is placed over the acromion process. • The stationary and moving arms are aligned with the lateral midline of the humerus and the lateral epicondyle.
  159. 159. Ending Position • The moving arm remains in line with the lateral epicondyle and the examiner should support the patient’s extremity. • The stationary arm in line with the midline of the thorax. • Normal ROM for glenohumeral extension is 40 to 60º; in the picture the patient is in 61º of extension.
  160. 160. Abduction• Patient Instructions:• Have the patient bring their arm out to their side and as close to their head as they can.• Make sure that their palm faces upward throughout the motion.
  161. 161. Starting Position • The patient is supine with arm at side; the palm should be facing interiorly. • The fulcrum is placed at the acromion process. • The stationary and moving arms are aligned with the anterior midline of the humerus.
  162. 162. Ending Position • The stationary arm should remain still and parallel to the sternum. • The moving arm should still be resting at the anterior midline of the humerus. • Normal ROM between 160 and 180º; the patient in the picture is in 174º of abduction
  163. 163. Medial (Internal( Rotation• Patient Instructions:• Ask the patient to rotate their arm down as far as they can.
  164. 164. Starting Position • Supine with 90º of shoulder abduction and the elbow is in 90º of flexion. • The table should not support the elbow. • The fulcrum centered over the olecranon process. • The moving arm is aligned with the ulnar styloid and the stationary arm should be perpendicular to the floor.
  165. 165. Ending Position • Same as above • Normal ROM is 60- 70 ˚ ; the patient is in 68º of internal rotation.
  166. 166. Lateral (External( Rotation• Patient Instructions:• Ask the patient to rotate their arm up toward their head as far as they can.
  167. 167. Starting and Ending Position • Supine with 90º of shoulder abduction and 90º of elbow flexion. • The table should not support the elbow. (Refer to above picture) • Fulcrum on the olecranon process. • The moving arm should be aligned with the ulnar styloid and the stationary arm should be perpendicular to the floor. • Ending Position: • Same as before
  168. 168. Normal ROM Reference ValuesShoulder Typical ROMFlexion 160 - 180˚Extension 40 - 60˚Abduction 160 - 180˚Internal Rotation 60-70˚External Rotation 40 - 45˚
  169. 169. Painful Elbow Joint
  170. 170. Clinical Examination of the Elbow
  171. 171. Anatomy Of the elbow
  172. 172. SURFACE ANATOMY OF THE ELBOW• Lateral elbow - labeled Lateral Epicondyle Olecranon
  173. 173. The bones (Figs. 1-4)Figure 1 Diagrammatic AP view of elbow jointFigure 2 Diagrammatic lateral view of elbowjoint. Note that the elbow is slightly twisted inrespect of the axis of the ulna.
  174. 174. • Figure 5 Diagrammatic view of the medial collateral ligament, with its three bundles. The anterior bundle is the most important functionally, since it provides valgus and anteroposterior stability. Figure 6 Diagrammatic view of the lateral ligament complex. It would appear that the most import structure is the lateral collateral ligament, which blends with the annular ligament. The lateral ulnar collateral ligament is indissociable from the lateral collateral ligament, at its attachment to the lateral epicondyle. Distally, it branches off, and attaches to the supinator crest. The role of the accessory lateral collateral ligament is poorly understood. Figure 7 Diagrammatic view of the origin and insertion of anconeus, which covers the capsule and collateral ligaments on the lateral side.
  175. 175. Diseases of the elbow joint• Arthritis• Fractures• Bursitis• Tendonitis (Tinness elbow and Glovers elbow)• Cubital Tunnel Syndrome
  176. 176. Bursitis
  177. 177. Tinness elbow
  178. 178. Cubital Tunnel Syndrome
  179. 179. CLINICAL EXAMINATION
  180. 180. INSPECTION• The patient should be standing, with shoulders slightly braced back, to display the elbow.• When the forearm is in full extension and supination, there will be a physiological valgus ("carrying angle") of 9-14°; in women, the angle will be 2-3° greater• This angle has been found to be 10-15° greater in the dominant arm of throwing athletes• This angle allows the elbow to be tucked into the waist depression above the iliac crest; it increases when a heavy object is being lifted• Any increase in, or loss of, this physiological angle is indicative either of major elbow instability or of malunion.• However, the angle varies from valgus in extension to varus in flexion, and its measurement is not of any practical importance.
  181. 181. Inspection• Sometimes, on the side of the elbow, bulging in the para-olecranon groove will be seen; such a swelling is produced by an effusion or by synovial tissue proliferation• On the back, prominence of the olecranon is a sign of posterior subluxation of the elbow, a feature commonly found in RA .• Rheumatoid nodules are extremely common• Bursitis is also a frequently encountered pathology, especially in RA patients.• Skin atrophy at steroid injection sites, or scars from previous surgery.
  182. 182. Figure 8The physiological valgus (“carrying angle”) of theelbow is increased when a load is being carried.Normally, the angle is between 9 and 14° when theelbow is extended and the forearm is supinated.
  183. 183. PALPATION• Palpation starts at the posterior aspect, with the patient standing with his or her shoulder braced backwards.• The three palpation landmarks - the two epicondyles and the apex of the olecranon - form an equilateral triangle when the elbow is flexed 90°, and a straight line when the elbow is in extension (Figs. 9, 10).
  184. 184. PALPATIONFigures 9, 10Three bony landmarks - the medial epicondyle, the lateralepicondyle, and the apex of the olecranon - form anequilateral triangle when the elbow is flexed 90°, and astraight line when the elbow is in extension
  185. 185. PALPATION• Since the elbow is a very superficial joint, it can be readily palpated from behind and from the sides.• The posterior aspect has the olecranon mid-way between the medial and the lateral condyle.• Slight elbow flexion will bring the olecranon out of the olecranon fossa, in which it lodges in extension; in this position, the proximal portion of the fossa on either side of the triceps tendon may be palpated (Fig. 11)
  186. 186. PALPATION • Figure 11 Flexing the elbow allows palpation of the olecranon fossa on either side of the triceps tendon. • Figure 12 Anatomical landmarks on the lateral aspect of the elbow: The lateral epicondyle continues proximally in the supracondylar ridge. • Two 2cms distally, the main landmark is formed by the radial head.
  187. 187. • The olecranon bursa is not in communication with the synovial cavity.• This is why the elbow may be mobilized in bursitis, and why even massive bursitis will not be tender.• In chronic bursitis, a boggy globular mass may be palpated; the overlying skin will be thickened. Flat, hard nodules may be felt under the palpating fingertips.• In infected bursitis, the skin will be tight and shiny; streaks of lymphangitis will be commonly seen; while in 25% of the cases, the axillary lymph nodes will be enlarged.• On the lateral side, the main landmarks are the lateral epicondyle proximally and the radial head distally.
  188. 188. • The supracondylar ridge is also very accessible to palpation; its chief value is that of a landmark for surgical approaches (Fig. 12).• Sometimes, palpation may be carried out all the way up to the deltoid tuberosity.• The radial head is palpated with the examiner’s thumb, while the other hand is used to pronate and supinate the forearm (Fig. 13).• The head is about 2 cm distal to the lateral epicondyle• Inside the triangle formed by the bony prominences of the lateral epicondyle, the radial head and the olecranon, the joint itself is palpated, to detect even very minor effusions or low-grade synovitis (Fig. 14(
  189. 189. Figure 13• Anatomical landmarks on the lateral aspect of the elbow:• The radial head is palpated with the thumb, while the examiner’s other hand is used to pronate and supinate the forearm PALPATION.Figure 14• The elbow joint may be palpated inside a triangle formed by the bony prominences of the lateral epicondyle, the radial head, and the olecranon.• This palpation will reveal even minor effusions or mild synovitis.• Puncture for joint aspiration is performed inside this triangle.• Similarly, an arthroscopy portal may be placed there (posterolateral portal(
  190. 190. • Figure 15 Palpation and testing of brachioradialis, a forearm flexor. • Figure 16 Palpation and testing of the wrist extensorsPALPATION
  191. 191. PALPATION• From the medial side, the joint is not very accessible to palpation, and the small amount of synovial tissue on the medial border of the olecranon makes joint palpation difficult• Palpation of the ridge that provides insertion for the intermuscular septum is useful mainly as a guide for surgical approaches. Also, the supracondylar lymph nodes may be palpated at this site (Fig. 17).• Over, and slightly anterior to, the supracondylar ridge, a bony excrescence may be palpated; this outgrowth may irritate the median nerve• This supracondylar process is present in 1-3% of the population, and is seen at a distance of 5-7 cm above the joint line• Behind the septum, the ulnar nerve may be palpated; in patients with a very mobile nerve, it may be seen to roll on the medial condyle(10) (Fig. 18).• Ulnar nerve instability is more easily tested with the arm in slight abduction and external rotation, with the elbow flexed between 20 and 70°.
  192. 192. Figure 17• Palpation of the medial aspect of the elbow.• Above the medial epicondyle is the ridge on which the intermuscular septum inserts.• Two centimetres above the epicondyle is the site used for lymph node palpation.Figure 18 The ulnar nerve is palpatedbehind the intermuscularseptum.It may sometimes sublux or rollon the epicondyle.Ulnar nerve instability is morereadily demonstrated if theelbow is flexed 60° and theupper limb is abducted andexternally rotated.
  193. 193. PALPATION• Anteriorly, the bulk of the flexor-pronator group restricts the extent of joint palpation.• The flexor-pronator muscles must be tested as a unit, by asking the patient to perform wrist adduction and flexion against resistance (Fig. 19).• Next, each one of these muscles should be tested individually.• The anterior aspect does not lend itself to palpation, since it is tucked away behind the muscles.• Laterally, brachioradialis will be felt; and in the middle, the biceps tendon is readily accessible if the patient is made to flex the forearm against resistance.• Lacertus fibrosus is palpated medial to the biceps tendon; the pulse of the brachial artery will be felt deep to this aponeurosis (Fig. 20).• Sometimes anterior protrusion cysts produced by herniated synovial membrane may be felt.
  194. 194. Figure 19Diagrammatic view of the pattern ofthe flexor-pronator group: The thumbrepresents pronator teres; the index,flexor carpi radialis; the middlefinger, palmaris longus; and the ringfinger, flexor carpi ulnaris.Figure 20Palpation of the medial bicepsexpansion (lacertus fibrosus), whichcourses over the brachial vesselsand the median nerve.
  195. 195. MOBILITY• The main function of the elbow is to bring the hand to the mouth; this is why the investigation of the elbow range of movement (ROM) is an important part of the examination process.• Any difference between passive and active mobility is usually due to reflex inhibition from pain• The end-feel - the feeling transmitted to the examiner’s hands at the extreme range of passive motion - must also be assessed (Table 1)• If the feel is abnormal, there is usually something wrong with the joint.
  196. 196. Table 1 Classification and description of end-feels(modified from TS Ellenbecker & AJ Mattalino)(12a( Bony Two hard surfaces meeting, bone to bone (elbow extension( Capsular Leathery feel, further motion available (forearm pronation and supination( Soft tissue approximation Soft tissue contact (elbow flexion( Spasm Muscle contraction limits motion Springy block Intra-articular block; rebound is felt Empty Movement causes pain, pain limits movement
  197. 197. ELBOW JOINT• The elbow is a complex joint with three different articulations.• The humeroulnar joint is a hinge joint, and allows the forearm to flex and extend, and provides stability.• The radiohumeral and radioulnar joints allow for flexion, extension and rotation of the radius on the ulna, which in turn allows the forearm to pronate and supinate.
  198. 198. RANGE OF MOTION• Flex and extend, and supinate and pronate.• Normal elbow range of motion• Extension: 0°• Flexion: 150°• Pronation: 70°• Supination: 90°
  199. 199. Elbow Goniometry
  200. 200. Flexion• Patient Instructions:• Ask the patient to bend their elbow as far as they can, try and touch their shoulder.
  201. 201. Starting Position• Position: Supine, arm in the anatomical position with arm of the patient is resting on the edge of the table.• The fulcrum aligned with the lateral epicondyle of the humerus.• The stationary arm is positioned along the midline of the humerus• The moving arm is aligned with the radial styloid process.
  202. 202. Ending Position• The arm is now flexed at the elbow, the goniometer should still be aligned with the correct anatomical landmarks as described below.• Normal ROM is between 150-160º, the patient has 155º of elbow flexion.
  203. 203. Pronation• Patient Instructions:• Have the patient turn their wrist down toward the ground.• Starting Position:• Patient sitting up with elbow bent 90 degrees and at patient’s side, wrist in a handshake position.• The fulcrum is placed just behind the ulnar styloid process.• The moving arm and stationary arm are parallel with the anterior midline of the humerus.
  204. 204. Ending Position• The fulcrum should remain in the same position as above.• The stationary arm will still be aligned parallel to the midline of the humerus, the moving arm will lie across the dorsum of the forearm just behind the ulnar and radial styloid processes.• Normal ROM is 90-96º, the patient has 95º of pronation.
  205. 205. Supination• Patient Instructions:• Have the patient turn their palm up as if they are holding something in the palm of their hand.• Starting Position:• Patient position is the same as for pronation.• The goniometer is placed on the medial aspect of the forearm with the fulcrum at the radioulnar joint.• The arms are both aligned with the anterior midline of the humerus.
  206. 206. Ending Position• The moving arm will be resting on the medial forearm at the radioulnar joint.• The moving arm should remain parallel to the midline of the humerus.• Normal ROM is 81-93º, the patient has 90º of Supination.
  207. 207. Normal ROM Reference ValuesElbow Typical ROMFlexion 150-160ºExtension 0Pronation 90-96ºSupination 81-93º
  208. 208. Elbow Joint
  209. 209. Elbow FlexionBrachioradialis Biceps Brachii Brachialis
  210. 210. Muscles contribute to Elbow Flexion Brachioradialis• Origin:• Upper 2/3 of lateral supracondylar ridge of humerus• Insertion:• Styloid process of radius• Action:• Elbow Flexion• Nerve supply:
  211. 211. Muscles contribute to Elbow Flexion Biceps Brachii• Origin:• Long head: supraglenoid tubercle• Short head: coracoid process• Insertion:• Radial tuberosity• Action:• Elbow Flexion• Nerve supply
  212. 212. Muscles contribute to Elbow Flexion Brachialis• Origin:• Lower portion of anterior surface of humerus• Insertion:• Coronoid process of ulna• Action:• Elbow Flexion• Nerve supply
  213. 213. Normal & Good• Position:• Sitting with slight shoulder flexion and the elbow flexed past 90°, forearm is supinated.• Ask the patient to, “hold your elbow bent, and don’t let me straighten it out.”• Palpation:• Muscle belly or just medial on crease of elbow tendon.• Stabilization:• Stabilizing hand is placed on the shoulder.• Desired Motion:• Patient flexes elbow through range of motion.• Resistance• Is given at the wrist in a downward direction.
  214. 214. Normal & GoodBiceps brctchii : forearm in supination Brachialis : forearm in pronationBrachioradialis: forearm in midposition between pronation and supination
  215. 215. Fair• Position:• Sitting with arm at side and forearm supinated• Stabilization:• Stabilize upper arm.• Desired Motion:• Patient flexes elbow through range of motion.
  216. 216. Poor• Position:• Supine with shoulder abducted to 90 and laterally rotated ْ.• Stabilization:• stabilizing hand is placed on the shoulder.• Desired Motion:• Patient slides forearm along table through complete range of elbow flexion.• (If range of motion is limited in lateral rotation at shoulder joint, test may be given with arm medially rotated.)
  217. 217. Trace & Zero• Examiners palpate the flexors on the forearm; muscle fibers may be found on anterior surface of arm.
  218. 218. Alternate Test for Elbow Flexion• This alternate test is performed if the biceps and brachialis are weak.• Pronating the hand will instead use the brachioradialis, extensor carpi radialis longus, pronator teres, and other wrist flexors.• Patients positioning is the same, except the forearm is now pronated and the stabilizing hand is under the elbow joint.• Testing procedure is the same as before.
  219. 219. Note• Note:• The wrist flexors may be contracted for assistance in elbow flexion.• Wrist will be strongly flexed as a result. Wrist should be relaxed.
  220. 220. Note• Range of motion: 0º to 145º - 160º• Factors Limiting Motion:1-Contact of muscle masses volar aspect of arm and forearm.2-Contact of coronoid process with coronoid fossa of humerus• Fixation:1-Weight of arm2-Fixator muscles of scapula• Substitutions:1. Brachioradialis2. Flexors group of the wrist and fingers:FCR, FCU, palmaris longus, FDS, FPL and pronator teres.
  221. 221. Elbow ExtensionTriceps Brachii
  222. 222. Muscles contribute to Elbow Extension Triceps Brachii• Origin:• Long head: Scapula, infraglenoid tubercle• Lateral head: Humerus, 1/3 lateral-posterior surface• Medial head: Humerus, lower 3/4 of posterior surface• Insertion: Olecranon process of ulna• Nerve supply
  223. 223. Note• Range of Motion: 145º – 160º to 0º• Factors Limiting Motion:1-Tension of anterior, radial and ulnar collateral ligaments of elbow joint.2-Tension of flexor muscles of forearm.3-Contact of olecranon process with olecranon fossa on posterior aspect of humerus.• Fixation:1-Weight of arm2-Contraction of Fixator muscles of scapula.• Substitutions Muscles:1-Rotators2-Wrist extensors3-Anconeous
  224. 224. Normal & Good• Position:• Patient is prone on the table with the shoulder abducted to 90°, the entire arm should be off the table and the therapist can stabilize the arm at the humerus just above the elbow. The elbow should be in full extension.• Palpation: Proximal to olecranon process.• Stabilization: Stabilize arm.• Desired Motion: Patient extends elbow through ROM.• Resistance: Is applied at wrist in a downward direction.
  225. 225. Fair• Position: Supine with shoulder flexed to 90ْ and elbow flexed.• Palpation: The same as before• Stabilization: Stabilize arm.• Desired Motion: Patient extends elbow through range of motion Alternate
  226. 226. Poor• Position: Supine with arm abducted to 90 degrees and laterally rotated. Elbow is flexed.• Stabilization: Stabilize arm.• Desired Motion: Ask the patient to, “straighten your elbow, don’t let him bend it down. (if range of motion is limited in lateral rotation at shoulder joint, test may be given with arm medially rotated)
  227. 227. Trace & Zero• Examiner may palpate tendon of Triceps brachii at the elbow joint and muscle fibers on posterior surface of arm.
  228. 228. Muscles contribute to Forearm SupinationBiceps Brachii Supinator Teres
  229. 229. Biceps Brachii• Origin:• Long head: supraglenoid tubercle• Short head: coracoid process• Insertion: Radial tuberosity• Nerve supply
  230. 230. Muscles contribute to Forearm Supination Supinator Teres• Origin:• lateral epicondyle of Humerus• posterior part of ulna• Insertion: upper 1/3 lateral surface of Radius.• Nerve supply
  231. 231. Note• Range of motion: 0ºTO 90º Supination from midposition• Factors Limiting Motion:1-Tension of Volar radioulnar ligament and ulnar collateral ligament of wrist joint.2-Tension of oblique cord and lowest fibers of interosseous muscles of forearm.• Fixation:• Weight of arm
  232. 232. Normal & Good• Position: Sitting with arm at side, elbow flexed to 90 degrees and forearm pronated to prevent rotation at the shoulder. Muscles of wrist and fingers are; relaxed.• Stabilization: Stabilize arm.• Desired Motion: Patient supinates forearm.• Resistance: Is given on dorsal surface of distal end of radius. (Resistance may be given by grasping around the dorsal surface of the hand instead of the position illustrated.)
  233. 233. Fair & Poor• Position: Fair• Silting with arm at side, elbow flexed to 90º, forearm pronated and supported by examiner.• Muscles of wrist and fingers are relaxed.• Desired Motion: Poor• Patient supinates forearm through full range of motion for fair grade and through partial for poor grade.
  234. 234. Trace & Zero• Supinator muscle is palpable on radial side of forearm if overlying extensor muscles are not functioning. Tendon of Biceps brachii is found in antecubital space
  235. 235. Note• Patient should not be allowed to laterally rotate arm and move elbow across thorax as forearm is supinated.• As a result of this movement the forearm may appear to be supinated, but range of motion is incomplete.• This motion may "roll" the forearm into supination without a muscular contraction taking place.
  236. 236. Forearm PronationPronator Teres
  237. 237. Muscles contribute to Forearm Pronation Pronator Teres• Origin:• Humerus, medial epicondyle• Insertion:• Radius, middle 3rd of lateral surface• Action:• Forearm Pronation• Nerve supply
  238. 238. Note• Range of motion: 0º to 90º Pronation from midposition• Factors Limiting Motion:1-Tension of dorsal radioulnar, ulnar collateral and dorsal radiocarpal ligaments.2-Tension of lowest fibers of interosseous membrane.• Fixation:• Weight of arm
  239. 239. Normal & Good• Position:• Sitting with arm at side, elbow flexed to 90º to prevent rotation at the shoulder and forearm supinated. Muscles of wrist and fingers are relaxed.• Stabilization:• Stabilize arm.• Desired Motion:• Patient pronates forearm through ROM.• Resistance :• Is given on volar surface of distal end of radius with counterpressure against the dorsal surface of the ulna.
  240. 240. Fair & Poor• Position: Fair• Sitting with arm at side, elbow flexed to 90º, forearm supinated and supported by examiner. Muscles of wrist and fingers are relaxed.• Desired Motion:• Patient pronates forearm through full Poor range of motion for fair grade and through partial range for poor grade
  241. 241. Trace & Zero• Position:• Sitting.• Palpation:• Examiner palpates fibers of Pronator teres on upper third of volar surface of forearm on a diagonal line from medial condyle of humerus to lateral border of radius
  242. 242. Note• Patient should not be allowed to medially rotate or abduct upper arm during pronation.• This movement makes the ROM in pronation appear complete and allows forearm to roll into pronated position
  243. 243. Wrist Joint
  244. 244. Painful Wrist• Trigger finger• De Quvarian syndrome• Fractures• Arthritis• Tendonitis• Peripheral nerve Injuries
  245. 245. Trigger finger
  246. 246. Muscles contribute to Wrist Flexion Wrist Flexion Flexor carpi radialis Flexor carpi ulnaris
  247. 247. Flexor carpi radialis• Origin: Medial epicondyle of humerus• Insertion: Base of 2nd & 3rd metacarpals, anterior surface• Nerve supply: Median Nerve (C6, C7)
  248. 248. Flexor carpi ulnaris• Origin: Medial epicondyle of humerus• Insertion: Pisiform, hamate & base of 5th metacarpal• Nerve supply: Ulnar Nerve C7, T1)
  249. 249. Note• Range of Motion: Wrist flexion: 0 to 90 ْ• Factors Limiting Motion:• Tension of dorsal radiocarpal ligament• Fixation:• Weight of arm
  250. 250. Normal & Good• Position: Sitting with forearm resting on table with forearm supinated.• Muscles of thumb and fingers relaxed.• Stabilization: Stabilize forearm.• Desired Motion: Patient flexes wrist
  251. 251. Note• To test Flexor carpi radialis, resistance is given at base of second metacarpal bone in direction of extension and ulnar deviation
  252. 252. Note• To test Flexor carpi ulnaris, resistance is given at base of fifth metacarpal bone in direction of extension and radial deviation
  253. 253. Fair• Position: Sitting with forearm resting on table with forearm supinated. Muscles of thumb and fingers relaxed.• Stabilization: Stabilize forearm.• Desired Motion: Patient flexes wrist with radial deviation or ulnar deviation Flexor carpi radialis Flexor carpi ulnaris
  254. 254. Poor• Position: Sitting, forearm supported, hand resting on medial border. Muscles of thumb and fingers relaxed.• Stabilization: Stabilize forearm.• Desired Motion: Patient flexes wrist, sliding hand along table. Deviation should be observed and muscles graded accordingly.
  255. 255. Trace & Zero• Examiner palpates tendon of Flexor carpi radialis on lateral palmar aspect of wrist and tendon of Flexor carpi ulnaris on medial palmar surface.
  256. 256. Muscles contribute to Wrist ExtensionExtensor carpi radialis longus Extensor carpi radialis Brevis Extensor carpi Ulnaris
  257. 257. Muscles contribute to Wrist Extension Extensor carpi radialis longus• Origin: Humerus, lower 3rd of lateral supracondylar ridge and lateral epicondyle of humerus• Insertion: Base of 2nd metacarpal (dorsal surface)• Nerve supply: Radial Nerve
  258. 258. Extensor carpi radialis Brevis• Origin: Lateral epicondyle of humerus• Insertion: Base of 3rd metacarpal (dorsal surface)• Nerve supply: Radial Nerve
  259. 259. Extensor carpi Ulnaris• Origin: Lateral epicondyle of humerus• Insertion: Base of 5th metacarpal• Nerve supply: Ulnar Nerve
  260. 260. Note• Range of Motion:• Wrist extension beyond midline; 0 to 70º• Factors Limiting Motion:• Tension of palmar radiocarpal ligament• Fixation:• Weight of arm Caution!!!!
  261. 261. Normal & Good• Position:• Sitting with forearm resting on the table and pronated.• Muscles of fingers and thumb relaxed.• Stabilization: Stabilize forearm.• Desired Motion: Patient extends wrist.
  262. 262. Note• To test Extensor carpi radialis longus and Brevis, resistance is given on dorsal surface of second and third metacarpal bones in direction of flexion and ulnar deviation.
  263. 263. Note• To test Extensor carpi ulnaris, resistance is given on dorsal surface of fifth metacarpal bone in direction of flexion and radial deviation.
  264. 264. Fair• Position:• Sitting with forearm resting on the table and pronated.• Muscles of fingers and thumb relaxed.• Stabilization: Stabilize forearm.• Desired Motion: Patient extends wrist with radial deviation or ulnar deviation.
  265. 265. Poor• Position: Sitting, forearm supported, hand resting on medial border.• Stabilization: Stabilize forearm.• Desired Motion:• Patient extends wrist, sliding hand along table through range of motion.• Deviation should be observed and muscles graded accordingly
  266. 266. Trace & Zero• Tendons of wrist extensors may be found on lateral dorsal surface of wrist in line with second and third metacarpal bones and on medial dorsal surface proximal to fifth metacarpal bone.
  267. 267. Joints of Fingers
  268. 268. Flexion of metacarpophalangeal joints of fingers Lumbricales
  269. 269. Muscles contribute to Flexion of metacarpophalangeal joints of fingers Lumbricales• Origin:• Four tendons of flexor digitorum profundus.• Radial 2: radial side only (unipennate).• Ulnar 2: cleft between tendons ( bipennate)• Insertion:• Proximal phalanx of fingers 2-5 radial side• Action:• Flexion of MP joints• Nerve supply
  270. 270. Normal & Good• Position:• Sitting with hand resting on dorsal surface.• Stabilization:• Stabilize metacarpals.• Desired Motion:• Patient flexes fingers at MCP joints, keeping IP joints extended.• Resistance:• Is given on palmar surface of proximal row of phalanges.• Note: Resistance may be given to each finger separately if Lumbricales are unequal in strength.
  271. 271. Fair & Poor• Position:• Sitting with hand supported.• Stabilization:• Stabilize metacarpals.• Desired Motion:• Patient flexes fingers at MCP joints through ROM, keeping IP joints extended.• Patient flexes MCP joints through full ROM for fair grade and through partial range for poor grade.
  272. 272. Trace & Zero• Contraction of Lumbricales may be detected by light pressure against palmar surface of proximal phalanges as patient attempts to flex at MCP joints.
  273. 273. Note• The Flexor digitorum superficialis and Flexor digitorum profundus should not be allowed to substitute for Lumbricales with flexion of fingers.• These muscles should be kept relaxed as much as possible with motion limited to meta-carpophalangeal joint.• Individual testing of fingers (in all tests) is often desirable as they vary in strength. Caution!!!!
  274. 274. Flexion of Proximal Interphalangeal Joints of Fingers Flexor digitorum superficialis
  275. 275. Diseases of the fingers• Arthritis (rheumatoid arthritis, gout arthritis)• Diabetes• Fractures• Trigger finger• Tendonitis• Trauma
  276. 276. Rheumatoid arthritis trigger
  277. 277. Trigger Finger• Definition• Trigger finger is an inflammation of the synovial sheath that encloses the flexor tendons of the thumb and fingers. Tendons are the cords that connect bones to muscles in the body. Usually, tendons slide easily through the sheath as the finger moves.• In the case of trigger finger, however, the synovial sheath becomes swollen and the tendon cannot move easily through small pulleys in the finger, causing the finger to remain in a flexed (bent) position.• In mild cases, the finger may be straightened with a pop, like a trigger being released.• In severe cases, the finger becomes stuck in the bent position.• Usually this condition can easily be treated; contact your doctor if you think you may have trigger finger.
  278. 278. Causes• Often, the cause of trigger finger is unknown. However, many cases of trigger finger are caused by one of the following:• Overuse of the hand from repetitive motions – Computer operation – Machine operation – Repeated use of hand tools – Playing musical instruments• Inflammation caused by a disease – Rheumatoid arthritis – Gout – Hypothyroidism
  279. 279. Risk Factors• The following factors increase your chances of developing trigger finger:• Age: 40-60• History of repetitive hand motions for work or play• Sex: female• History of certain diseases: – Rheumatoid arthritis – Gout – Hypothyroidism
  280. 280. Symptoms• If you experience any of these symptoms do not assume it is due to trigger finger. Some of these symptoms may be caused by other health conditions. If you experience any one of them for a period of time, see your physician. – Finger or thumb stiffness – Finger, thumb, or hand pain – Swelling or a lump in the palm – Catching or popping when straightening the finger or thumb – Finger or thumb stuck in bent position
  281. 281. Diagnosis• Your doctor will ask about your symptoms and medical history, and perform a physical exam. The physical exam may include:• Asking you to move the affected finger or thumb• Feeling the hand and fingers• For severe cases of trigger finger, your doctor may refer you to a hand specialist.
  282. 282. Treatment• The goals of treatment for tenosynovitis are: –to reduce swelling and pain –to allow the tendon to move freely with the tendon sheath.
  283. 283. • Treatment options include the following:• Rest• Stopping movement in the finger or thumb, sometimes with the help of a brace or splint, is often the best treatment for mild cases of trigger finger.• Rest may be combined with stretching of the muscle tendon unit involved.
  284. 284. • Medications• Several medications are used to treat tenosynovitis. These include:• Corticosteroids, given as an injection into the synovial tendon sheath to reduce swelling of the tendon sheath• Nonsteroidal anti-inflammatory drugs (NSAIDs) to help reduce inflammation and pain: – Ibuprofen (Advil, Motrin) – Naproxen (Aleve, Naprosyn)• For severe cases of trigger finger that do not respond to medications, surgery may be used to release the finger from a locked position and to allow the tendon to move freely through the sheath.• This surgery is usually performed on an outpatient basis and requires only a small incision in the palm of the hand.
  285. 285. Prevention• The most important action you can take to prevent trigger finger is to avoid overuse of your thumb and fingers.• If you have a job or hobby that involves repetitive motions of the hand, you can take the following steps: – Adjust your workspace to minimize the strain on your joints – Alternate activities when possible – Take breaks throughout the day – Exercise regularly
  286. 286. Muscles contribute to Flexion of proximal interphalangeal joints of fingers Flexor digitorum superficialis• Origin:• Humeral head: common flexor origin of medial epicondyle humerus, medial ligament of elbow.• Ulnar head: medial border of coronoid process and fibrous arch.• Radial head: whole length of anterior oblique line• Insertion:• Tendons split to insert onto sides of middle phalanges of medial four fingers• Action:• Flexion of PIP & DIP joints• Nerve supply
  287. 287. Normal & Good• Position:• Sitting with hand resting palm upward on table and fingers extended.• Stabilization:• Stabilize proximal phalanx of finger.• Desired Motion:• Patient flexes middle phalanx.• Resistance:• Is given on palmar surface of middle phalanx of finger.
  288. 288. Fair & Poor• Patient flexes proximal phalanx through full range of motion for fair grade and through partial range for poor grade.
  289. 289. Trace & Zero• Superficial portion of the Flexor digitorum superficialis may be palpated at the wrist under the Palmaris longus
  290. 290. Caution!!!
  291. 291. Flexion of Distal Interphalangeal Joints of Fingers Flexor digitorum profundus
  292. 292. Muscles contribute to Flexion of distal interphalangeal joints of fingers Flexor digitorum profundus • Origin: • Medial olecranon, upper three quarters of anterior and medial surface of ulna as far round as subcutaneous border and narrow strip of interosseous membrane • Insertion: • Distal phalanges of medial four fingers. • Tendon to index finger separates early • Action: • Flexion of PIP & DIP joints • Nerve supply
  293. 293. Normal & Good• Position:• Sitting with hand resting palm upward on table and fingers extended.• Stabilization:• Stabilize middle phalanx of finger.• Desired Motion:• Patient flexes distal phalanx.• Resistance:• Is given on palmar surface of distal phalanx of finger
  294. 294. Fair & Poor• Patient flexes distal phalanx through full ROM for fair grade and through partial range for poor grade.
  295. 295. Trace & Zero• Flexor digitorum profundus may be palpated on the palmar surface of the middle phalanx
  296. 296. Caution!!!!
  297. 297. Extension of metacarpophalangeal joints of fingersExtensor digitorum communis Extensor indicis proprius Extensor digiti minimi
  298. 298. Muscles contribute to Extension of metacarpophalangeal joints of fingers Extensor digitorum communis• Origin:• Common extensor origin on anterior aspect of lateral epicondyle of humerus• Insertion:• External expansion to middle and distal phalanges by four tendons. Tendons 3 and 4 usually fuse and little finger just receives a slip• Action:• Extension of MP joints• Nerve supply

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