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Examination of muscles
This document provides an overview of how to examine muscles, including: 1) Inspection of muscles to identify abnormalities in volume, contour, fasciculations, hypertrophy, and atrophy. 2) Palpation of muscles to assess consistency, tenderness, and contractures. 3) Assessing muscle tone using percussion. 4) Grading muscle strength using the MRC scale through specific testing positions and maneuvers to isolate individual muscles.
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Examination of muscles
- 1.
- 2. Goal • Quadriparesis • Hemiparesis/ Crossed • Paraparesis • Diplegia • Monoparesis • Proximal Vs distal ( Limb Girdle type, Scapulo Peroneal type, Distal upperlimb+ Proximal Lower limb ) • Selectivity of weakness •Normal •Weakness •Pattern of weakness •Associated findings
- 3.
- 4. Inspection • Volume andcontour • Fasciculations, Myokymia
- 5. Increased volume andcontour Hypertrophy Firm Increased or normal strength Pseudo hypertrophy Rubbery /doughy Decreased strength Generalized Physiological Myotonia congenita (Thomsen disease) Hypothyroidism (Hoffman’s Kocher Debre semelaigne) Segmental Dystonia Focal Radiculopathy Few muscles Dystrophinopathy Dysferlinopathy Cysticercosis, Sarcoidosis,Amyloidosis
- 6. Hypertrophy of calfmuscles • Dystrophinopathy ( EDB, Sartorius, Tongue, Hand muscles and infraspinatus ) • LGMD2C-F (sarco),LGMD2I , LGMD2L,LGMD2G • Myotonic Dystrophy type2 (DM type2) • Metabolic Myopathy ( Acid maltase, Cori Forbes ) • SMA • Hypothyroidism
- 7. Decreased volume andcontour Atrophy (Amyotrophy) Neurogenic Early wasting Wasting : Weakness Fasciculations Myogenic- proximal selective Weakness appears early Wasting : weakness Weakness> wasting Dystrophies Acid Maltase Hyperthyroidism HyperparathyroidismGeneralized/ Multisegmental – MND Proximal – SMA Distal- Neuropathy CMT Segmental- Syrinx ,Hirayama Plexopathy Disuse atrophy,Cachexia Normal power Parietal lobe lesion
- 9. • Valley sign •Poly Hill Sign • Calf heads on trophy sign • Popeye the sailor • Hatchet face with swan neck • Inverted Champagne bottle appearance • DMD • FSHD • LGMD Type2B • FSHD • DM • CMT
- 10. Few Muscles maybe absent • Mobius Duanes, Congenital Ptosis • Holt oram syndrome • Poland’s syndrome • Trapezius • Palmaris longus
- 11. Inspection • Fasciculations :Anterior Horn cell diseases, Radiculopathy, Hyperthyroidism, Hyperparathyroidism • Myokymia : Radiation plexopathy Isaacs Syndrome
- 12. Palpation • Feel thecontour • Consistency • Tenderness ( inflammatory, Infections, polio) • Contractures of the muscle ( Dystrophinopathy, Emery, Congenital Muscular dystrophy,LGMD,Bethlem, Ulrich, Centro Nuclear, Minicore) • Cramps and contractures ( metabolic)
- 13. Percussion • Brief feeblecontraction of muscle (normal) • Myotatic irritability prominent and exaggerated contraction ( tetany,tetanus, Electrolyte disturbance) • Myotonia (Thenar, EDC, Tongue) • Myoedema ( hypothyroidism )
- 14. Muscle Power- MMT •Strength of the movement • Many muscles participate in specific movement (prime muscles, synergist, fixators ) • By proper positioning of the limb and body single or limited muscles strength can be assessed
- 15. Supination – Byproper position we can involve one muscle Supinator ( Radial Nerve C7), Biceps, Brachio radialis Supinator Biceps Brachioradialis
- 16. • Anatomy ofmuscle • Origin, insertion, Nerve supply, and roots • Action • In which position to be examined ( supine, prone, sitting, standing) • How to activate the muscle • How to fix the limb or the part • Where to apply the resistance • How to grade the power
- 18. • Static Strength •Kinetic Strength
- 19.
- 20. Patient – Clinicianmiss match Long Lever Short Lever
- 21. Muscle power MRC gradingModified • 0 • 1 • 2 • 3 • 4 4+, 4, 4- • 5
- 22.
- 23. Neck Flexors (C1-C8) SCM, Supra Hyoid Infra hyoid, Platysma, Longus capitis, Longus collis, Scalene, Rectus capitis
- 24. Neck Extensors (C1-8) Trapezius,Splenius capitis cervicis, Semi spinalis, Longissmus Dropped head sign
- 25.
- 26. Scapular Muscles • Trapezius– elevation, retraction and lateral rotation of scapula • Levator scapulae – elevation, medial rotation • Rhomboids – Retraction and medial rotation • Serratus anterior - Protraction and lateral rotation • Lateral rotation by Trapezius and Serratus helps to elevate the arm above shoulder level
- 27. Trapezius ( Upper,middle, lower) Spinal Accessory C3,4
- 28. Trapezius ( Upper,middle, lower) Spinal Accessory C3,4
- 29.
- 30.
- 31. Serratus Anterior Long ThoracicNerve C5,6,7
- 32. Serratus anterior insupine position
- 33. Scapular winging • Serratusanterior and Trapezius weakness • SA- medial scapular winging more prominent in flexion of shoulder • Trapezius- lateral scapular winging more prominent in abduction of shoulder
- 34. Muscles of Shoulderjoint • Abductor - Deltoid, Supraspinatus • Adductors - Pectoralis major, Latissimus dorsi • Flexors - Pectoralis major, anterior fibers of deltoid • Extensors - Latissimus Dorsi, Teres Major, Deltoid posterior fibers • Medial Rotation- Subscapularis, Teres major, Latissimus, Pectoralis • Lateral Rotation - Infraspinatus,Teres minor • Elevation of arm above shoulder level- Trapezius, Serratus
- 35. Supraspinatus Suprascapular nerve Uppertrunk of Brachial plexus –C5,6
- 36.
- 37. Pectoralis Major Clavicularportion Medial and lateral pectoral nerves medial and lateral cords-C5-T1
- 38. Pectoralis Major Sternalportion Medial and lateral pectoral nerves medial and lateral cords-C5-T1
- 39. Latissimus Dorsi Thoraco DorsalNerve- Posterior cord- C6,7,8 Prone position
- 40. Shoulder – LateralRotation Infraspinatus ( Supra scapular nerve C5,6) Teres Minor
- 41. Shoulder- Medial Rotation Subscapularis TeresMajor Pectoralis Latissimus
- 42. Elbow flexion Biceps, Brachialis,( Musculo cutaneous Medial cordC5 6 ) Brachio radialis ( Radial nerve Posterior cord C5,6)
- 43. Elbow Extension Triceps AnconeusRadial Nerve Posterior cord C6,7
- 44. Pronation ( Pronatorteres and quadratus Median nerve C6,7 )
- 45. Supination Supinator ( RadialNerve C7), Biceps, Brachio radialis Supinator Biceps Brachioradialis
- 46. Flexor Carpi Radialis( Median C6,7) Flexor Carpi Ulnaris ( Ulnar C7,8)
- 47. Extensor Carpi Radialislongus and Brevis ( Radial nerve C7,8 Extensor carpi ulnaris (Radial Nerve PIN C7,8)
- 48. Flexor digitorum Superficialis(Median C7-T1) Flexor Digitorum Profundus ( UlnarC8-T1)
- 49. Extensor Digitorum communis ExtensorIndicis, Extensor digiti minimi ( PIN C7,8)
- 50. Flexor Pollicis Longus( Median C8) Extensor Pollicis Longus and brevis ( Radial C7,8)
- 51. Radial Abduction ofthumb APL ( Radial C7,8) Along the plane of palm
- 52. Palmar Abduction ofThumb APB ( Median Nerve C8) Perpendicular to the plane of palm
- 53. Flexor Pollicis Brevis,Opponene pollicis, Adductor Pollicis
- 54.
- 55. Abductor Digiti minimi,Flexor Digiti minimi, Opponens digit minimi ( Ulnar C8T1)
- 56. Dorsal Interossei Palmarinterossei Lumbricals
- 57. Hip Flexion Ilio Psoas(L1,2,3,4) (Tensor, Rectus femoris, Sartorius, pectineus) Fix the pelvis while testing the hip muscles Resistance on the medial aspect of leg Tensor fasciae latae
- 58.
- 59. Hip Extension Gluteusmaximus Inferior Gluteal Nerve (L5 S1)
- 60. Hip Adductor Adductor Longus,Brevis, Magnus Obturator nerve L2,3,4
- 61. Hip Abductors Gluteus Medius, Minimus Superior Gluteal Nerve L4,5,S1
- 62. Hip Medial Rotation GluMedius and Minimus Hip Lateral Rotation Glu Maximus, Obturator, Piriformis
- 63. Knee Extension QuadricepsFemoris ( Femoral L3L4)
- 64. Knee Flexion (Hamstrings) Tibial division of Sciatic Nerve L5 S1
- 65. Ankle Dorsi Flexion Tibialisanterior (Deep Peroneal Nerve L4,5) Ankle Plantar Flexion Gastrocnemius Soleus Tibial nerve S1,2
- 66. Ankle plantar Flexionin prone position
- 67. Ankle Inversion inflexion Tibialis posterior ( Tibial Nerve L5) Ankle inversion in Dorsiflexion Tibialis Anterior ( Deep Pero L5) Weakness in case of foot drop Localizes to L5 root
- 68. Ankle Eversion Peroneus longus,Brevis, Tertius (Sup Peroneal Nerve L5 S1)
- 69. Toes Extension EHL,EDL,EDB Deep Peroneal L5 , L5 S1 Toes Flexion FHL, FDL Tibial Nerve
- 70. Abdominal Muscles –Beevor’s sign Flexors of Spine
- 71.
Editor's Notes
- #2 Muscle examination skill is to be acquired properly . Understand the method of examination and practice it for number of times.
- #5 Volume of a muscle normal, increased or decreased. Muscle volumes are highly variable among the normal people. When the volume of muscle decreases the contour of the muscle also changes. Expose the muscles. Look and feel the volume and contour of the muscles. We have to examine all the muscles from front and back. Compare side to side. Look for Fascicualtions Myokymia is a ripple like contraction of muscle