Manual Muscle Tests - UE

Wrist Flexion

• Muscles Involved

  • Flexor carpi radialis

  • Flexor carpi ulnaris

• Patient Positioning

  • The patient is seated with the dorsal surface of the forearm supported on the table in supination

• Therapist Position

  • The therapist is seated to access test-side

  • Palpation of wrist flexors

• To Test

  • The patient actively flexes the wrist through the range.

  • For grades 4 to 5 apply resistance through the palm in a direction opposite to flexion.

  • To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through a complete range of motion (active resistance testing) OR maintain an endpoint range (break testing) against maximum resistance.

• Biasing Muscles/ Muscle Groups

  • To bias flexor carpi ulnaris: instruct patient to flex wrist leading with 5th digit and apply resistance in the direction of radial deviation and extension over 5th metacarpal.

  • To bias flexor carpi radialis: instruct patient to flex wrist leading with the thumb and apply resistance in the direction of ulnar deviation and extension over 2nd metacarpal.

Wrist Extension

• Muscles Involved

  • Extensor carpi radialis longus

  • Extensor carpi radialis brevis

  • Extensor carpi ulnaris

• Patient Positioning

  • The patient is seated with palmar surface of forearm supported in pronation on the table, the wrist is neutral

• Therapist Position

  • The therapist is seated to access test-side

  • Palpation of wrist extensors

• To Test

  • The patient actively extends the wrist through the range.

  • For grades 4 to 5 apply resistance through the dorsal aspect of the hand in a direction opposite to extension.

  • To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through a complete range of motion (active resistance testing) OR maintain an endpoint range (break testing) against maximum resistance.

• Biasing Muscles/ Muscle Groups

  • To bias extensor carpi radialis longus & brevis: preposition the wrist in slight extension and radial deviation and instruct the patient to extend the wrist leading with the thumb side. Resistance is applied over the 2nd metacarpal (radial side) in the direction of flexion and ulnar deviation.

  • To bias extensor carpi ulnaris: preposition the wrist in slight extension and ulnar deviation and instruct the patient to extend the wrist leading with the 5th digit ("pinky") side. Resistance is applied over the dorsal surface of the 5th metacarpal (ulna side) in the direction of flexion and radial deviation.

Forearm Supination

• Muscles Involve

  • Supinator

  • Biceps brachii

• Patient Position

  • Grade 3 to 5: Short sitting, arm at side, elbow flexed to 90°.

  • Grade 2: Short sitting with shoulder flexed between 45° and 90° and elbow flexed to 90°, forearm in a neutral position.

  • Grade 1 and 0: Short sitting, arm, and elbow are flexed as for grade 3.

• Therapist Position

  • Grade 3 to 5: Stand at the side or in front of the patient. One hand supports the patient elbow and for resistance, grasp the forearm on the volar surface of the wrist.

  • Grade 2: Support the test arm by cupping the hand under the elbow.

  • Grade 1 and 0: Support the forearm just distal to the elbow.

• To Test

  • The instruction to the patient should be given in a language that the patients understand more clearly.

  • From the pronation, the patient begins to supinate until the palm faces the ceiling. The resistance motion applied by the therapist is in the direction of Pronation. To test Grade 3 no resistance is given, for Grade 4 minimum resistance is given and for 5 maximum resistance is given.

  • The patient supinates the forearm through a partial range of motion in the above given patient position.

  • For Grade 1 palpate the supinator muscle distal to the head of the radius on the dorsal aspect of the forearm. No limb movement is seen but contractile activity is present.

  • If there is no contractile activity then the grade is 0.

Forearm Pronation

• Muscle Involved

  • Pronator teres

  • Pronator quadratus

• Patient Position

  • Grade 3 to 5: Short sitting, arm at side, elbow flexed to 90°and forearm is positioned in supination.

  • Grade 2: Short sitting with shoulder flexed between 45° and 90° and elbow flexed to 90°, forearm in a neutral position.

  • Grade 1 and 0: Short sitting, arm, and elbow are flexed as for grade 3.

• Therapist Position

  • Grade 3 to 5: Stand at the side or in front of the patient. One hand supports the patient elbow and for resistance, grasp the forearm on the Dorsal surface of the wrist.

  • Grade 2: Support the test arm by cupping the hand under the elbow.

  • Grade 1 and 0: Support the forearm just distal to the elbow.

• To Test

  • The instruction to the patient should be given in a language which the patients understand more clearly.

  • From the Supination patient begins to pronate until the palm faces downward. The resistance motion applied by the therapist is in the direction of Supination. To test Grade 3 no resistance is given, for Grade 4 minimum resistance is given and for 5 maximum resistance is given.

  • Complete available range of motion and hold maximum resistance for grade 5. Complete available range of motion and hold moderate to minimum resistance for grade 4. Complete available range of motion without resistance. For grade 2 Instruct the patient to pronate the forearm in the given position.

  • For Grade 1 palpate the pronator teres over the upper third of the volar surface of the forearm on a diagonal line from the medial condyle of the humerus to the lateral border of the radius. No limb movement is seen but contractile activity is present.

  • If there is no contractile activity then the grade is 0.

Elbow Flexion

• Muscles Involved

  • Biceps brachii

  • Brachialis

  • Brachioradialis

• Patient Positioning

  • Grades 2 to 5 testing - the patient is seated

  • Grades 0 to 1 testing - the patient is supine for 'gravity minimal' position

  • Hand positioning depends on specific muscle:

    • Biceps: supination

    • Brachialis: pronation

    • Brachioradialis: mid-position

• Therapist Position

  • Therapist at test side

  • Ensure wrist flexors are not contracting

  • Palpation over intended test muscle

• To Test

  • The patient is to flex the elbow

  • Grades 4 and 5 with resistance over flexor surface at the distal forearm with force in the direction opposite to flexion.

  • To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through a complete range of motion (active resistance testing) OR maintain an end point range (break testing) against maximum resistance.

Elbow Extension

• Muscles Involved

  • Triceps brachii

  • Anconeus

• Patient Positioning

  • Prone with test side shoulder in ~90° abduction

  • The patient's test side forearm is hanging over the side of the plinth; the upper arm is supported on the plinth to the elbow.

  • For grades 0-2, the gravity minimal position is supported sitting with feet flat on the floor. The shoulder remains in the same position.

• Therapist Position

  • At test side

  • Provide stabilization support just above the elbow

• To Test

  • The patient is to extend elbow to the full available range

  • Grades 4 and 5 - The therapist will apply resistance over the dorsal forearm in the direction opposite to extension

  • To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through a complete range of motion (active resistance testing) OR maintain an endpoint range (break testing) against maximum resistance.

Shoulder Flexion

• Shoulder Flexion to 90 Degrees Muscles Involved

  • Deltoid (anterior)

  • Corcobrachialis

• Patient Positioning

  • Grades 3 to 5 - Patient is seated with arms at sides with elbows slightly flexed with the forearm in pronation

  • Grades 0 to 2 - Patient is side-lying with the knee flexed to 90 degrees and supported by the therapist ('gravity minimal' position)

• Therapist Position

  • Therapist to stand on the test side

  • Palpation shoulder flexors

• To Test

  • Patient to actively flex the shoulder to 90 degrees

  • For grades 4 to 5 apply resistance over the distal humerus just above the elbow in the direction opposite to shoulder flexion.

  • To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through a complete range of motion (active resistance testing) OR maintain an end point range (break testing) against maximum resistance.

Shoulder Extension

• Muscles Involved

  • Latissimus dorsi

  • Deltoid (posterior)

  • Teres major

• Patient Positioning

  • The patient is prone with the elbow extended with an arm free to move, palm directed up in direction of internal rotation

  • For grades 0-2 patient is in side-lying ('gravity minimal' position) +/- low friction board

• Therapist Position

  • Therapist stands on test-side

  • Palpation over shoulder extensors

• To Test

  • The patient actively extends the shoulder through the available range

  • For grades 4 to 5 apply resistance over the posterior surface of the distal humerus in a direction opposite to the extension

  • To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through a complete range of motion (active resistance testing) OR maintain an endpoint range (break testing) against maximum resistance.

Shoulder External Rotation

• Muscle Involved

  • Infraspinatus

  • Teres minor

• Patient Position

  • Grade 3 to 5: Prone position, head turned towards the test side, Shoulder abducted to 90°, and folded towel placed under the distal arm and forearm hanging vertically from the edge of the bed.

  • Grade 2 and 1: Prone position, head turned towards the test side, Patient at the edge of the bed so that the entire arm hangs freely from the edge of the bed. The arm is placed in a neutral position (palm facing the table).

• Therapist Position

  • Grade 3 to 5: Stand at the test side. For resistance place, the hand on the dorsal side of the forearm is just above the wrist, and the other hand provides counterforce at the elbow.

  • Grade 2,1 and 0: Stand or sit on a low table on the test side. The therapist should stabilize the test arm at the shoulder.

• To Test

  • Instruction to the patient should be given in the language they are comfortable with.

  • The Patient moves the arm in the available range of external rotation (upward).

  • Complete available range of motion and hold maximum resistance for grade 5. Complete available range of motion and hold moderate to minimum resistance for grade 4. Complete available range of motion without resistance. For grade 2 instruct the patient to rotate the shoulder externally in the given position.

  • For grade 1 palpate the infraspinatus over the body of the scapula below the spine of the scapula in the infraspinous fossa. Palpate the teres minor on the inferior margin of the axilla and along the axillary border of the scapula. Palpation contraction is present for grade 1 for either one or both muscles, and no palpable or visible contraction occurs for grade 0.

Shoulder Internal Rotation

• Muscle Involved

  • Subscapularis

• Patient Position

  • Grade 3 to 5: Prone position, head turned towards the test side, Shoulder abducted to 90°, and folded towel placed under the distal arm and forearm hanging vertically from the edge of the bed.

  • Grade 2 and 1: Prone position, head turned towards the test side, Patient at the edge of the bed so that the entire arm hangs freely from the edge of the bed. The arm is placed in a neutral position (palm facing the table).

• Therapist Position

  • Grade 3 to 5: Stand at the test side. For resistance place, the hand on the volar side of the forearm just above the wrist, and the other hand provides counterforce at the elbow. The resistance hand applies resistance in the downward and forward directions. The counterforce is applied backward and slightly upward.

  • Grade 2,1 and 0: Stand or sit on a low table on the test side. The therapist should stabilize the test arm at the shoulder.

• To Test

  • Instruction to the patient should be given in the language they are comfortable with.

  • The Patient moves the arm in the available range of internal rotation (backward and upward).

  • Complete available range of motion and hold maximum resistance for grade 5. Complete available range of motion and hold moderate to minimum resistance for grade 4. Complete available range of motion without resistance. For grade 2 Instruct the patient to rotate the shoulder internally in the given position.

  • For grade 1 palpate the subscapularis tendon deep in the central area of the axilla. Palpation contraction is present for grade 1 and No palpable or visible contraction is occur for grade 0.

Shoulder Horizontal Adduction

• Muscles Involved

  • Pectoralis Major

• Patient Positioning

  • Supine with the elbow flexed to 90° & shoulder abducted to either 60°, 90°, or 120° depending on desired target fibers to be tested.

  • For grades 0 to 2 patient is in sitting ('gravity minimal' position)

• GENERAL FUNCTIONAL SCREENING TEST

  • Shoulder abduction to 90°

• CLAVICULAR HEAD - C5 + C6 nerve root innervation, superior 1/3 of muscle fibers

  • Shoulder abduction to 60°

• STERNAL HEAD - C7, C8 + T1 nerve root innervation, inferior 2/3 of muscle fibers

  • Shoulder abduction to 120°

• Therapist Position

  • The therapist is standing at the test side

• To Test

  • The patient actively horizontally adducts the shoulder through the full available range.

  • The difference between this test as a general screen or specifically for the clavicular or sternal head will be direction of the movement against resistance

  • GENERAL SCREENING starting at 90° abduction, arm horizontally across the chest

  • CLAVICULAR HEAD starting from 60° abduction, the arm will move up and across the chest

  • STERNAL HEAD starting from 120° abduction, the arm will move down and across the chest

  • For grades 4 to 5 apply resistance to the forearm, just proximal to the wrist in a direction opposite to horizontal adduction

  • To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through a complete range of motion (active resistance testing) OR maintain an endpoint range (break testing) against maximum resistance.

Shoulder Abduction

• Muscles Involved

  • Deltoid (middle)

  • Supraspinatus

• Patient Positioning

  • Seated, shoulder positioned in the scapular plane 25 degrees anterior to the frontal plane, thumb directed up

  • For Grades 0-2 there is no 'gravity minimal' position for this movement.

• Therapist Position

  • The therapist is standing at the test side

  • Palpation over shoulder abductors.

• To Test

  • The patient actively abducts the shoulder

  • For grades 4-5 therapist to provide resistance over distal humerus in the direction opposite to shoulder abduction in the scapular plane.

  • To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through complete range of motion (active resistance testing) OR maintain an end point range (break testing) against maximum resistance.

Scapular Retraction/Adduction

• Muscles Involved

  • Trapezius (middle)

  • Rhomboid major

• Patient Positioning

  • The patient is prone, head turned to non-test-side

  • Test-side arm shoulder at 90° abduction and elbow in 90° flexion

  • For grades 0-2 the patient is seated with the arm externally rotated (palm up) and the arm supported on a flat surface such as a plinth ('gravity minimal' position)

• Therapist Position

  • Stand at the test side

  • Palpate shoulder adductor muscles

• To Test

  • Patient to perform scapula adduction "lift tip of elbow towards the ceiling"

  • For grades 4 to 5, provide resistance over distal humerus in the direction opposite to scapular adduction

  • Note: as with all resisted testing of vertebra-scapular muscles, the preferred resistance point is that which constitutes the longest lever as this more closely reflects the functional demands of the limb.

  • To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through a complete range of motion (active resistance testing) OR maintain an endpoint range (break testing) against maximum resistance.

Scapula Elevation

• Muscles Involved

  • Trapezius (upper)

  • Levator scapulae

• Patient Positioning

  • Seated with arms relaxed in lap, patient to have head turned away from test-side.

  • For grades 0-2 gravity eliminated, patient in prone.

• Therapist Position

  • Therapist to stand behind the patient

  • Palpation over scapular elevators

  • For grades 4 and 5: provide resistance downward at the top of the shoulder

• To Test

  • The patient actively elevates the scapula

  • For grades 4 and 5: the therapist to give resistance downwards in the direction opposite to elevation.

  • Note: as with all resisted testing of vertebroscapular muscles, the preferred resistance point is that which constitutes the longest lever as this more closely reflects the functional demands of the limb. To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through a complete range of motion (active resistance testing) OR maintain an end point range (break testing) against maximum resistance.