International Standards for the Classification of Spinal Cord Injury Motor Exam Guide

C5 Elbow Flexors | Biceps Brachii, Brachialis

• Grade 3

  • Patient Position: The patient's shoulder is in neutral rotation, neutral flexion/extension, and neutral ab/adduction. The elbow is kept fully extended, with the forearm maintained in full supination. The wrist is positioned in neutral flexion/extension.

  • Examiner Position: The examiner supports the wrist.

  • Instructions to Patient: ‘‘Bend your elbow and try to reach your hand to your nose.’’

  • Action: The patient attempts to move through the full range of motion in elbow flexion against gravity.

• Grades 4 & 5

  • Patient Position: The shoulder occupies a position of neutral rotation, neutral flexion/extension, and neutral ab/adduction. The elbow is flexed specifically to $90^{\circ}$ and the forearm is in full supination.

  • Examiner Position: The examiner places a stabilizing hand on the anterior shoulder of the patient. The other hand grasps the volar aspect of the wrist and exerts a pulling force in the direction of elbow extension.

  • Instructions to Patient: ‘‘Hold your arm. Don’t let me move it.’’

  • Action: The patient resists the examiner’s pull, attempting to maintain the elbow in the $90^{\circ}$ flexed position.

• Grade 2

  • Patient Position: The shoulder is in internal rotation and adducted. The forearm is positioned above the abdomen, settling just below the umbilicus. the elbow is set at $30^{\circ}$ of flexion. Both the forearm and wrist are in neutral pronation/supination. Note: Sufficient shoulder flexion must be allowed so the forearm can move comfortably over the abdomen.

  • Examiner Position: The examiner supports the arm.

  • Instructions to Patient: ‘‘Bend your elbow and try to bring your hand to your nose.’’

  • Action: The patient attempts elbow flexion through a full range of motion in a gravity-eliminated plane.

• Grades 0 & 1

  • Patient Position: The position is identical to Grade 2 (shoulder in internal rotation and adducted; palm and ventral forearm over the abdomen; elbow at $30^{\circ}$ of flexion; neutral forearm/wrist pronation/supination).

  • Examiner Position: One hand supports the forearm while the alternate hand palpates the biceps tendon located in the cubital fossa. The examiner may also palpate or observe the belly of the biceps brachii muscle for movement.

  • Instructions to Patient: ‘‘Bend your elbow and try to bring your hand to your nose.’’

  • Action: The patient attempts elbow flexion; the examiner looks for trace muscle contraction.

C6 Wrist Extensors | Extensor Carpi Radialis Longus, Extensor Carpi Radialis Brevis

• Grade 3

  • Patient Position: Shoulder in neutral rotation, neutral flexion/extension, and neutral ab/adduction. The elbow is fully extended, the forearm is in full pronation, and the wrist is in a flexed starting position.

  • Examiner Position: One hand supports the distal forearm to ensure the wrist is pre-positioned in enough flexion for effective testing.

  • Instructions to Patient: ‘‘Bend your wrist upwards. Lift your fingers toward the ceiling.’’

  • Action: The patient attempts to extend the wrist through a full range of motion.

• Grades 4 & 5

  • Patient Position: Same as Grade 3, except the wrist starts in a fully extended position.

  • Examiner Position: The examiner grasps the distal forearm to stabilize the wrist. Pressure is applied across the metacarpals in a downward direction toward flexion and ulnar deviation. Note: The force must be angled specifically toward the ulnar side because the radial wrist extensors are the primary muscles being tested.

  • Instructions to Patient: ‘‘Hold your wrist up. Don’t let me push it down.’’

  • Action: The patient resists the examiner's downward and ulnar force to maintain full wrist extension.

• Grades 0, 1 & 2

  • Patient Position (Primary): The arm rests on the exam table. Shoulder is in neutral (flexion/extension, rotation, ab/adduction). Elbow is fully extended. Forearm is in neutral pronation-supination. Wrist begins fully flexed.

  • Patient Position (Alternate): Shoulder in slight flexion, internal rotation, and abducted with the arm above the abdomen. Elbow flexed to $90^{\circ}$, forearm in full supination, and wrist flexed.

  • Examiner Position: Support the forearm. For trace function (Grade 1), palpate the radial wrist extensors just proximal to the wrist on the radial aspect of the distal forearm; observe the muscle belly for movement.

  • Instructions to Patient: ‘‘Bend your wrist backwards.’’

  • Action: The patient attempts to extend the wrist through a full range of motion.

• C6 Common Muscle Substitution

  • Wrist extension can be mimicked by forearm supination combined with the use of gravity. The examiner must ensure the forearm is stabilized and correctly positioned to avoid this error.

C7 Elbow Extensors | Triceps

• Grade 3

  • Patient Position: Shoulder in neutral rotation, neutral ab/adduction, and $90^{\circ}$ of flexion. The elbow is fully flexed, with the palm of the hand resting near the ear.

  • Examiner Position: The examiner supports the upper arm.

  • Instructions to Patient: ‘‘Straighten your arm.’’

  • Action: The patient attempts full elbow extension against gravity.

• Grades 4 & 5

  • Patient Position: Identical to Grade 3, but the elbow is pre-positioned at $45^{\circ}$ of flexion.

  • Examiner Position: Support the upper arm. Grasp the wrist and apply resistance to the distal forearm in the direction of elbow flexion.

  • Instructions to Patient: ‘‘Hold this position. Don’t let me bend your elbow.’’

  • Action: The patient attempts to maintain the $45^{\circ}$ elbow flexion position against the examiner’s pressure.

• Grade 2

  • Patient Position: Support the arm under the elbow and the wrist. Shoulder is in internal rotation with the forearm positioned above the abdomen. Forearm in neutral pronation/supination. Elbow starts fully flexed. Note: Shoulder flexion must allow the forearm to clear and move over the chest/abdomen.

  • Examiner Position: Support the arm at the elbow and wrist.

  • Instructions to Patient: ‘‘Straighten your arm.’’

  • Action: The patient attempts to move through a full range of elbow extension in a gravity-eliminated plane.

• Grades 0 & 1

  • Patient Position: Maintain the Grade 2 position (shoulder internal rotation, forearm above abdomen, neutral pronation/supination), but with the elbow at $30^{\circ}$ of flexion.

  • Examiner Position: Support the arm. For trace function, palpate the distal triceps at its insertion on the olecranon. The muscle belly may also be palpated or observed for movement.

  • Instructions to Patient: ‘‘Straighten your arm.’’

  • Action: The patient attempts to fully extend the elbow.

• C7 Common Muscle Substitution

  • Elbow extension can be falsely mimicked by:

  1. External rotation of the shoulder.

  2. Quick elbow flexion followed by relaxing (rebound).

  3. Spasticity of the triceps.

  • Mitigation: Maintain correct testing position, provide clear instructions, and avoid starting with elbow flexion. Palpate the triceps to confirm correct muscle use.

C8 Long Finger Flexors | Flexor Digitorum Profundus

• Grade 3

  • Patient Position: Shoulder in neutral (rotation, flexion-extension, ab/adduction). Elbow fully extended, forearm fully supinated. Wrist in neutral flexion-extension. Metacarpal phalangeal (MCP) and proximal interphalangeal (PIP) joints are stabilized in extension.

  • Examiner Position: Use two hands to grasp the patient's hand and stabilize the wrist in neutral. Secure PIP and MCP joints in extension while isolating the middle finger. Stabilize the volar aspect of the 3rd middle phalanx with the thumb of the opposite hand.

  • Alternate Method: One hand can stabilize if the patient’s hand is supinated on a bed/mat. Ensure wrist tenodesis is avoided by stabilizing the forearm.

  • Instructions to Patient: ‘‘Bend the tip of your middle finger.’’

  • Action: The patient attempts to flex the distal interphalangeal (DIP) joint through the full range of motion.

• Grades 4 & 5

  • Patient Position: Same as Grade 3, but the DIP joint is fully flexed.

  • Examiner Position: Stabilize wrist, MCP, and PIP joints as in Grade 3. Apply pressure with the tip of the finger or thumb against the distal phalanx of the patient’s middle finger.

  • Instructions to Patient: ‘‘Hold the tip of your finger in this bent position. Don’t let me move it.’’

  • Action: Patient resists the examiner’s extension force to maintain DIP flexion.

• Grades 0, 1 & 2

  • Patient Position: Shoulder neutral, elbow fully extended, forearm in neutral pronation-supination, and wrist neutral. MCP and PIP joints are stabilized in extension.

  • Examiner Position: Stabilize the wrist in neutral to avoid tenodesis; stabilize MCP and PIP joints in extension. For trace function, palpate the tendons of the long finger flexors or observe the muscle belly.

  • Instructions to Patient: ‘‘Bend the tip of your middle finger.’’

  • Action: Patient attempts to flex the DIP joint through full range of motion.

• C8 Common Muscle Substitution

  • For Grades 1-3, active wrist extension can cause involuntary movement of the distal phalanx (tenodesis), which may be misinterpreted as voluntary flexion. The wrist must be carefully stabilized.

  • For Grades 4-5, the proximal phalanges must be stabilized to avoid misinterpreting movement caused by the hand intrinsics or the flexor digitorum superficialis.

T1 Small Finger Abductor | Abductor Digiti Minimi

• Grade 3

  • Patient Position: Shoulder in internal rotation, neutral ab/adduction, and $15^{\circ}$ flexion. Elbow at $90^{\circ}$ flexion, forearm pronated, and wrist neutral.

  • Examiner Position: Support the hand, ensuring MCP joints are stabilized to prevent hyperextension.

  • Instructions to Patient: ‘‘Move your little finger away from your ring finger, or spread your fingers apart.’’

  • Action: Patient attempts to abduct the little finger through the full range of motion.

• Grades 4 & 5

  • Patient Position: Same as Grade 3, but the little finger starts fully abducted.

  • Examiner Position: Support the hand and stabilize MCP joints. Use the index finger to apply pressure against the side of the patient’s distal phalanx.

  • Instructions to Patient: ‘‘Hold your little finger away from your ring finger. Don’t let me push it in.’’

  • Action: Patient resists the examiner's inward pushing force to maintain abduction.

• Grades 0, 1 & 2

  • Patient Position: Shoulder neutral, elbow in full extension, forearm in full pronation, wrist in neutral. MCP joint is stabilized.

  • Alternate Position: Elbow at $90^{\circ}$ flexion, forearm and wrist neutral (or palm flat on abdomen), and MCP stabilized to avoid extension.

  • Examiner Position: Stabilize the dorsal wrist and hand by pressing down lightly on the back of the hand. Ensure MCPs do not hyperextend. Palpate the abductor digiti minimi muscle.

  • Instructions to Patient: ‘‘Move your little finger away from your ring finger or spread your fingers apart.’’

  • Action: Patient attempts full range of abduction.

• T1 Common Muscle Substitution

  • Finger extension can mimic 5th finger abduction. Proper positioning and stabilization are required to minimize error.

L2 Hip Flexors | Iliopsoas

• Grade 3

  • Patient Position: Hip in neutral rotation, neutral abduction/adduction, with both hip and knee in $15^{\circ}$ of flexion.

  • Examiner Position: Support the dorsal aspect of the distal thigh and leg.

  • Instructions to Patient: ‘‘Lift your knee towards your chest as far as you can, trying not to drag your foot on the exam table.’’

  • Action: Patient attempts to flex hip to $90^{\circ}$.

  • Note: For acute traumatic lesions below T8, do not allow the hip to flex passively or actively beyond $90^{\circ}$ to avoid kyphotic stress on the lumbar spine.

• Grades 4 & 5

  • Patient Position: Hip in $90^{\circ}$ of flexion with the knee relaxed.

  • Examiner Position: Brace the anterior superior iliac spine (ASIS) on the opposite side. Place a hand on the distal anterior thigh, just above the knee, and apply pressure toward hip extension.

  • Instructions to patient: ‘‘Hold your knee in this position. Don’t let me push it down.’’

  • Action: Patient resists the downward push to maintain $90^{\circ}$ hip flexion.

• Grade 2

  • Patient Position: Gravity-eliminated position. Hip in external rotation and $45^{\circ}$ of flexion. Knee flexed at $90^{\circ}$.

  • Examiner Position: Support the leg at the knee and ankle.

  • Instructions to Patient: ‘‘Try to bring your knee out to the side,’’ or ‘‘Try to flex your hip toward the side of the body.’’

  • Action: Patient attempts to move through the full range of motion in hip flexion.

• Grades 0 & 1

  • Patient Position: Gravity-eliminated position (Grade 2 position).

  • Examiner Position: Support the thigh to eliminate friction while palpating the superficial hip flexors (sartorius and rectus femoris) just distal to the ASIS.

  • Instructions to Patient: ‘‘Move your knee out to the side.’’

  • Action: Patient attempts to flex the hip out to the side.

  • Note on Palpation: For Grade 1, the examiner cannot palpate the iliopsoas directly as it is too deep at this strength level; instead, palpation focus is on the more superficial sartorius and rectus femoris.

• L2 Common Muscle Substitution

  • Trunk muscles that elevate or rotate the pelvis can mimic hip flexion, including the rectus abdominis, adductor muscles, obliques, or the quadratus lumborum. Monitor for trunk movement.

L3 Knee Extensors | Quadriceps

• Grade 3

  • Patient Position: Hip in neutral rotation, neutral adduction/abduction, and $15^{\circ}$ of flexion. Knee begins at $30^{\circ}$ of flexion.

  • Examiner Position: Place an arm under the tested knee, resting the hand on the patient’s distal thigh to maintain the $30^{\circ}$ flexion.

  • Instructions to Patient: ‘‘Straighten your knee.’’

  • Action: Patient attempts to straighten the knee through the full range of motion.

• Grades 4 & 5

  • Patient Position: Same as Grade 3, but the knee is at $15^{\circ}$ of flexion.

  • Examiner Position: Place arm under the knee and hand on the opposite thigh. Grasp the tested leg just proximal to the ankle to apply downward force into flexion.

  • Instructions to Patient: ‘‘Hold this position. Don’t let me bend your knee.’’

  • Action: Patient resists the downward force to maintain $15^{\circ}$ of extension.

• Grade 2

  • Patient Position: Gravity-eliminated position: hip in external rotation and $45^{\circ}$ of flexion, knee flexed at $90^{\circ}$.

  • Examiner position: Support the distal thigh and ankle.

  • Instructions to Patient: ‘‘Straighten your knee.’’

  • Action: Patient attempts to move through the full range of motion.

• Grades 0 & 1

  • Patient Position: Grade 2 position.

  • Examiner Position: Support distal thigh and leg. Palpate the patellar tendon or the belly of the quadriceps muscle. Look for movement in the muscle belly.

  • Alternate Position: Hip neutral, hip and knee at $15^{\circ}$ flexion with examiner's hand under the knee. Instruct the patient to ‘‘push the back of the knee downward into the table’’ while palpating.

  • Instructions to Patient: ‘‘Straighten your knee.’’

  • Action: Patient attempts knee extension.

L4 Ankle Dorsiflexors | Tibialis Anterior

• Grade 3

  • Patient Position: Hip in neutral rotation/abduction, slightly flexed (knee also slightly flexed). Ankle starts in plantarflexion.

  • Examiner Position: Support the leg under the knee and ankle.

  • Instructions to Patient: ‘‘Bend your ankle to pull your foot and toes up toward your head.’’

  • Action: Patient attempts full range of dorsiflexion against gravity.

• Grades 4 & 5

  • Patient Position: Same as Grade 3, but the ankle starts fully dorsiflexed.

  • Examiner Position: Place hand on the dorsum of the foot and apply pressure downward toward plantarflexion.

  • Instructions to Patient: ‘‘Hold your ankle in this position. Don’t let me push it down.’’

  • Action: Patient resists the pressure to maintain full dorsiflexion.

• Grade 2

  • Patient Position: Gravity-eliminated: hip external rotation ($45^{\circ}$ flexed), knee flexed to $90^{\circ}$, ankle fully plantarflexed.

  • Examiner Position: Support under knee and ankle.

  • Instruction to Patient: ‘‘Lift the toes upward toward the head, bending the ankle upward.’’

  • Action: Patient attempts full range of dorsiflexion.

• Grades 0 & 1

  • Patient Position: Grade 2 position.

  • Examiner Position: Palpate the tibialis anterior muscle belly on the proximal lower leg or its tendon as it crosses the anterior ankle.

  • Instructions to Patient: ‘‘Bring your toes upward toward your head, letting your ankle bend.’’

  • Action: Patient attempts dorsiflexion.

• L4 Common Muscle Substitution

  • Ankle dorsiflexion can be mimicked by the long toe extensors (especially extensor hallucis longus). The examiner must look for active ankle movement, not just toe movement. Use stabilization and palpation to differentiate.

L5 Long Toe Extensors | Extensor Hallucis Longus

• Grade 3

  • Patient Position: Hip neutral, knee fully extended.

  • Examiner Position: Support the foot.

  • Instructions to Patient: ‘‘Lift your big toe upwards toward your knee.’’

  • Action: Patient attempts full range of great toe extension.

• Grades 4 & 5

  • Patient Position: Same as Grade 3, but the toe is fully extended.

  • Examiner Position: Place thumb on the distal phalanx of the great toe and apply downward pressure into toe flexion.

  • Instructions to Patient: ‘‘Keep your toe lifted upward. Don’t let me push it down.’’

  • Action: Patient resists the pressure to maintain full extension.

• Grade 2

  • Patient Position: Gravity-eliminated: hip external rotation ($45^{\circ}$), knee flexed ($90^{\circ}$). Ankle and long toe in a relaxed neutral position.

  • Examiner Position: Support under the knee and ankle.

  • Instructions to Patient: ‘‘Lift your big toe upwards toward the knee.’’

  • Action: Patient attempts full range of motion for toe extension.

• Grades 0 & 1

  • Patient Position: Grade 2 position.

  • Examiner Position: Support the leg and palpate the extensor tendon of the long toe.

  • Instructions to Patient: ‘‘Lift your big toe upwards toward your knee.’’

  • Action: Patient attempts to extend the great toe.

• L5 Common Muscle Substitution

  • Great toe extension can be facilitated by active plantarflexion of the foot (tenodesis effect). Proper stabilization to eliminate ankle movement is necessary.

  • Passive relaxation from a flexed position back to neutral can also be mistaken for active extension.

S1 Ankle Plantarflexors | Gastrocnemius, Soleus

• Grade 3 (Supine Modification)

  • Note: Supine testing for S1 differs from standard text methods.

  • Patient Position: Hip in neutral rotation and $45^{\circ}$ of flexion. Knee is fully flexed and ankle begins in full dorsiflexion.

  • Examiner Position: Support behind the knee. Place the other hand under the sole of the foot, pushing it into dorsiflexion. Patient’s heel remains on the table.

  • Instructions to Patient: ‘‘Push your foot down into my hand and lift your heel off the table.’’

  • Action: Patient pushes forefoot downward and raises the heel through full range of motion into plantarflexion.

• Grades 4 & 5

  • Patient position: Hip neutral, knee fully extended, ankle fully plantarflexed.

  • Examiner Position: One hand on the distal lower leg; the other grasps the plantar surface of the metatarsals. Apply pressure in the direction of dorsiflexion.

  • Instructions to patient: ‘‘Hold your foot pointed down. Don’t let me push it up.’’

  • Action: Patient resists the force to maintain full plantarflexion.

• Grade 2

  • Patient Position: Gravity-eliminated: Hip external rotation ($45^{\circ}$), knee flexed ($90^{\circ}$). Ankle supported in full dorsiflexion.

  • Examiner Position: Support under knee and ankle. Palpate gastrocnemius muscle belly or Achilles tendon.

  • Instructions to Patient: ‘‘Point your toes downward like a ballet dancer.’’

  • Action: Patient attempts full range of motion in plantarflexion.

• Grades 0 & 1

  • Patient Position: Grade 2 position.

  • Examiner Position: Support under knee and ankle. Palpate gastrocnemius belly or Achilles tendon; observe muscle belly for movement.

  • Instructions to Patient: ‘‘Point your toes downward like a ballet dancer.’’

  • Action: Patient attempts plantarflexion.

• S1 Common Muscle Substitution

  • Visually monitor hip flexors to ensure they are not being used to assist or facilitate plantarflexion.