BUERGER’S DISEASEBUERGER’S DISEASE

HISTORYHISTORY

USUAL CHIEF COMPLAINTS AREUSUAL CHIEF COMPLAINTS ARE Pain in right / left lower limb – Pain in right / left lower limb –

intermittent claudication, rest pain intermittent claudication, rest pain UlcerationUlceration Black discoloration of toes / footBlack discoloration of toes / foot

HISTORY OF PRESENT HISTORY OF PRESENT ILLNESSILLNESS

PAINPAIN Site, character, radiation of painSite, character, radiation of pain Enquire whether patient has history Enquire whether patient has history

of intermittent claudication or notof intermittent claudication or not Site of pain – foot, calf or thigh Site of pain – foot, calf or thigh Whether pain appears on walking, if Whether pain appears on walking, if

so after walking for how long?so after walking for how long?

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Mention the distance he can walk Mention the distance he can walk before the pain starts (Claudication before the pain starts (Claudication distance) distance)

What happens to pain if he continues What happens to pain if he continues walkingwalking

Does it compel him to take rest or the Does it compel him to take rest or the pain disappears on walking or the pain disappears on walking or the patient can continue walking inspite patient can continue walking inspite of painof pain

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Progress of claudication- Is the Progress of claudication- Is the claudication distance same from the claudication distance same from the onset or the claudication distance has onset or the claudication distance has reduced?reduced?

Enquire whether patient has rest pain Enquire whether patient has rest pain or not. If rest pain is present – site of or not. If rest pain is present – site of rest pain in the toes / foot / calf / over rest pain in the toes / foot / calf / over the ulcer or gangrenous area the ulcer or gangrenous area

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How does the patient get relief?How does the patient get relief? Often patient has some relief by Often patient has some relief by

keeping the leg hanging below the keeping the leg hanging below the bed or by application of warmthbed or by application of warmth

DETAILS ABOUT THE DETAILS ABOUT THE ULCERATION OR THE ULCERATION OR THE GANGRENEGANGRENE

Onset, any history of trauma, Onset, any history of trauma, progress of ulceration or the progress of ulceration or the gangrenegangrene

Any pain over the siteAny pain over the site

ANY HISTORY OF SUPERFICIAL ANY HISTORY OF SUPERFICIAL PHLEBITISPHLEBITIS

Ask whether patient has any pain, Ask whether patient has any pain, swelling or discolouration along the swelling or discolouration along the course of superficial veinscourse of superficial veins

ANY HISTORY OF RAYNAUD’S ANY HISTORY OF RAYNAUD’S PHENOMENONPHENOMENON

Ask whether patient has pain, Ask whether patient has pain, pallorpallor on exposure to cold and afterwards on exposure to cold and afterwards any any bluishbluish discolouration of toes or discolouration of toes or fingers and whether this is followed fingers and whether this is followed by by dusky red dusky red congestion in the feet congestion in the feet and hand and any burning painand hand and any burning pain

Enquire whether gangrene at finger Enquire whether gangrene at finger tips has been preceded by such tips has been preceded by such attack or notattack or not

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Enquire about chest pain and its Enquire about chest pain and its relation with exercise (Suggesting relation with exercise (Suggesting anginal pain)anginal pain)

Any history of blackout or loss of Any history of blackout or loss of consciousness (Suggesting any consciousness (Suggesting any cerebrovascular disease)cerebrovascular disease)

Any history of abdominal pain or Any history of abdominal pain or other gastrointestinal symptoms other gastrointestinal symptoms

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Any tingling, numbness or weakness Any tingling, numbness or weakness of any of the limbsof any of the limbs

Any history of impotence (may Any history of impotence (may suggest aortoiliac disease)suggest aortoiliac disease)

Bladder and bowel habitsBladder and bowel habits

PAST HISTORYPAST HISTORY

Similar illness in any other limb in the Similar illness in any other limb in the pastpast

Any history of hypertension or other Any history of hypertension or other cardiac diseasecardiac disease

Any history of diabetes or collagen Any history of diabetes or collagen diseasedisease

PERSONAL HISTORYPERSONAL HISTORY

Detail history of smokingDetail history of smoking When did he start smokingWhen did he start smoking How many cigarette / bidi per dayHow many cigarette / bidi per day Is he still continuing smoking or given Is he still continuing smoking or given

up If so when? Any relief after thatup If so when? Any relief after that

FAMILY HISTORYFAMILY HISTORY

Enquire about peripheral vascular Enquire about peripheral vascular disease particularly atherosclerotic disease particularly atherosclerotic disease in the family disease in the family

TREATMENT HISTORYTREATMENT HISTORY

Any drug treatmentAny drug treatment Any surgical treatment already doneAny surgical treatment already done

HISTORY OF ALLERGYHISTORY OF ALLERGY

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

General SurveyGeneral Survey DecubitusDecubitus Patient may be Patient may be

comfortable with the affected legs comfortable with the affected legs hanging below the level of the bedhanging below the level of the bed

Pulse rPulse rate, rhythm, character of ate, rhythm, character of pulse, condition of arterial wallpulse, condition of arterial wall

Details of peripheral pulses is to be Details of peripheral pulses is to be described under local examinationdescribed under local examination

LOCAL EXAMINATIONLOCAL EXAMINATION

EXAMINATION OF BOTH LOWER LIMBSEXAMINATION OF BOTH LOWER LIMBS Inspection Inspection Keep both lower limbs side Keep both lower limbs side

by sideby side Attitude of limbAttitude of limb Any deformity – loss of toes or any Any deformity – loss of toes or any

other deformityother deformity Any muscle wasting in thigh, calf or Any muscle wasting in thigh, calf or

foot foot

CONDITION OF VEINSCONDITION OF VEINS Normally filled veins are seen in both Normally filled veins are seen in both

lower limbslower limbs Any discolouration along the veinsAny discolouration along the veins Look for any guttering of veins (In Look for any guttering of veins (In

ischaemic limb the veins will be ischaemic limb the veins will be collapsed and pale blue gutters are collapsed and pale blue gutters are seen along the course of the veins)seen along the course of the veins)

This may appear with the patient This may appear with the patient supine or while elevating the leg supine or while elevating the leg during Buerger’s testduring Buerger’s test

WHAT DO YOU MEAN BY WHAT DO YOU MEAN BY GUTTERING OF VEINSGUTTERING OF VEINS

In a normal person the veins on the In a normal person the veins on the legs are fulllegs are full

When the legs are raised above the When the legs are raised above the level of the heart the veins collapselevel of the heart the veins collapse

However if the circulation is normal However if the circulation is normal the veins do not empty completelythe veins do not empty completely

In ischaemic limbs the veins may In ischaemic limbs the veins may remain collapsedremain collapsed

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In case of severe ischaemia on raising In case of severe ischaemia on raising the limb to 10 to 15 degree pale blue the limb to 10 to 15 degree pale blue gutters may appear along the course gutters may appear along the course of veinsof veins

This is called guttering of veinsThis is called guttering of veins

LOOK FOR SIGNS OF PEIPHERAL LOOK FOR SIGNS OF PEIPHERAL ISCHAEMIAISCHAEMIA

Condition of skin – Thin shiny skinCondition of skin – Thin shiny skin Loss of subcutaneous fatLoss of subcutaneous fat Loss or diminished hair over toes, Loss or diminished hair over toes,

dorsum of footdorsum of foot Changes in nail – whether nails are Changes in nail – whether nails are

brittle and there are transverse brittle and there are transverse ridges on the nailridges on the nail

GANGRENEGANGRENE Site and extent of gangreneSite and extent of gangrene Type (dry or moist)Type (dry or moist) Colour of the gangrenous areaColour of the gangrenous area

CONTDCONTD Line of demarcation- note the level Line of demarcation- note the level

and depth of demarcation – whether and depth of demarcation – whether skin, muscle or bone deepskin, muscle or bone deep

Observe the limb above the Observe the limb above the gangerenous area – whether pale, gangerenous area – whether pale, congested or oedematous congested or oedematous

Look at the pressure areas – heel, Look at the pressure areas – heel, malleoli, ball of the foot, tip of the malleoli, ball of the foot, tip of the toestoes

PALPATIONPALPATION

SKIN TEMPERATURESKIN TEMPERATURE – start palpating – start palpating from the foot and find at what level from the foot and find at what level temperature becomes normal in temperature becomes normal in comparison to the normal sidecomparison to the normal side

GANGRENE GANGRENE SiteSite SensationSensation Tenderness Tenderness Any local crepitus Any local crepitus

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Limb adjacent to gangrenous areasLimb adjacent to gangrenous areas TendernessTenderness Pitting oedemaPitting oedema

SPECIAL TESTS FOR SPECIAL TESTS FOR ASSESSMENT OF ASSESSMENT OF CIRCULATORY INSUFFICIENCYCIRCULATORY INSUFFICIENCY

BUERGER’S TESTBUERGER’S TEST (Vascular (Vascular angle) In a normal person the leg angle) In a normal person the leg can be kept at 90 degree angle can be kept at 90 degree angle without appearance of any pallorwithout appearance of any pallor

Appearance of pallor at 20 Appearance of pallor at 20 degree indicates severe degree indicates severe ischaemiaischaemia

HOW WILL YOU ASSESS HOW WILL YOU ASSESS BUERGER’S ANGLE OF BUERGER’S ANGLE OF

CIRCULATORY INSUFFICIENCY CIRCULATORY INSUFFICIENCY VASCULAR ANGLEVASCULAR ANGLE

Keeping the patient supine in the Keeping the patient supine in the bed, raise leg gradually and keep at bed, raise leg gradually and keep at 20 degree angle to the bed for 2 20 degree angle to the bed for 2 minutes and look for pallor or any minutes and look for pallor or any discomfort – pain discomfort – pain

If no pallor – raise limb to 30 degree / If no pallor – raise limb to 30 degree / 45 degree / 60 degree / 90 degree and 45 degree / 60 degree / 90 degree and look for pallorlook for pallor

Mention at what level pallor appears Mention at what level pallor appears

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The angle at which pallor appears is The angle at which pallor appears is called Buerger’s angle of circulatory called Buerger’s angle of circulatory insufficiencyinsufficiency

In a normal person the leg can be In a normal person the leg can be kept at 90 degree angle without kept at 90 degree angle without appearance of any pallor appearance of any pallor

Appearance of pallor at 20 degree Appearance of pallor at 20 degree indicates severe ischaemiaindicates severe ischaemia

HOW WILL YOU ASSESS HOW WILL YOU ASSESS CAPILLARY FILLING TIMECAPILLARY FILLING TIME

After estimating the vascular angle After estimating the vascular angle by noting the level at which pallor by noting the level at which pallor appearsappears

Patient is asked to sit up and hang Patient is asked to sit up and hang his leg below the bedhis leg below the bed

A normal leg will maintain the pink A normal leg will maintain the pink colour colour

An ischaemic leg will show change of An ischaemic leg will show change of colour from pallor to pink and red colour from pallor to pink and red purple colourpurple colour

HOW WILL YOU TEST FOR HOW WILL YOU TEST FOR CAPILLARY REFILLINGCAPILLARY REFILLING

Press the nail bed or the pulp of the Press the nail bed or the pulp of the tip of the finger for two seconds- and tip of the finger for two seconds- and then release then release

Look for the rapidity of capillary Look for the rapidity of capillary refillingrefilling

In normal person there is quick In normal person there is quick capillary refilling capillary refilling

In severe ischaemia capillary refilling In severe ischaemia capillary refilling may be delayed may be delayed

HOW WILL YOU TEST FOR HOW WILL YOU TEST FOR VENOUS REFILLINGVENOUS REFILLING

Empty a segment of vein by milking Empty a segment of vein by milking with two index fingers and the distal with two index fingers and the distal finger is released finger is released

Note the time of venous refilling Note the time of venous refilling

HOW WILL YOU DO CROSSED HOW WILL YOU DO CROSSED LEG TEST OR FUCHSIG’S TESTLEG TEST OR FUCHSIG’S TEST

Method – Patient sits on a chair with Method – Patient sits on a chair with the legs crossed the legs crossed

One knee resting on the other – divert One knee resting on the other – divert attention – look for oscillatory attention – look for oscillatory movement of upper leg.movement of upper leg.

If oscillatory movement is seen – then If oscillatory movement is seen – then popliteal pulse is present popliteal pulse is present

If oscillatory movement is absent – If oscillatory movement is absent – then popliteal pulse is absentthen popliteal pulse is absent

WHAT IS REACTIVE WHAT IS REACTIVE HYPERAEMIA TESTHYPERAEMIA TEST

Inflate the sphygmomanometer cuff Inflate the sphygmomanometer cuff around the limb and inflate the cuff to around the limb and inflate the cuff to about 250 mmHg and keep for 5 about 250 mmHg and keep for 5 minutesminutes

A pallor will appear release the A pallor will appear release the pressure in the cuffpressure in the cuff

Record the time interval between the Record the time interval between the release of cuff and appearance of red release of cuff and appearance of red flush in the skinflush in the skin

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In presence of normal circulation the In presence of normal circulation the red flush appear within 1-2 seconds red flush appear within 1-2 seconds

In a severly ischaemic limb the red In a severly ischaemic limb the red flush may not appear at allflush may not appear at all

This is called reactive hyperaemia This is called reactive hyperaemia testtest

MOVEMENTS OF JOINTS MOVEMENTS OF JOINTS ADJACENT TO GANGRENOUS ADJACENT TO GANGRENOUS

AREAAREA Movement of interphalangeal joint Movement of interphalangeal joint Midtarsal joint movementMidtarsal joint movement Movement of ankle jointMovement of ankle joint Movement of knee jointMovement of knee joint

EXAMINATION FOR NERVE EXAMINATION FOR NERVE LESION IN LOWER LIMBSLESION IN LOWER LIMBS

Motor system of lower limbsMotor system of lower limbs ToneTone Power of ankle dorsiflexor and Power of ankle dorsiflexor and

plantar flexorplantar flexor Power of knee flexor and extensorPower of knee flexor and extensor Power of hip flexor / extensor / Power of hip flexor / extensor /

abductor / adductorsabductor / adductors

SENSORY SYSTEM IN LOWER SENSORY SYSTEM IN LOWER LIMBSLIMBS

Crude touch and fine touchCrude touch and fine touch Pain sensation tested by pin prickPain sensation tested by pin prick Temperature sensationTemperature sensation REFLEXESREFLEXES Ankle jerk / knee jerk Ankle jerk / knee jerk Plantar responsePlantar response

EXAMINATION OF INGUINAL EXAMINATION OF INGUINAL LYMPH NODESLYMPH NODES

If palpable, number, size, surface, If palpable, number, size, surface, consistency and mobilityconsistency and mobility

PALPATION OF PERIPHERAL PULSESPALPATION OF PERIPHERAL PULSES ++ normal ++ normal + palpable but feeble+ palpable but feeble - not palpable- not palpable

1.1. Arteria dorsalis pedisArteria dorsalis pedis2.2. Anterior tibialAnterior tibial3.3. Posterior tibialPosterior tibial4.4. PoplitealPopliteal5.5. FemoralFemoral6.6. RadialRadial7.7. UlnarUlnar8.8. BrachialBrachial9.9. SubclavinSubclavin10.10. CarotidCarotid11.11. Superficial TemporalSuperficial Temporal

CONTDCONTD Condition of arterial wallCondition of arterial wall Palpate along the vessel for any Palpate along the vessel for any

tendernesstenderness Auscultation along major arteriesAuscultation along major arteries Listen for any bruit along the arteries Listen for any bruit along the arteries To listen to the bruit over an artery To listen to the bruit over an artery

use the bell of the stethoscope and use the bell of the stethoscope and do not press firmly over the arterydo not press firmly over the artery

GENERAL EXAMINATIONGENERAL EXAMINATION

Examination of abdomenExamination of abdomen Examination of cardiovascular systemExamination of cardiovascular system Examination of respiratory systemExamination of respiratory system Examination of nervous systemExamination of nervous system Examination of spine and craniumExamination of spine and cranium

WHAT IS THE IMPORTANCE OF WHAT IS THE IMPORTANCE OF BUERGER’S ANGLEBUERGER’S ANGLE

The height at which pallor appears The height at which pallor appears indicates the severity of ischaemiaindicates the severity of ischaemia

The height in cm between the level of The height in cm between the level of sternal angle and the level of heel at sternal angle and the level of heel at elevation indicates pressure in mm of elevation indicates pressure in mm of Hg in the foot vesselsHg in the foot vessels

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The time taken for the appearance of The time taken for the appearance of pink colour is called the capillary pink colour is called the capillary filling time and this depends upon the filling time and this depends upon the degree of arterial obstruction degree of arterial obstruction

A capillary filling time more than 30 A capillary filling time more than 30 seconds suggests severe ischaemia seconds suggests severe ischaemia

Appearance of the bed purple colour Appearance of the bed purple colour in the dependant leg also suggests in the dependant leg also suggests severe ischaemiasevere ischaemia

WHERE DO YOU PALPATE THE WHERE DO YOU PALPATE THE NORMAL PERIPHERAL PULSESNORMAL PERIPHERAL PULSES

ARTERIA DORSALIS PEDIS PULSEARTERIA DORSALIS PEDIS PULSE This is palpated on the dorsum of the This is palpated on the dorsum of the

foot lateral to the tendon of extensor foot lateral to the tendon of extensor hallucis longus at the proximal first hallucis longus at the proximal first intermetatarsus space from a point intermetatarsus space from a point midway between the two malleolimidway between the two malleoli

ANTERIOR TIBIAL ARTERY ANTERIOR TIBIAL ARTERY PULSEPULSE

Anterior tibial pulse is palpated in Anterior tibial pulse is palpated in front of the ankle midway between front of the ankle midway between the two malleoli and just lateral to the two malleoli and just lateral to the extensor hallucis longus tendon the extensor hallucis longus tendon

POSTERIOR TIBIAL ARTERY POSTERIOR TIBIAL ARTERY PULSEPULSE

This is palpated in the medical aspect This is palpated in the medical aspect of the ankle at a point one third of of the ankle at a point one third of the way between the tip of medical the way between the tip of medical malleolus and the point of the heel malleolus and the point of the heel and slightly inverting the foot to relax and slightly inverting the foot to relax the flexor retinaculumthe flexor retinaculum

POPLITEAL PULSEPOPLITEAL PULSE Patient lies supine, flex the knee to Patient lies supine, flex the knee to

135 degree, heel resting on the bed 135 degree, heel resting on the bed Place the thumbs over the tibial Place the thumbs over the tibial

tuberositytuberosity The popliteal artery is palpated The popliteal artery is palpated

against the tibia in between the against the tibia in between the medial and lateral condyles of tibia medial and lateral condyles of tibia with the fingers of both handswith the fingers of both hands

Alternatively patient lies prone-knee Alternatively patient lies prone-knee flexed popliteal pulse may be flexed popliteal pulse may be palpated over the posterior surface of palpated over the posterior surface of the lower end of femurthe lower end of femur

FEMORAL PULSEFEMORAL PULSE

Palpated in the groin below the Palpated in the groin below the inguinal ligament at the level of the inguinal ligament at the level of the deep inguinal ring which is midway deep inguinal ring which is midway between the anterior superior iliac between the anterior superior iliac spine and the symphysis pubisspine and the symphysis pubis

RADIAL PULSERADIAL PULSE

Palpated in the forearm just above Palpated in the forearm just above the wrist joint in between the tendon the wrist joint in between the tendon of flexor carpi radialis and the lateral of flexor carpi radialis and the lateral border of the lower end of the radiusborder of the lower end of the radius

BRACHIAL PULSEBRACHIAL PULSE

Palpated in front of the elbow medial Palpated in front of the elbow medial to the tendon of biceps brachiito the tendon of biceps brachii

AXILLARY PULSEAXILLARY PULSE

Palpated in the lateral wall of the Palpated in the lateral wall of the axilla against the shaft of humerus in axilla against the shaft of humerus in between the two axillary folds between the two axillary folds

SUBCLAVIAN PULSESUBCLAVIAN PULSE

Palpated in the supraclavicular fossa Palpated in the supraclavicular fossa at the level of midclavicular point at the level of midclavicular point with the patient lifting the shoulder with the patient lifting the shoulder to relax the deep cervical fasciato relax the deep cervical fascia

CAROTID PULSECAROTID PULSE

Palpated at the medial border of the Palpated at the medial border of the sternocleidomastoid at the level of sternocleidomastoid at the level of the upper border of thyroid cartilagethe upper border of thyroid cartilage

SUPERFICIAL TEMPORAL SUPERFICIAL TEMPORAL PULSEPULSE

Palpated in front of the tragus over Palpated in front of the tragus over the zygomatic bone the zygomatic bone

WHAT IS INTERMITTENT WHAT IS INTERMITTENT CLAUDICATIONCLAUDICATION

Intermittent claudication is cramp like Intermittent claudication is cramp like pain in the muscle during walking due pain in the muscle during walking due to inadequate blood supply to the to inadequate blood supply to the muscle during exercisemuscle during exercise

The pain disappears when the patient The pain disappears when the patient takes rest and the muscle is relaxed takes rest and the muscle is relaxed

WHAT ARE THE GRADES OF WHAT ARE THE GRADES OF INTERMITTENT CLAUDICATIONINTERMITTENT CLAUDICATION

BOYD’S CLASSIFICATIONBOYD’S CLASSIFICATION GRADE I After walking for sometime GRADE I After walking for sometime

patient has pain, however the pain patient has pain, however the pain disappears when the patient disappears when the patient continues to walk continues to walk

The pain producing substances are The pain producing substances are washed off by the adequate collateral washed off by the adequate collateral supplysupply

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GRADE II Patient has pain after GRADE II Patient has pain after walking but he can continue to walk walking but he can continue to walk inspite of slight paininspite of slight pain

GRADE III Patient has pain after GRADE III Patient has pain after walking for sometime with continued walking for sometime with continued walking the pain aggravates and walking the pain aggravates and patient has to take rest to get relief patient has to take rest to get relief from pain from pain

WHAT IS NEUROGENIC WHAT IS NEUROGENIC CLAUDICATIONCLAUDICATION

This is pain in the legs during walking This is pain in the legs during walking due to some neurological cause and is due to some neurological cause and is usually due to nerve compressionusually due to nerve compression

HOW WILL YOU HOW WILL YOU DIFFERENTIATE A DIFFERENTIATE A

NEUROGENIC AND VASCULAR NEUROGENIC AND VASCULAR CLAUDICATIONCLAUDICATION

In vascular claudication patient In vascular claudication patient usually has pain after walking for usually has pain after walking for some distance and patient gets relief some distance and patient gets relief by simply taking restby simply taking rest

In neurogenic claudication patient In neurogenic claudication patient usually has pain after walking for usually has pain after walking for some distance often after taking few some distance often after taking few stepssteps

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Patient gets relief after taking rest Patient gets relief after taking rest and on assuming some posture so as and on assuming some posture so as to relieve compression of nerveto relieve compression of nerve

All peripheral pulses are palpableAll peripheral pulses are palpable

WHAT IS REST PAINWHAT IS REST PAIN

Rest pain is defined as continuous Rest pain is defined as continuous pain throughout day and night in the pain throughout day and night in the limb due to severe ischaemialimb due to severe ischaemia

The rest pain is due to ischaemia of The rest pain is due to ischaemia of the nerves and patient has some the nerves and patient has some comfort keeping the foot dependant comfort keeping the foot dependant below the level of bedbelow the level of bed

WHY REST PAIN IS MORE AT WHY REST PAIN IS MORE AT NIGHTNIGHT

Rest pain often awakes the patient up Rest pain often awakes the patient up from sleepfrom sleep

During sleep there is diminution of During sleep there is diminution of heart rate and blood pressure may be heart rate and blood pressure may be lowerlower

This result in further hypoperfusion This result in further hypoperfusion and may aggravate the ischaemic and may aggravate the ischaemic painpain

HOW WILL YOU ASSESS HOW WILL YOU ASSESS WASTING OF MUSCLES IN THE WASTING OF MUSCLES IN THE

LIMBSLIMBS Muscle bulk can be assessed by Muscle bulk can be assessed by

inspection on comparing the two inspection on comparing the two sides if there is wasting on one sidesides if there is wasting on one side

If there is bilateral wasting it may be If there is bilateral wasting it may be assessed by looking at the thinning of assessed by looking at the thinning of the limbs with bony prominencethe limbs with bony prominence

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In unilateral wasting it can be further In unilateral wasting it can be further confirmed by measuring the confirmed by measuring the circumference of the two limbs at circumference of the two limbs at same level from a bony point say 15 same level from a bony point say 15 cm below the tibial tuberosity for cm below the tibial tuberosity for assessing the calf muscle wastingassessing the calf muscle wasting

HOW WILL YOU GRADE HOW WILL YOU GRADE MUSCLE POWERMUSCLE POWER

While testing for muscle power it can While testing for muscle power it can be graded asbe graded as

Grade 0 No muscle contraction. Grade 0 No muscle contraction. Complete paralysisComplete paralysis

Grade 1 Only flicker of contraction. Grade 1 Only flicker of contraction. No movement No movement

Grade 2 Can move only when the Grade 2 Can move only when the gravity is eliminatedgravity is eliminated

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Grade 3 Can move against gravity Grade 3 Can move against gravity but not against resistancebut not against resistance

Grade 4 Can move against some Grade 4 Can move against some resistanceresistance

Grade 5 Can move against normal Grade 5 Can move against normal resistance. Normal power resistance. Normal power