shoulder+flexion+3

Manual Muscle Testing

of the Shoulder

PHTH 224

Evaluation, Testing and Measurements

Sem 2 - Ms. I. Devreux 1

2Objectives of the Lecture

To know the muscles active in shoulder flexion, extension, abduction and adduction and their anatomical basis.

To be aware and able to measure the ROM for these movements.

To be able to test the strength of the movements from a theoretical and practical aspect.


Sem 2 - Ms. I. Devreux

3SHOULDER FLEXION

TO 90

Evaluation and Measurements

PHTH 223



4Shoulder Flexion Movement to 90

1. Deltoid Anterior Muscle:

Action:

Flexes and medially rotates the shoulder joint.

Acts as stabilizer when abduction of shoulder is performed by the deltoid middle fibers.

Origin: anterior border & superior surface of the lateral 1/3 of the clavicle.

Insertion: Deltoid tuberosity of humerus

Deltoid Anterior

Coracobrachialis

Pectoralis Major (accessory)




2. Coracobrachialis muscle:

Action: Flexes and adducts the shoulder

Origin: apex of coracoid process of scapula.

Insertion: antero-medial surface of middle shaft of humerus, opposite to deltoid tuberosity.

Nerve: C6, C7.




Accessory Muscles:

-Pectoralis Major (clavicular fibers)

-Biceps Brachii.

ROM= 0 to 90.

Limitation of ROM: by ankylose ( stiffness) of the shoulder joint.



7Shoulder Flexion Movement to 90: MMT Procedure

Grade FAIR Strength( 3):

Pt. sits with elbow slightly flexed.

Therapist stands behind the pt.s affected shoulder. One hand is placed over the shoulder to fix the scapula.

Command: Pull your arm up in front of you and your palm toward the floor ( to 90) relax. Evaluation, Testing and Measurements Sem 2 - Ms. I. Devreux

8Shoulder FlexionMovement to 90: MMT ProcedureGrade 4-5 : Good and Normal Strength

Patient is sitting as in Gr. 3.

Therapist is behind, Proximal handstabilizes the scapula, distal handgives resistance above the elbowjoint.

Gr. 4: Moderate resistance is givenopposite the line of motion.

Gr.5: Maximum resistance + Holdposition is kept at the end of therange.

Command: Pull your arm up in frontof you and your palm to the floor +resist (for gr. 5: hold) at the end ofthe motion( to 90).



9Shoulder Flexion Movement to 90: Deltoid Anterior - Note

1. The pt. is requested to keep the forearm in pronation to avoid substitution by the biceps brachii when testing the elbow in extension.

2. To isolate the coraco-brachialis muscle,the motion is performed with complete elbow flexion and supinated forearm.(Shoulder flexion will then be with a

slight lateral rotation).

Biceps Brachii assists but with limitation

because the movement ( flex+ sup. ) will place the m. in a too short position.



10

Shoulder Movement to 90: Grade 2: Poor Strength:

Pt. is in sidelying with affected arm (over) supported on a smooth board( or by therapist) and elbow is slightly flexed.

Therapist is behind the affected shoulder to stabilize the scapula. The distal hand stabilizes the board( or supports the arm).

Command: Pull your arm in front of you( to 90) relax.



11

Shoulder Flexion Movement to 90:Grade 1 and 0: Trace & Zero

Strength:

Pt. Position: Side or supine lying.

Therapist palpates on the anterior aspect of the shoulder joint with proximal hand.

The therapist will fix the scapula with one hand and the other palpates.



12

Shoulder Flexion Movement to 90: Note

Effect of Weakness:

Weakness of these muscles will decrease

the strength of shoulder flexion.

Weakness of the coracobrachialis will

impaire function for movements that need

complete elbow flexion and supination as for

combing the hair.



13

Shoulder Extension

1. Lattissimus Dorsi

2. Teres Major

Origin:

Spinous processes of last 6 vertebrae.

Last 3 or 4 ribs.

Posterior 1/3 of external lip of iliac crest.

Part of inferior angle of the scapula.

Insertion: Intertubercular groove of humerus.



14

Shoulder Extension:

Accessory Muscles:

Triceps ( Long Head)

Teres Minor

Range of Motion :

From 0 to 50 beyond the midline.

Nerve: Thoracodorsal nerve

C6, C7, C8, C5 for the

Deltoid) Tetraplegia after hyperextension of neck



15

Shoulder extension: Latissimus Dorsi

Action of Latissimus Dorsi:

With the origin fixed:

medial rotation of the shoulder

adduction and extension of shoulder joint.

it depresses the shoulder girdle

assists in lat. flexion of the trunk.

With the insertion fixed, it assists in tilting the pelvis anteriorly and laterally.



16

Shoulder Extension: Latissimus Dorsi

If acting bilaterally, the muscle assists in : Hyperextension of the spine

Anterior tilting of the pelvis.

In flexing the spine depending on the axes of motion.

This m. is very important for: climbing, walking with crutches, hoisting the body up on parallel bars in which the m. acts to lift the body toward the fixed arm.



Activities

Forcefull swimming, rowing, chopping are largely dependent on the strength of this muscle.

Shoulder adductors & medial rotators are important but the latissimus dorsi is the most important one.

The Latissimus Dorsi may act as accessory muscle in respiration.



18

Shoulder extension: Teres Major

Origin: Dorsal surfaces of

inferior angle & lower third of

lat. border of scapula.

Insertion: crest of lesser

tubercle of humerus.

Action: Medially rotates,

adducts & extends shoulder

joint.



19

Shoulder extension: DeltoidDeltoid: ( Posterior Fibers)

Origin: Inferior lip of posterior

border of spine scapula.

Insertion: Deltoid tuberosity of

humerus.

Action: Extends and laterally

rotates the shoulder joint.

Acts as stabilizer when medial

fibers of deltoid are performing

abduction of the shoulder.Evaluation, Testing and Measurements


20

Shoulder extension: Test Procedure

Grade 3: Fair Strength:

Pt. Is in prone lying with arm

along body side.

Therapist stands beside the tabel

and fix the scapula with her

proximal hand placed over the

shoulder.

Command: Pull your arm up with palm uprelax.



21

Shoulder extensionGrades 4 and 5:

Same positions as in Gr. 3 .

Therapist applies the

resistance with the distal hand

above the elbow joint.

Resistance is moderate for gr.

4 and maximal for gr. 5 + hold

at the end of the ROM.

Command as in gr.3 + hold for

gr. 5 (Pull up arm with palm up)



22

Shoulder extensionGrade 2 (Poor strength):

Pt. in sidelying with the affected arm over & resting on a smooth board or supported by therapist in forearm pronation.

Therapist stands in front of the patient. Proximal hand is placed over the shoulder to stabilize the scapula.

Command: Pull your arm backwards relax)



23

Shoulder extension

Grade 1 & 0: Trace & Zero

grade:

Pt. In sidelying or prone.

Therapist is in at the back,

prox. hand stabilizes the

scapula.

distal hand palpates fibers

of the teres major.

Palpation on the lower part of

the axillary border of the

scapula and fibers of

latissimus dorsi slightly below.



24

Shoulder extension: Note

Motion should take place

primarily at the gleno humeral

joint.

Patient should not be allowed

to tip the scapula forward in an

effort to complete the range.



25

Shoulder extension: Weakness

Weakness of latissimus Dorsi:weak adduction of the arm toward the body or the body toward the arm.

Reduced strength of shoulder extension & lateral trunk flexion is diminished.

Weakness of Teres Major: Diminished strength of medial rotation and extension of humerus.

Weakness of Deltoid ( post. fibers):Diminished strength of extension of humerus.



26

New MOVEMENT:

shoulder abduction



27

SHOULDER ABDUCTION TO 90

ROM: 0 to 90.

2 muscles: Deltoid ( middle fibers)

Supraspinatus

Accessory ms. : Deltoid anterior and

posterior fibers act as stabilizers

The ROM may be limited by ankylose of the shoulder joint Evaluation, Testing and Measurements


28

SHOULDER ABDUCTION TO 90

Deltoid Middle Fibers :

Origin: Lateral margin of superior surface of acromion.

Insertion: Deltoid tuberosity of humerus.

Nerve : C5, C6.

Action:

Abducts the shoulder joint.



29

SHOULDER ABDUCTION TO 90:

Supraspinatus:

Origin: Medial 2/3 of supraspinatus fossa of scapula.

Insertion: Sup. facet of greater tubercle of

humerus.

Shoulder joint capsule.

Nerve : C4, C5, C6.

Action:

Abducts the shoulder.

Stabilizes the head of humerus in the glenoid cavity during movements of this joint.



30

SHOULDER ABDUCTION TO 90: Test procedure

Grade 3 Fair strength : Pt. sits over the edge of the table,

arm at side in mid position between lateral & medial rot., elbow flexed at a few degrees.

Therapist stands behind the pt. with proximal hand on the shoulder to stbilize scapula.

Command: With palm down ,raise your arm up & out to 90 ---Relax

! Action without lat. rotation to avoid substitution by biceps brachii.



31

SHOULDER ABDUCTION TO 90:Test procedure

Grades 4 & 5:

Pt. sits over the edge of the table.

Therapist is behind the pt., prox.

hand stabilizes scapula & distal

hand is placed proximal to elbow

joint to give resistance ( by

pressing down moderately for gr. 4

and maximally for gr. 5 + hold at

the end of range.

Command : with palm down raise your arm + hold for gr. 5 at the

end--- relax. Evaluation, Testing and Measurements


32


Grade 2 : Poor strength

Pt. Is in supine lying, arm beside

the body in mid position between

medial and lateral rotation.

Therapist position and grasp:

beside the table, proximal hand is

placed on the shoulder to

stabilize the scapula.

Command: with palm down, pull your arm out to 90---relax.



33


Grade 1 & 0: Trace & zero strength

Pt. Position in supine.

Therapist grasp the forearm to

give a sense of motion to the pt.,

proximal hand palpates the

middle fibers of the deltoid on

lateral surface of the upper third

of arm.

Command: try to pull your arm out ( to 90) ---relax.



34

SHOULDER ABDUCTION TO 90:Effects of weakness

Weakness of Deltoid middle fibers: inability to lift the arm in abduction against gravity.

If paralysis of deltoid + supraspinatus, the humerus tends to subluxate downward if arm is unsupported:

1 inch separation

of the head of

the humerus &

the glenoid cavity.



If axillary nerve isinvolved: deltoid is weak& supraspinatus is notaffected.

Supraspinatus weaknessor rupture decreases theshoulder joint stabilityallowing the head ofhumerus to change itsrelationship with glenoidcavity.



38

New Movement:



39

SHOULDER ADDUCTION Latissimus dorsi:

as shoulder extensors.

Teres Major : as sh. extensor.

Pectoralis Major:

Action:

For Upper fibers:Flexes the sh.

jt. & horiz. adduct the humerus

toward the opposite side.

For Lower fibers: Depress the

sh. girdle by the attachment on

the humerus.

Horizontally adduct the humerus

toward the opposite iliac crest.Evaluation, Testing and Measurements


40

Shoulder Adduction

Pectoralis Major:

Origin:

Anterior surface of sternal of clavicle.

Anterior surface of sternum.

Cartilage of first 6th or 7th ribs.

Insertion: Lateral lip of

intertubercular groove of

humerus.

Nerve supply: C5, C6, C7, C8, T1Evaluation, Testing and Measurements


41

SHOULDER ADDUCTION

Accessory muscle:Subscapularis.

Range of motion:

Pure adduction of the shoulder joint is from 90 of abduction to the 0 position.

Tests: as for shoulder extension & medial rotators as most of them have triple action ( in prone).

Pectoralis major is tested as for horizontal adduction.



42

New Movement



43

Shoulder Horizontal Abduction

Deltoid muscle: (posterior fibers)

ROM: 135

The ROM can be limited by : Tension of ant. fibers of capsule

of glenohumeral joint.

Tension of pectoralis major & deltoid anterior fibers.



44

Shoulder Horizontal Abduction: Test Procedure gr.3 Fair

Pt. is in prone lying position; shoulder abducted to 90, upper arm resting on the table & forearm hanging vertically over the edge.

Therapist stands beside the table, prox. hand is on the shoulder& distal hand stabilizes on the lateral border of the scapula.

Command: Pull your upper arm up.Relax . Evaluation, Testing and Measurements


45

Shoulder Horizontal Abduction:

Testing Procedure grade 4-5

Pt. In prone as in gr. 3.

Therapist proximal hand is on the shoulder, distal hand gives resistance proximal to elbow joint.

Gr4: resistance is moderate by pressing the upper arm down.

Gr.5: Maximum resistance is applied throughout the motion + hold at the end of ROM.Command: Pull your upper arm up---- (hold for gr.5)---relax.



46

Shoulder Horizontal AbductionTesting procedure for grade 2 Poor Strength

Patient is sitting on a stool, arm supported on a table in a 90 flexion position.

Therapist stands behind, proximal hand is placed on the shoulder, distal hand is on the lateral border of the scapula to stabilize it.

Command: Move your arm backward-----Relax .



47

Shoulder Horizontal Abduction:Testing for gr. 1 0

Pt. is in sitting as for gr. 2.

Therapist stands in front of

the patient, the proximal

hand is placed on shoulder

from the back of the pt.

The distal hand palpates

the fibers of the deltoid

(posterior portion) on

posterior aspect of shoulder

joint.

Command: Try to move your arm backwards .



48

Effects of Weakness

Weakness of the deltoid

muscle (Posterior fibers)

will result in inability to

perform horizontal

abduction of the shoulder

against gravity.



49

Shoulder Horizontal Adduction

Pectoralis Major: as in shoulder

adduction.

Accessory muscle: Deltoid

anterior fibers.

ROM : + or - 135

ROM can be limited by:

Tension of the shoulder

extensor muscles (Lattisimus

Dorsi, Teres Major)

Contact of arm with the chest.



50

Shoulder Horizontal Adduction:

Testing Procedure for Grade 3- Fair Strength

Patient is in backlyingposition, arm abducted to 90.

Therapist stands near the edge of table,

prox. hand is placed under the shoulder to stabilize the scapula.

Command: Raise your arm up to vertical position .



51


Testing Procedure for Grade 4 -5- Good/ Normal

Pt. is in supine, arm at 90abduction.

Therapists distal hand grasps the upper arm prox. to elbow joint for resistance.

Moderate( for gr.4) and maximal + hold (for gr. 5) is applied opposing the line of raising.

Command: Raise your arm up to the vertical position ---(hold-gr.5) ---Relax. Evaluation, Testing and Measurements


52


Testing Procedure for Grade 2- Poor Strength

Pt. Position:

Sitting in a stool, arm resting on the table in a position of 90 abd.

Therapist stands behind the patient , proximal hand is placed on the shoulder to stabilize the trunk.

*Command: Pull your arm forward---relax



53

Note:Horizontal AdductionSternal and clavicular portions of

pectoralis major may be isolated to some degree.In gr. 4 5 resistance is in a direction opposite to the line of pull of the muscle fibers:

Sternal & lower portion: upward & outward.

Clavicular & upper portion: downward & outward.

For gr. 3 the arm is placed above 90 abd. for testing the lower portion, & below 90 for testing the upper portion while in supine.

The pt. is asked to pull his arm to the vertical position for each direction of m. fibers being tested.

54


Effects of weakness:

Upper fibers: decreased ability to draw the arm inhorizontal adduction accross the chest, making it difficultto touch the hand to the opposite shoulder.

It also decreases strength of shoulder flexion and medialrotation.



55

Weakness of the lower fibers: Weakness decreases the strength of medial

rotation of the shoulder & add. obliquely toward the opposite hip.

There is loss of continuity of ms. action of the pectoralis major to the external oblique on the opposite side with the result that chopping or striking movements are difficult.

From supine, if the arm is placed diagonally overhead, he will find it difficult to lift the arm from the table.

He will also have difficulty holding any large or heavy object in both hands at or near waist level.



56

New Movement

External Rotation of the Shoulder



57

External Rotation Infraspinatus muscle:

1. Origin: medial 2/3 of infraspinous

fossa of scapula.

2. Insertion: middle facet of greater

tubercule of humerus

3. Shoulder joint capsule.

Nerve: suprascapular:C4, C5, C6

Action:

Laterally rotates the shoulder joint.

Stabilizes the head of humerus in the

glenoid cavity during movements of

this joint.Evaluation, Testing and Measurements


58

External RotationTeres Minor Muscle:

Origin: upper 2/3 dorsal surface of

lateral border of scapula.

Insertion: lowest facet of greater

tubercule of humerus & shoulder

jt. capsule.

Nerve C5 C6

Action: laterally rotates sh. joint &

stabilizes the head of humerus.

Accessory muscle: Deltoid

posterior fibers.

ROM = 90Evaluation, Testing and Measurements


59

External Rotation: ROM

ROM is approximatively 90.

Limitation of ROM is due to:

Tension of the superior portion

of capsular (glenohumeral)

ligament and coraco-humeral

ligament.

Tension of the medial rotator

muscles of the shoulder

(antagonists).



60

External Rotation: Grade 3: Fair strength

Pt. is in prone lying.

Shoulder is abducted to 90; upper arm is supported on table & hanging vertically over the edge.

Therapist stabilizes the scapula, distal hand is placed over the arm above the elbow to prevent abduction.

Command: Pull your hand up & toward your head ---relax



61

External Rotation: Grade 4-5 Testing

Position as in gr. 3, but distal

hand is over the wrist to give

resistance.

For gr. 4 : moderate resistance

while for gr. 5 maximal

resistance & hold at the end of

ROM.



62

External Rotation: Grade 2 ; Poor strength

Prone lying with the affected armentirely over the edge in mediallyrotated position. The palm is inthe direction of the foot of thetable.

Therapist is stabilizing thescapula by holding over & underthe shoulder.

Command: Turn your wholearm so that your palm & theinside of your elbow is facing you---relax



63

External Rotation: Gr. 1 & 0 strength.

Pt. Is in prone as in gr. 2.

Therapist is palpating the ms.

contraction of Teres Minor on the

axillary border of scapula &

Palpate the Infraspinatus over the

body of the scapula below the

spine of the scapula.

Command: Try to turn your arm so that your palm & inside elbow

faces you Evaluation, Testing and Measurements Sem 2 - Ms. I. Devreux

64

External Rotation: Weakness

Effects of weakness of these muscles will cause a medial rotation of the humerus.

Lateral rotation in anti-gravitypositions is difficult or impossible.

Note:

For grading a weak lateral rotator group against gravity, the prone position can be used but the supine position is preferred to eliminate the necessity of maximal trapezius fixation & decrease the assistance of deltoid posterior.



65

Internal Rotation

New MovementEvaluation, Testing and Measurements


66

Internal Rotation Muscles:

Subscapularis

Pectoralis Major

Latissimus Dorsi

Teres Major

Accessory: Deltoid (Anterior fibers)

ROM: aproximatively 90

ROM is limited : due to capsular ligament.

Lateral rotator muscles of the shoulder.



67

Internal Rotation : testing gr. 3 Fair strength

Pt. s in prone with shoulder abd. to

90, upper arm is supported on the table & forearm hanging vertically

over the edge.

Ph.Th. stands beside the table,

proximal hand & forearm is placed

on shoulder & scapula to stabilize it

but allowing freedom for the

shoulder rotation.

Pull your hand back & up keeping

your upper arm on the table---

relax. Evaluation, Testing and Measurements Sem 2 - Ms. I. Devreux

68

Internal Rotation : Testing gr.4-5 Good-Normal strength

Pt. Is in prone as in gr. 3.

Distal hand of therapist gives

resistance on the pt.s wrist.

Gr. 4: moderate resistance by

pressing down.

Gr. 5: Maximum resistance +

hold at end of ROM.

Command: Pull your hand back &

up keeping your upper arm on

the table + hold at end of ROM.



69

Internal Rotation : Testing gr.2 Poor strength

Pt. Position in prone, with entire arm hanging over the edge of the table in lateral rotation (palm & interior of elbow facing the patient).

Therapist grasps as for gr.3 on the scapula but allowing movements.

Command: Turn your whole arm in so that your palm & the interior of your elbow face me---relax.



70

Internal Rotation : Testing gr.1-0 Trace & Zero Strength

Position of therapist and patient as

for Gr. 3.

The distal hand palpates m.

contraction of:

Subscapularis: deep in the axilla

near insertion.

Latissimus Dorsi: palpated below

the lower part of the axillary

border of the scapula.

Pectoralis Major: on the anterior

aspect of the thorax ( sternal &

clavicular portions).



71

Internal Rotation :Effects of Weakness

Shoulder ext. rotators are also strong shoulder

adductor muscles,

The ability to perform medial rotation and

adduction is decreased by the weakness of

these muscles.



72



73

Elbow Flexion: Biceps Brachii, Brachialis

Muscles: Biceps Brachii:

Origin: Short Head: Apex of coracoid

process (scapula).

Long Head: Supraglenoid tubercle of scapula.

Insertion: Tuberosity of Radius and aponeurosis of Biceps Brachii.

Nerve: C5 C6Evaluation, Testing and Measurements


74


Action:

Flexes the shoulder joint & long head assists in abduction ifhumerus is laterally rotated.

With origin fixed; it flexes the elbow by moving the arm toward the humerus & supinates forearm.

With insertion fixed, it flexes the elbow jt. moving the humerus toward the forearm as in pull-up or chinning exercises.



75


Brachialis:

1. Origin: Distal of ant. surface of humerus.

2. Insertion: tuberosity of coronoid

process of ulna.

3. Nerve: C5, C6

4. Action: With the origin fixed, it

flexes the elbow moving the

forearm toward the humerus.

5. With the insertion fixed, it flexes

the elbow joint moving the

humerus toward the forearm as

in pull up or chinning exercises.Evaluation, Testing and Measurements


76

Elbow Flexion: Biceps Brachii, Brachialis, Brachoradialis

Brachioradialis:

Origin: proximal 2/3 of lateral

supracondylar ridge of humerus.

Insertion: lateral side of base of

styloid process of radius.

Nerve C5 C6.

Action:

Flexes the elbow jt.,

assists in pronating to

midposition

and supination to midposition.Evaluation, Testing and Measurements Sem 2 - Ms. I. Devreux

77

Elbow Flexion: Biceps Brachii, Brachialis, Brachioradialis

Accessory ms. : flexor ms. of the wrist & fingers (arising from medial epicondyle of humerus).

(Always test with fingers and wrist in a relaxed position

ROM: 0 to 145 - 160.

Limited ROM :

Contact of m. mass on volar aspect of arm & forearm.

Contact of coronoid process with coronoid fossa of humerus.



78

Elbow Flexion Test procedures:

To isolate brachioradialis from the biceps & brachialis muscle.

Brachioradialis works at its best when the flexion of the elbow is with forearm in mid position.

Biceps brachii: when forearm is in supination.

Brachialis : as inserted on the ulna, supination or pronation does not affect the action of the muscle.

All the following procedures can be done

in supination for Biceps brachii & brachialis &

in mid position for brachioradialis.



79

Elbow Flexion: Grade 3- Fair strength

Pt. is sitting with the arms along side ofthe body, forearm in Sup. (biceps,brachialis) or in midposition for thebrachioradialis.

Therapist is behind the pt. , proximalhand is on shoulder, distal handgrasps the arm over the elbow. Bothgrasps stabilize the patients upperarm.

Command: Bend your elbow---relax



80

Elbow Flexion: Grade 4-5; Good to Normal strength

Pt. its as in grade 3.

Therapist is in front of the patient &proximal hand grasps the upper armto stabilize it, distal hand appliesresistance at wrist joint level.

Command: Bend your elbow----hold(gr.5)---relax.

Moderate resistance for gr. 4 &maximum resistance for grade 5;directly opposite the line of motion +hold.



81

Elbow Flexion: Grade 2; Poor strength

Pt. Is in supine lying with shoulder at 90 abd. + lateral rotation.

Alternate: pt. in sitting on a low stool or kneeling on floor & arm in 90abd. on table.

Forearm in supination: for Biceps Brachii, brachialis.

Forearm in midposition for brachioradialis testing.

Therapist is near the affected arm , proximal grasps the upper arm to stabilize it.

Command: Bend your elbow---Relax



82

Elbow Flexion: Grade 1-0; Trace & Zero Strength

Patient in supine or sitting as in gr.2.

Therapist : proximal hand stabilizes the upper arm, distal hand palpates the tendon of:

Biceps Brachii on the ante cubital space.

Brachioradialis on the anterolateral aspect of the elbow.

Command: Try to bend your elbow---relax .



83

Elbow Flexion: Effect of weakness

Biceps Brachii &

Brachialis:

Weakness:

Decreased ability to flex

the forearm against gravity

especially when the

forearm is in supination.

Marked interference in ADL

such as feeding, combing

hair.

Substitution:

If musculocutaneous nerve

lesion, pt. will pronate the

forearm before he/ she flexes

using:

brachioradialis,

extensor carpi radialis

longus,

pronator teres

& wrist flexor muscles.Evaluation, Testing and Measurements


84

Elbow Flexion: Effect of weakness

Brachioradialis

Weakness : decreased strength of elbow

flexion, & supination or pronation to the

midline.



85



86

Elbow ExtensionTriceps Brachii:

Origin:

Long head on infraglenoid

tubercule of scapula.

Short head on lat. & post.

Surface of proximal of body of humerus, lateral intermuscular

sceptum.

Medial Head: distal 2/3 of medial

& post. surfaces of humerus

below the radial groove.

Insertion: posterior surface of

olecranon process of ulna.

Nerve: C6, C7, C8, T1

Action: extends the elbow

+ long head may assist in

shoulder add.&

extension.



87

Elbow ExtensionAnconeus:

Origin: Lateral epicondyle of

humerus, post. surface.

Insertion: lateral side of the

olecranon process.; upper of post. surface of ulna.

Nerve: C7 C8

Action: elbow extension + stabilizes

the ulna during pronation.



88

Elbow Extension

Acessory muscle: Extensor muscles of the wrist and fingers rising from the lateral condyle of the humerus.

ROM can be limited by:

Tension of the anterior radial and ulnar collateral ligaments of the elbow jt.

Tension of the flexor muscles of the forearm.

Contact of olecranon process with olecranon fossa on posterior aspect of humerus.

ROM: 0 to 145-160.



89

Elbow Extension

Grade 3: Fair strength.

Pt. Is in supine with shoulder

flexed to 90 & elbow flexed.

Therapist stands beside the table

at shoulder level; Proximal hand

fixes the upper arm by grasping

just above the elbow joint.

Command: Extend your elbow ---relax or move your arm upwards .



90

Elbow Extension: Testing Gr. 4-5; Good to Normal Str.

Pt. is in supine as in gr.3

Therapist stabilizes the upper arm above the elbow jt. & distal hand applies resistance on post. surface of the wrist.

Resistance: Moderate for gr.4.

Maximum resistance + hold for gr. 5.

Command: Move your arm upwards ---Hold (gr. 5) at end of ROM ---Relax .



91

Elbow Extension: Testing Gr.2 ;Poor strength

Pt. is sitting on a low stool with arm supported on the table, shoulder in 90 abduction & elbow flexion.

Or

Pt. in supine lying with shoulder abducted to 90 & laterally rotated + elbow flexed.

Therapist is behind the pt. , proximal hand stabilizes the upper arm by grasping above the elbow joint.

Note: in sitting, the shoulder girdle needs to be also stabilized to avoid shoulder protraction.

Command: Move your arm away from you .



92

Elbow Extension: Testing Gr.1-0 ;Trace to Zero strength

Pt. & Therapsit Position is as in gr.

2.

Distal hand of the therapist may

palpate the muscle contraction on

the superior surface of the arm

just above the olecranon.

Command : Try to move your arm away from you.



93

Elbow Extension: Effects of Weakness

ability to extend the elbow against gravity.

Interference with ADL as in reaching upward to a high shelve.

Loss of ability to throw objects or push with the extended elbow.

Unability to use crutches or cane as one cannot extend his elbow & transfer weight to his hand.



94

Elbow Extension: Note

Grades 3,4,5 can also be tested in prone position in

addition to supine.

In prone + horiz. abduction, the long head of the triceps is

shortened over both the elbow and the shoulder joint.

In supine + shoulder flexion, the long head of the triceps is

shortened over the elbow jt. while elongated over the

shoulder jt.

Therefore in prone, the triceps withstands less pressure than

when tested in supine. It is made less effective in the prone

position by being shortened fully over both joints.



95

Elbow extension: Note ( cont.)While the triceps & anconeus act together in elbow

extension, we can differentiate the 2 muscles.

By palpation: the belly of the anconeus is belowthe elbow joint.

By the nerve involvement: the radial nerveresponsible of the anconeus arises near the mid humeral level & is quite long a lesion can involve only this branch & leave the triceps unaffected.

Paralysis of the anconeus materially reduces the strength of elbow extension.



96



97



shoulder+flexion+3

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