Daniels and Worthingham's Muscle Testing PDF - 10th Edition

Daniels and Worthingham's Muscle Testing Techniques of Manual Examination and Performance Testing 10 TH EDITION Dale Avers | PT, DPT, PhD, FAPTA Professor Department of Physical Therapy Education College of Health Professions SUNY Upstate Medical University Syracuse, New York Marybeth Brown | P...

Daniels and Worthingham's Muscle Testing Techniques of Manual Examination and Performance Testing 10 TH EDITION Dale Avers | PT, DPT, PhD, FAPTA Professor Department of Physical Therapy Education College of Health Professions SUNY Upstate Medical University Syracuse, New York Marybeth Brown | PT, PhD, FAPTA, FACSM Professor Emeritus Physical Therapy Program, Biomedical Sciences University of Missouri Columbia, Missouri 2 Table of Contents Cover image Title Page Copyright Dedication Tribute page Helen J. Hislop, PT, PhD, FAPTA — A Tribute Preface Alphabetical List of Muscles A B C D E F G H I L M N O P Q R S T U V Z 3 Introduction Brief History of Muscle Testing How to Use This Book Names of the Muscles Anatomical Authorities The Convention of Arrows in the Text References Chapter 1 Principles of Manual Muscle Testing Muscle Test References Chapter 2 Relevance and Limitations of Manual Muscle Testing Relevance and Limitations References Chapter 3 Testing the Muscles of the Neck Testing the Muscles of the Neck Capital Extension Cervical Extension Capital Flexion (Chin Tuck) Cervical Flexion Flexion to Isolate a Single Sternocleidomastoid Cervical Rotation References Chapter 4 Testing the Muscles of the Trunk and Pelvic Floor Trunk Extension Elevation of the Pelvis Trunk Flexion Trunk Rotation Core Tests Quiet Inspiration Forced Expiration Pelvic Floor References Chapter 5 Testing the Muscles of the Upper Extremity Introduction to Shoulder Girdle Strength Testing Scapular Abduction and Upward Rotation Scapular Elevation Scapular Adduction (Retraction) 4  Scapular Depression and Adduction Scapular Adduction (Retraction) and Downward Rotation Latissimus Dorsi Introduction to Testing the Deltoid Shoulder Flexion Shoulder Extension Shoulder Abduction Shoulder Horizontal Abduction Shoulder Horizontal Adduction Introduction to the Rotator Cuff Shoulder External Rotation Shoulder Internal Rotation Elbow Flexion Elbow Extension Forearm Supination Forearm Pronation Wrist Flexion Wrist Extension Introduction to Testing the Muscles of the Hand Finger PIP and DIP Flexion PIP Tests DIP Tests Finger MCP Extension Finger MCP Flexion Finger Abduction Finger Adduction Thumb MCP and IP Flexion Thumb MCP and IP Flexion Thumb IP Flexion Thumb MCP and IP Extension Thumb MCP and IP Extension Thumb Abduction Thumb Abduction Thumb Abduction Thumb Adduction Opposition (Thumb to Little Finger) Grip Strength References Chapter 6 Testing the Muscles of the Lower Extremity Hip Flexion Hip Flexion, Abduction, and External Rotation With Knee Flexion 5  Hip Extension Hip Abduction Hip Abduction From Flexed Position Hip Adduction Hip External Rotation Hip Internal Rotation Knee Flexion Knee Extension Ankle Plantar Flexion Foot Dorsiflexion and Inversion Foot Inversion Foot Eversion With Plantar Flexion Hallux and Toe MP Flexion Hallux and Toe MP Flexion Hallux and Toe DIP and PIP Flexion Hallux and Toe MP and IP Extension References Chapter 7 Alternatives to Manual Muscle Testing Alternatives to Manual Muscle Testing References Chapter 8 Testing Functional Performance Chair Stand Gait Speed Physical Performance Test and Modified Physical Performance Test Timed Up and Go Stair Climb Floor Rise Gait References Chapter 9 Handheld Muscle Dynamometry Shoulder Flexion Shoulder Extension Shoulder Abduction Shoulder External Rotation Shoulder Internal Rotation Elbow Flexion Elbow Extension Wrist Extension Hip Flexion 6  Hip Extension Hip Abduction Hip External Rotation Hip Internal Rotation Knee Flexion Knee Extension Foot Dorsiflexion and Inversion References Chapter 10 Case Studies Introduction References Index List of Muscles by Region Head and Forehead Eyelids Ocular Muscles Nose Mouth Ear Jaw (Mastication) Tongue Pharynx Palate Larynx Neck Back Thorax (Respiration) Abdomen Perineum Upper Extremity Lower Extremity 7 Copyright 3251 Riverport Lane St. Louis, Missouri 63043 DANIEL AND WORTHINGTON'S MUSCLE TESTING, TENTH EDITION ISBN: 978-0-323-56914-9 Copyright © 2019, Elsevier Inc. All Rights Reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-0-323-56914-9 Content Strategist: Lauren Willis Content Development Manager: Ellen Wurm-Cutter Content Development Specialist: Linda Wood/Sarah Vora Publishing Services Manager: Julie Eddy Senior Project Manager: David Stein/Richard Barber Design Direction: Maggie Reid Printed in China Last digit is the print number 9 8 7 6 5 4 3 2 1 8 Dedication To my students and colleagues, who continue to challenge me to be the best I can be. —, Dale Avers This book is dedicated to my wonderful colleagues, who are the true backbone of our profession, and to my students, for these are the men and women who have made my days tremendously fun and totally worthwhile. This book is also dedicated to Helen J. Hislop—friend, mentor, and incredible woman. —, Marybeth Brown 9 Tribute page 10 Helen J. Hislop, PT, PhD, FAPTA — A Tribute In 2013 the physical therapy profession lost one of the brightest beacons it had ever known. Helen Hislop was an extraordinary woman who changed the course of our profession, in part by implementing heightened standards of academic success and by creating the DPT and PhD degrees during her tenure at the University of Southern California. She also took the editorship of Physical Therapy, the professional journal of the American Physical Therapy Association, and transformed it from an anecdotal “how to” magazine into a scientific journal with genuine credibility in the medical community. The sheer magnitude of her contributions is probably beyond that of any physical therapist in the history of our profession. One of the most notable achievements in Helen's repertoire was her authorship of four editions of the classic text, Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination. First published in 1946, the original Daniels, Williams, and Worthingham book was a “how to” manual for testing the patient with poliomyelitis. Although the book was modified to some extent over the next 30 years, the practice of physical therapy changed considerably during that time span and the earlier muscle testing book did not reflect the expansion of the profession to include the testing of neurological patients, the testing of men and women with orthopedic injuries and joint replacements, and contending with the burgeoning older adult population. Helen became involved in shepherding the book to a more contemporary text beginning with the 6th edition, and when the book was published in 1995, it reflected a sea change. Beautiful anatomical drawings produced under Helen's direction were incorporated, the testing of new patient populations was added, and there was the inclusion of new muscle tests that had evolved from clinical practice that were far more accurate than those described in previous texts, such as the 25× heel rise. Although these changes were the product of Helen's vision, the contributions of her coauthor, Jacqueline Montgomery, MA, PT, were of tremendous importance as Jackie was a clinician with her finger on the pulse of clinical practice. In 2010, Helen called to ask if I would become a contributor to the 9th edition, and I agreed. After multiple trips to Helen's home in North Carolina it became apparent that her declining health was going to preclude completion of the book without a great deal more help. We worked for another year, but with looming deadlines and the need for a move away from “manual” muscle testing, and the inclusion of functional testing, it became necessary to enlist additional help. Dale Avers, PT, DPT, PhD, FAPTA, was asked to be an author and edition 9 continued to evolve in response to changing practice. Even with multiple hospitalizations and further declines in health, Helen continued to be a vital contributor to edition 9. At all times she was “in charge.” Her fortitude was extraordinary; once a vision was planted in her brain, there was no dissuading her from the task at hand. She never saw the final completed copy of edition 9 but she contributed to each and every one of the enormous changes brought forth in the new book. Even though Helen is gone, her contributions will persist through many more iterations of this text. Wherever Helen may be, there is no question she is lustily singing Gilbert and Sullivan tunes, engaging those around her in lively and insightful conversation, regaling anyone who will listen with tales of Scottish history, and making people laugh. Hopefully, too, she has caught the “big fish” that eluded her for her entire 84 years. Rest in peace, dear friend. — Mb 11 Preface For more than 70 years, Daniels and Worthingham's Muscle Testing has been informing students and practitioners about the art and science of manual muscle testing. Over the past seven decades there have been nine editions of the text, not including this current edition. So, why an Edition 10? Muscle Testing has evolved into a different entity during its lengthy history. Initially a primer on how to test muscles affected by poliomyelitis, Daniels and Worthingham's Muscle Testing book now reflects the muscle testing requirements for a far broader scope of practice. Additionally, muscle testing techniques are now appropriate for patients who range in age from young adults to those who have lived 100 or more years (material appropriate for children may be found in other sources). Building on manual testing, this edition includes power testing and endurance testing, as well as alternate testing using free-weights, weight machines, elastic bands, body weight, functional testing, and most recently, handheld dynamometry. The tests included in this edition are far more evidence-based than they have been in the past due to the contributions of numerous researchers who have advanced our understanding of assessment. In many instances, normative values now exist and they have been included in Edition 10. Finally, for the beginning practitioner, exercises have been added to help the new therapist in the design of appropriate treatment programs. Thus, as the health professions have evolved, so too has muscle testing. We believe this book is the most up-to-date muscle testing book available, with detailed “how to” information on hundreds of tests. Importantly, this new edition is evidence-based, an imperative in our contemporary health-care system. For those of you with historical perspective, it is evident that a number of editors and contributors to Muscle Testing have come and gone over the years. The historical figures associated with the early editions of this text are long gone, but each made important contributions and passed the mantle to the next generation of scholars. Now, it is we who are the caretakers of the book and in due time we too will pass the torch to younger individuals with their fingers on the pulse of practice and scholarship. Why us? We were chosen because of a long and rich association with Helen Hislop, the previous author who was at the helm of the book for nearly 40 years. Helen valued our clinical expertise and anatomical knowledge and gave her blessing to this change of the book's leadership. We hope you will be pleased with our efforts. We are enormously grateful to our forebears for the work that went into the creation of this text. We are grateful as well to the individuals who helped in the creation of the book, particularly our developmental editor, Linda Wood, who has skillfully guided the development of five editions of the book. We also thank Yoshi Miyake for the drawings of the new tests and Jeanne Robertson for the new anatomical drawings. For the original videos, we thank Judith Burnfield, whose work we have built upon in developing the new videos for this edition. Additional thanks go to the individuals who contributed to and reviewed sections of the book during its development: Richard Bohannan, PT, PhD, FAPTA, of Campbell University; Christopher Neville, PT, PhD, of Upstate Medical University; and Kevin Neville, PT, DPT, of Upstate Medical University. We are grateful for their valuable insights. We are also grateful for the four second-year DPT students from Upstate Medical University who were the models for many of the illustrations in the new edition: Melanie Chapman, Marissa Coppola, Kathryn Dziwulski, and Vanessa Sweet. And finally, we thank the team at Elsevier including Sarah Vora, Michael Fioretti, and many others whose behind-the-scenes work helped bring the book to fruition. Dale Avers PT, DPT, PhD, FAPTA Marybeth Brown PT, PhD, FAPTA 12 13 Alphabetical List of Muscles 14 A 215 Abductor digiti minimi (foot) 159 Abductor digiti minimi (hand) 224 Abductor hallucis 171 Abductor pollicis brevis 166 Abductor pollicis longus 180 Adductor brevis 225 Adductor hallucis 179 Adductor longus 181 Adductor magnus 173 Adductor pollicis 144 Anconeus 53 Arytenoid Oblique Transverse 27 Auriculares 15 B 140 Biceps brachii 192 Biceps femoris 141 Brachialis 143 Brachioradialis 26 Buccinator 120 Bulbospongiosus 16 C 34 Chondroglossus 116 Coccygeus 139 Coracobrachialis 5 Corrugator supercilii 117 Cremaster 50 Cricothyroid [Cricothyroideus] 17 D 133 Deltoid [Deltoideus] 23 Depressor anguli oris 24 Depressor labii inferioris 14 Depressor septi 101 Diaphragm 78 Digastricus [Digastric] 18 E 149 Extensor carpi radialis brevis 148 Extensor carpi radialis longus 150 Extensor carpi ulnaris 158 Extensor digiti minimi 154 Extensor digitorum 212 Extensor digitorum brevis 211 Extensor digitorum longus 221 Extensor hallucis longus 155 Extensor indicis 168 Extensor pollicis brevis 167 Extensor pollicis longus 19 F 209 Fibularis brevis 208 Fibularis longus 210 Fibularis tertius 151 Flexor carpi radialis 153 Flexor carpi ulnaris 216 Flexor digiti minimi brevis (foot) 160 Flexor digiti minimi brevis (hand) 214 Flexor digitorum brevis 213 Flexor digitorum longus 157 Flexor digitorum profundus 156 Flexor digitorum superficialis 223 Flexor hallucis brevis 222 Flexor hallucis longus 170 Flexor pollicis brevis 169 Flexor pollicis longus 20 G 205 Gastrocnemius 190 Gemellus inferior 189 Gemellus superior 32 Genioglossus 77 Geniohyoid [Geniohyoideus] 182 Gluteus maximus 183 Gluteus medius 184 Gluteus minimus 178 Gracilis 21 H 33 Hyoglossus 22 I 176 Iliacus 66 Iliocostalis cervicis 90 Iliocostalis lumborum 89 Iliocostalis thoracis 38 Inferior longitudinal (tongue) [Longitudinalis inferior] 41 Inferior pharyngeal constrictor [Constrictor pharyngis inferior] 84–87 Infrahyoids (see Sternothyroid, Thyrohyoid, Sternohyoid, Omohyoid) 136 Infraspinatus 102 Intercostales externi 103 Intercostales interni 104 Intercostales intimi 219 Interossei, dorsal (foot) [Interossei dorsales] 164 Interossei, dorsal (hand) [Interossei dorsales] 165 Interossei, palmar or volar [Interossei palmares] 220 Interossei, plantar [Interossei plantares] 69 Interspinales cervicis 98 Interspinales lumborum 97 Interspinales thoracis 70 Intertransversarii cervicis 99 Intertransversarii thoracis and lumborum 121 Ischiocavernosus 23 L 52 Lateral cricoarytenoid [Cricoarytenoideus lateralis] 30 Lateral pterygoid [Pterygoideus lateralis] 130 Latissimus dorsi 17 Levator anguli oris 115 Levator ani (includes Puborectalis, Pubococcygeus, and Iliococcygeus) 15 Levator labii superioris 16 Levator labii superioris alaeque nasi 3 Levator palpebrae superioris 127 Levator scapulae 46 Levator veli palatini 107 Levatores costarum 60 Longissimus capitis 64 Longissimus cervicis 91 Longissimus thoracis 74 Longus capitis 79 Longus colli 218 Lumbricales (foot) [Lumbricals] 163 Lumbricales (hand) [Lumbricals] 24 M 28 Masseter 31 Medial pterygoid [Pterygoideus medialis] 21 Mentalis 42 Middle pharyngeal constrictor [Constrictor pharyngis medius] 94 Multifidi 48 Musculus uvulae 75 Mylohyoid [Mylohyoideus] 25 N 13 Nasalis 26 O 54 Oblique arytenoid [Arytenoideus obliquus] 59 Obliquus capitis inferior 58 Obliquus capitis superior 110 Obliquus externus abdominis 11 Obliquus inferior oculi 111 Obliquus internus abdominis 10 Obliquus superior oculi 188 Obturator externus [Obturatorius externus] 187 Obturator internus [Obturatorius internus] 1 Occipitofrontalis 87 Omohyoid [Omohyoideus] 161 Opponens digiti minimi 172 Opponens pollicis 4 Orbicularis oculi 25 Orbicularis oris 27 P 36 Palatoglossus 49 Palatopharyngeus 162 Palmaris brevis 152 Palmaris longus 177 Pectineus 131 Pectoralis major 129 Pectoralis minor 186 Piriformis 207 Plantaris 88 Platysma 51 Posterior cricoarytenoid [Cricoarytenoideus posterior] 12 Procerus 147 Pronator quadratus 146 Pronator teres 174 Psoas major 175 Psoas minor 114 Pyramidalis 28 Q 191 Quadratus femoris 100 Quadratus lumborum 217 Quadratus plantae 196–200 Quadriceps femoris (see Rectus femoris, Vastus intermedius, Vastus medialis longus, Vastus medialis oblique, Vastus lateralis) 29 R 113 Rectus abdominis 72 Rectus capitis anterior 73 Rectus capitis lateralis 56 Rectus capitis posterior major 57 Rectus capitis posterior minor 196 Rectus femoris 7 Rectus inferior 9 Rectus lateralis 8 Rectus medialis 6 Rectus superior 125 Rhomboid major [Rhomboideus major] 126 Rhomboid minor [Rhomboideus minor] 20 Risorius 71 Rotatores cervicis 96 Rotatores lumborum 95 Rotatores thoracis 30 S 45 Salpingopharyngeus 195 Sartorius 80 Scalenus anterior 81 Scalenus medius 82 Scalenus posterior 194 Semimembranosus 62 Semispinalis capitis 65 Semispinalis cervicis 93 Semispinalis thoracis 193 Semitendinosus 128 Serratus anterior 109 Serratus posterior inferior 108 Serratus posterior superior 206 Soleus 123 Sphincter ani externus 122 Sphincter urethrae 63 Spinalis capitis 68 Spinalis cervicis 92 Spinalis thoracis 61 Splenius capitis 67 Splenius cervicis 83 Sternocleidomastoid [Sternocleidomastoideus] 86 Sternohyoid [Sternohyoideus] 84 Sternothyroid [Sternothyroideus] 35 Styloglossus 76 Stylohyoid [Stylohyoideus] 44 Stylopharyngeus 132 Subclavius 105 Subcostales 134 Subscapularis 37 Superior longitudinal (tongue) [Longitudinalis superior] 43 Superior pharyngeal constrictor [Constrictor pharyngis superior] 145 Supinator 75–78 Suprahyoids (see Mylohyoid, Stylohyoid, Geniohyoid, Digastricus) 135 Supraspinatus 31 32 T 29 Temporalis 2 Temporoparietalis 185 Tensor fasciae latae 47 Tensor veli palatini 138 Teres major 137 Teres minor 55 Thyroarytenoid [Thyroarytenoideus] 85 Thyrohyoid [Thyrohyoideus] 203 Tibialis anterior 204 Tibialis posterior 39 Transverse lingual [Transversus linguae] 112 Transversus abdominis 22 Transversus menti 119 Transversus perinei profundus 118 Transversus perinei superficialis 106 Transversus thoracis 124 Trapezius 142 Triceps brachii 33 U 48 Uvula (see Musculus uvulae) 34 V 198 Vastus intermedius 197 Vastus lateralis 199 Vastus medialis longus 200 Vastus medialis oblique 40 Vertical lingual [Verticalis linguae] 35 Z 18 Zygomaticus major 19 Zygomaticus minor 36 Introduction This 10th edition presents manual muscle testing within the context of strength testing. Classic muscle testing is a fundamental skill of every physical therapist and is essential to the diagnosis and assessment of movement impairments. However, as manual muscle testing has come under scientific scrutiny, it is obvious that its use to evaluate and assess strength as a component of functional movement patterns and tasks is inadequate. Therefore, in addition to the classic presentation of manual muscle testing, this edition presents methods of strength testing that are valid, objective, and applicable across various settings. A number of noteworthy changes have been made in the new edition. First and foremost, it is a modern 21st century text that has been thoroughly researched. Each test presented is backed by evidence, and the utility of each muscle testing approach is presented in context with alternative options. Throughout the text there are updated testing methods. Origins, insertions, and actions of key muscles for each manual muscle test are now included and precede the description of most test procedures. Additionally, for each specific muscle (e.g., serratus anterior, tibialis anterior), there are exercises that the therapist can use to strengthen weak muscles in patients. Each recommended exercise has been demonstrated, in most instances, to elicit at least 40% of maximum voluntary strength. Thus exercises are sufficiently rigorous to induce genuine strength increases in patients. Chapter 7 presents a variety of strength testing methods using common equipment. Although this chapter was introduced in the previous edition, additional tests have been added to it and modifications to other tests were made. Additional normative values have been included and values for reliability, validity and specificity are now part of the text, when these values exist. Chapter 8 describes functional tests that have a significant strength component. Age-based norms are included when available, and patient scenarios are presented that provide the rationale for each recommended approach to strength testing. Finally, there is a new Chapter 9 on handheld dynamometry, an emerging technology that offers an additional means of distinguishing between limbs that have subtle strength differences and an opportunity for more precise testing. Normative values for handheld dynamometry have also been included when normative values exist. We believe that you will find this a very different text from Edition 9 and a welcome addition to your library. Muscle strength is a critical component of functional movement. Assessment must include accurate measurement of the quantity of strength within the context of functional tasks and movement. Especially for the lower extremities, methods that allow the expansion of the findings of manual muscle testing from an impairment to a function level are needed. Quantitative assessment promotes accurate assessment of progress and patient performance within the context of age-based normative values. Although few “hard numbers” of threshold strength levels exist for specific functional movements, we have identified the known muscles that have been correlated with a specific task and, in some cases, have suggested values that may serve as a target for the minimum strength required for a specific functional task. The manual muscle testing portion of this book, as in previous editions, directs its focus on manual procedures. For the most part, joint motions (e.g., hip flexion) rather than individual muscles (e.g., iliopsoas) are the focus of this text because of the contributions of more than one muscle to a movement. Although prime movers of a movement can be identified, secondary or accessory movers may be equally important and should not be overlooked or underestimated. Rarely is a prime mover the only active muscle, and rarely is it used under isolated control for a given movement. For example, knee extension is the prerogative of the five muscles of the quadriceps femoris, yet none of these five extend the knee in isolation from its synergists. Regardless, definitive activity of any muscle in a given movement can be precisely detected by electromyography, and such studies, when they exist, are now included as important pieces of evidence in this updated text. Range of motion in this book is presented only to illustrate the range required to test a movement correctly. A consensus of typical ranges is presented with each test, but the techniques of measurement used are not within the scope of this text. 37 38 Brief History of Muscle Testing Wilhelmine Wright and Robert W. Lovett, MD, Professor of Orthopedic Surgery at Harvard University Medical School, were the originators of the muscle testing system that incorporated the effect of gravity.1,2 Janet Merrill, PT, Director of Physical Therapeutics at Children's Hospital and the Harvard Infantile Paralysis Commission in Boston, an early colleague of Dr. Lovett, stated that the tests were used first by Wright in Lovett's office gymnasium in 1912.3 The seminal description of the tests used largely today was written by Wright and published in 19121; this was followed by an article by Lovett and Martin in 19164 and by Wright's book in 1928.5 Miss Wright was a precursor of the physical therapist of today, there being no educational programs in physical therapy in her time, but she headed Lovett's physical therapeutic clinic. Lovett credits her fully in his 1917 book, Treatment of Infantile Paralysis,6 with developing the testing for polio. In Lovett's book, muscles were tested using a resistance-gravity system and graded on a scale of 0 to 6. Another early numerical scale in muscle testing was described by Charles L. Lowman, MD, founder and medical director of Orthopedic Hospital, Los Angeles.7 Lowman's system (1927) covered the effects of gravity and the full range of movement on all joints and was particularly helpful for assessing extreme weakness. Lowman further described muscle testing procedures in the Physiotherapy Review in 1940.8 H.S. Stewart, a physician, published a description of muscle testing in 1925 that was very brief and was not anatomically or procedurally consistent with what is done today.9 His descriptions included a resistance-based grading system not substantially different from current use: maximal resistance for a normal muscle, completion of the motion against gravity with no other resistance for a grade of fair, and so forth. At about the time of Lowman's book, Arthur Legg, MD, and Janet Merrill, PT, wrote a valuable small book on poliomyelitis in 1932. This book, which offered a comprehensive system of muscle testing, was used extensively in physical therapy educational programs during the early 1940s; muscles were graded on a scale of 0 to 5, and a plus or minus designation was added to all grades except 1 and zero.10 Among the earliest clinicians to organize muscle testing and support such testing with sound and documented kinesiologic procedures in the way they are used today were Henry and Florence Kendall. Their earliest published documents on comprehensive manual muscle testing became available in 1936 and 1938.11,12 The 1938 monograph on muscle testing was published and distributed to all Army hospitals in the United States by the U.S. Public Health Service. Another early contribution came from Signe Brunnström and Marjorie Dennen in 1931; their syllabus described a system of grading movement rather than individual muscles as a modification of Lovett's work with gravity and resistance.13 The first comprehensive text on muscle testing was written by Lucille Daniels, MA, PT; Marian Williams, PhD, PT; and Catherine Worthingham, PhD, PT, published in 1946.14 These three authors prepared a comprehensive handbook on the subject of manual testing procedures that was concise and easy to use. It remains one of the most used texts the world over and is the predecessor for all subsequent editions of Daniels and Worthingham's Muscle Testing including this edition. The Kendalls (together and then Florence alone after Henry's death in 1979) developed and published work on muscle testing and related subjects for more than 6 decades15-17 Their first edition of Muscles: Testing and Function appeared in 1949.15 Earlier, the Kendalls had developed a percentage system ranging from 0 to 100 to express muscle grades as a reflection of normal; they reduced the emphasis on this scale, only to return to it in the latest edition (1993), in which Florence again advocated the 0 to 10 scale.17 The contributions of the Kendalls should not be considered as limited to grading scales, however. Their integration of muscle function with posture and pain in two separate books15,16 and then in one book17 is a unique and extremely valuable contribution to the clinical science of physical therapy. Muscle testing procedures used in national field trials that examined the use of gamma globulin in the prevention of paralytic poliomyelitis were described by Carmella Gonnella, Georgianna Harmon, and Miriam Jacobs, all physical therapists.18 The later field trials for the Salk vaccine also used muscle testing procedures.19 The epidemiology teams at the Centers for Disease Control were charged with assessing the validity and reliability of the vaccine. Because there was no other method of accurately “measuring” the presence or absence of muscular weakness, manual muscle testing techniques were used. A group from the D.T. Watson School of Physiatrics near Pittsburgh, which included Jesse 39 Wright, MD; Mary Elizabeth Kolb, PT; and Miriam Jacobs, PT, PhD, devised a test procedure that eventually was used in the field trials.20 The test was an abridged version of the complete test procedure but did test key muscles in each functional group and body part. It used numerical values that were assigned grades, and each muscle or muscle group also had an arbitrary assigned factor that corresponded (as closely as possible) to the bulk of the tissue. The bulk factor multiplied by the test grade resulted in an “index of involvement” expressed as a ratio. Before the trials, Kolb and Jacobs were sent to Atlanta to train physicians to conduct the muscle tests, but it was decided that experienced physical therapists would be preferable to maintain the reliability of the test scores.20 Lucy Blair, then the Poliomyelitis Consultant in the American Physical Therapy Association, was asked by Catherine Worthingham of the National Foundation for Infantile Paralysis to assemble a team of experienced physical therapists to conduct the muscle tests for the field trials. Kolb and Jacobs trained a group of 67 therapists in the use of the abridged muscle test.20 This work of determining the presence or absence of weakness and paralysis had enormous impact on the eventual approval of the Salk vaccine. A partial list of participants was appended to the Lilienfeld paper in the Physical Therapy Review in 1954.19 40 How to Use This Book The general principles that govern manual muscle testing are described in Chapter 1. Chapter 2 describes the purposes and limitations of manual muscle testing, placing manual muscle testing in the context of strength testing across settings. Chapters 3 through 7 present traditional and updated techniques for testing motions of skeletal muscle groups in the body region covered by that chapter. Chapter 4 reflects additional changes to practice through the expansion of the trunk muscle strength testing section, particularly trunk endurance; the pelvic floor muscle testing section; and the respiratory muscle section. Chapter 7 describes methods of strength testing using equipment and instruments, and Chapter 8 is devoted to functional tests, which have become critical for successful documentation. Students should learn manual muscle testing within the context of strength testing to avoid some of the limitations described in Chapter 2. Chapter 9 is completely new and describes manual testing using a handheld dynamometer and includes normative values where they exist. Chapter 10 provides case studies to describe different methods of strength testing in various patient populations and settings. For instant access to anatomical information without carrying a large anatomy text to a muscle testing session, see the Ready Reference Anatomy section on Evolve. This chapter is a synopsis of muscle anatomy, muscles as part of motions, muscle innervations, and myotomes. To assist readers, each muscle has been assigned an identification number based on a regional sequence, beginning with the head and face and proceeding through the neck, thorax, abdomen, perineum, upper extremity, and lower extremity. This reference number is retained throughout the text for cross-referencing purposes. Two lists of muscles with their reference numbers are presented, one alphabetical and one by region, to assist readers in finding muscles in the Ready Reference section. These can also be found on the inside front and back covers of the book. 41 Names of the Muscles Muscle names have conventions of usage. The most formal usage (and the correct form for many journal manuscripts) is the terminology established by the Federative International Committee on Anatomical Terminology (FCAT) in 1998. However, common usage often neglects these prescribed names in favor of shorter or more readily pronounced names. The authors of this text make no apologies for not keeping strictly to formal usage. Most of the muscles cited follow Terminologia Anatomica. Others are listed by the names in most common use. The alphabetical list of muscles (see the inside front cover of the book) gives the name used in this text and the correct Terminologia Anatomica term, when it differs, in parentheses. 42 Anatomical Authorities The authors of this book relied on both the American and British versions of Gray's Anatomy as principal references for anatomical information, as well as Sabotta's Atlas of Human Anatomy. Because proficiency in muscle testing can only be achieved if the practitioner has a thorough understanding of anatomy, anatomical drawings are presented throughout the book, many in cross- section format, and descriptions of origins and insertions and functions are provided in multiple places, in detail and in abbreviated form. 43 The Convention of Arrows in the Text Red arrows in the text denote the direction of movement of a body part, either actively by the patient or passively by the examiner. The length and direction of the arrow indicates the relative excursion of the part. Black arrows in the text denote resistance by the examiner. It is important to remind the reader that mastery of muscle testing, whether performed manually or using a strength-testing device, requires substantial practice. The only way to acquire proficiency in clinical evaluation procedures is to practice over and over again. As experience with patients matures over time, the nuances that can never be fully described for the wide variety of patients encountered by the clinician will become as much intuition as science. Muscle testing continues to be among the most fundamental skills of the physical therapist and others who are concerned with abnormalities of human motion. The skill of manual muscle testing is a critical clinical tool that every physical therapist must not only learn but also master. A physical therapist who aspires to be recognized as a master clinician will not achieve that status without acquiring exquisite skills in manual muscle testing and precise assessment of muscle performance. 44 References 1. Wright WG. Muscle training in the treatment of infantile paralysis. Boston Med Surg J. 1912;167:567–574. 2. Lovett RW. Treatment of infantile paralysis. Preliminary report. JAMA. 1915;64:2118. 3. Merrill J. Personal letter to Lucille Daniels dated January 5. 1945. 4. Lovett RW, Martin EG. Certain aspects of infantile paralysis and a description of a method of muscle testing. JAMA. 1916;66:729–733. 5. Wright WG. Muscle Function. Paul B. Hoeber: New York; 1928. 6. Lovett RW. Treatment of Infantile Paralysis. 2nd ed. Blakiston's Son & Co.: Philadelphia; 1917. 7. Lowman CL. A method of recording muscle tests. Am J Surg. 1927;3:586–591. 8. Lowman CL. Muscle strength testing. Physiotherap Rev. 1940;20:69–71. 9. Stewart HS. Physiotherapy: Theory and Clinical Application. Paul B. Hoeber: New York; 1925. 10. Legg AT, Merrill J. Physical therapy in infantile paralysis. W.F. Prior: Hagerstown, MD; 1932. Mock. Principles and Practice of Physical Therapy. Vol. 2. 11. Kendall HO. Some interesting observations about the after care of infantile paralysis patients. J Excep Child. 1936;3:107. 12. Kendall HO, Kendall FP. Care During the Recovery Period of Paralytic Poliomyelitis. U.S. Public Health Bulletin No. 242. U.S. Government Printing Office: Washington, D.C.; 1938. 13. Brunnstrom S, Dennen M. Round table on muscle testing. [New York: Annual Conference of the American Physical Therapy Association, Federation of Crippled and Disabled, Inc. (mimeographed)] 1931. 14. Daniels L, Williams M, Worthingham CA. Muscle Testing: Techniques of Manual Examination. W.B. Saunders: Philadelphia; 1946. 15. Kendall HO, Kendall FP. Muscles: Testing and Function. Williams & Wilkins: Baltimore; 1949. 16. Kendall HO, Kendall FP. Posture and Pain. Williams & Wilkins: Baltimore; 1952. 17. Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed. Williams & Wilkins: Baltimore; 1993. 18. Gonella C, Harmon G, Jacobs M. The role of the physical therapist in the gamma globulin poliomyelitis prevention study. Phys Ther Rev. 1953;33:337–345. 19. Lilienfeld AM, Jacobs M, Willis M. Study of the reproducibility of muscle testing and certain other aspects of muscle scoring. Phys Ther Rev. 1954;34:279–289. 20. Kolb ME. Personal communication. [October] 1993. 45 CHAPTER 1 46 Principles of Manual Muscle Testing Grading System Overview of Test Procedures Criteria for Assigning a Muscle Test Grade Screening Tests Preparing for the Muscle Test Exercises Prime Movers Summary 47 Muscle Test Grading System Grades for a manual muscle test are recorded as numeric ordinal scores ranging from zero (0), which represents no discernable muscle activity, to five (5), which represents a maximal or best- possible response or as great a response as can be evaluated by a manual muscle test. Because this text is based on actions (e.g., elbow flexion) rather than tests of individual muscles (e.g., biceps brachii), the grade represents the performance of all muscles contributing to that action. The numeric 0 to 5 system of grading is the most commonly used muscle strength scoring convention across health care professions. Each numeric grade (e.g., 4) can be paired with a word grade (e.g., good) that describes the test performance in qualitative, but not quantitative, terms. (See table.) Use of these qualitative terms is an outdated convention and is not encouraged because these terms tend to misrepresent the strength of the tested action. For knee extension, forces that are less than 50% of average and therefore not “normal” are often graded 5.1 Knee extension actions graded as 4 may generate forces as low as 10% of maximal expected force, a level clearly not described appropriately as “good.” For this reason, the qualitative terms have largely been removed from this book. The numeric grades are based on several factors that will be addressed later in this chapter. Numeric Score Qualitative Score 5 Normal (N) 4 Good (G) 3 Fair (F) 2 Poor (P) 1 Trace activity (T) 0 Zero (no activity) (0) Overview of Test Procedures Break Test Manual resistance is applied to a limb or other body part after it has actively completed its test range of motion against gravity. The term resistance is always used to denote a concentric force provided by the tester that acts in opposition to contracting muscles. Manual resistance should always be applied opposite to the muscle action of the participating muscle or muscles. The patient is asked to hold the body segment at or near the end of the available range, or at the point in the range where the muscle is most strongly challenged. At this point, the patient is instructed to not allow the therapist to “break” the hold while the therapist applies manual resistance. For example, a seated patient is asked to flex the elbow to its end range (Grade 3); when that position is reached, the therapist applies resistance just proximal to the wrist, trying to “break” the muscle's hold and thus allow the forearm to move downward into extension. This is called a break test, and it is the procedure most commonly used in manual muscle testing nowadays. However, there are alternatives to the break test for grading specific muscle actions. As a recommended alternative procedure, the therapist may choose to place the muscle or muscle group to be tested in the end or test position, after ensuring that the patient can complete the available range (Grade 3), before applying additional resistance. In this procedure the therapist ensures correct positioning and stabilization for the test. Make Test An alternative to the break test is the application of manual resistance against an actively contracting muscle or muscle group (i.e., opposite the direction of the movement) that matches the patient's resistance but does not overcome it. During the maximum contraction, the therapist gradually, over approximately 3 seconds, increases the amount of manual resistance until it matches the patient's maximal level. The make test is not as reliable as the break test, therefore making the break test the preferred test. Active Resistance Test Resistance is applied opposite the actively contracting movement throughout the range, starting at the fully lengthened position. The amount of resistance matches the patient's resistance but allows 48 the joint to move through the full range. This kind of manual muscle test requires considerable skill and experience to perform and is not reliable; thus its use is not recommended as a testing procedure but may be effective as a therapeutic exercise technique. Application of Resistance The principles of manual muscle testing presented here and in all published sources since 1921 follow the basic tenets of muscle length–tension relationships, as well as those of joint mechanics.2,3 In the case of the elbow flexion, for example, when the elbow is straight, the biceps are long but the lever is short; leverage increases as the elbow flexes and becomes maximal at 90°, where it is most efficient. However, as flexion continues beyond that point, the biceps are short and their lever arm again decreases in length and efficiency. In manual muscle testing, external force in the form of resistance is applied at the end of the range or after backing off slightly from the end of range in the direction opposite the actively contracting muscle. For some muscle actions (e.g., knee flexion), this backing off is considerable—to the point that the primary muscles tested are at what may be considered mid-range. Two-joint muscles are typically tested in mid-range where length-tension is more favorable. Ideally, all muscles and muscle groups should be tested at optimal length-tension, but there are many occasions in manual muscle testing where the therapist is not able to distinguish between Grades 5 and 4 without putting the patient at a mechanical disadvantage. Thus the one-joint brachialis, gluteus medius, and quadriceps muscles are tested at end range and the two-joint hamstrings and gastrocnemius muscles are tested in mid-range. Critical to the accuracy of a manual muscle test are the location of the applied resistance and the consistency of application across all patients. The placement of resistance is typically near the distal end of the body segment to which the tested muscle attaches. There are exceptions to this rule. One exception is when resistance cannot be provided effectively without moving to a more distal body segment. In the case of shoulder and hip internal and external rotators, this involves applying resistance through the hand placed on the distal forearm or lower leg. Another exception involves patients with a shortened limb segment as in an amputation. Take for example a patient with a transfemoral amputation. Even if the patient could hold against maximum resistance while abducting the hip, the weight of the lower limb is so reduced and the therapist's lever arm for resistance application is so short, that a grade of 5 cannot be assumed regardless of the resistance applied. A patient holding against maximum resistance may still struggle with the force demands of walking with a prosthesis. If a variation is used, the therapist should make a note of the placement of resistance to ensure consistency in testing. The application of manual resistance should never be sudden or uneven (jerky). The therapist should apply resistance with full patient awareness and in a somewhat slow and gradual manner, slightly exceeding the muscle's force as it builds over 2 to 3 seconds to achieve the maximum tolerable intensity. Applying resistance that slightly exceeds the muscle's force generation will more likely encourage a maximum effort and an accurate break test. The therapist also should understand that the weight of the limb plus the influence of gravity is part of the test response. Heavier limbs and longer limb segments put a higher demand on the muscles that move them. Therefore lifting the lower limb against gravity can demand more than 20% of the “normal strength” of the hip muscles.4 In contrast, lifting the hand against gravity requires less than 3% of the normal strength of the wrist muscles.4 When the muscle contracts in a parallel direction to the line of gravity, it is noted as “gravity minimal.” It is suggested that the commonly used term “gravity eliminated” be avoided because, of course, that can never occur except in a zero-gravity environment. Weakened muscles are tested in a plane horizontal to the direction of gravity with the body part supported on a smooth, flat surface in such a way that friction force is minimal (Grades 2, 1, and 0). A powder board may be used to minimize friction. For stronger muscles that can complete a full range of motion in a direction against the pull of gravity (Grade 3), resistance is applied perpendicular to the line of gravity (Grades 4 and 5). Acceptable variations to antigravity and gravity-minimal positions are discussed in individual test sections. Stabilization Stabilization of the body or segment is crucial to assigning accurate muscle test grades. Patients for whom stabilization is particularly important include those with weakness in stabilizing muscles 49 (e.g., scapular stabilizers) when testing the shoulder muscles and those who are particularly strong in the tested muscle action. Numerous muscles, some seemingly remote, can contribute as stabilizers to the performance of tested muscle actions. However, muscle test performance is not meant to be dependent on muscles other than the prime movers. To give an extreme example, shoulder abduction on the left side should not be dependent on the trunk muscles on the right side. Therefore a patient with weak trunk muscles and limited sitting balance should be supported and stabilized either through patient positioning or by a stabilizing hand on the right shoulder. A muscle or muscle group that is particularly strong may also require patient stabilization if the full capacity of a muscle group is to be accurately tested.5 For example, a tester may not be able to break the knee extension action of a patient who is allowed to rise off of a support surface during the performance of a break test. However, the same patient, properly stabilized by the tester, an assistant, or a belt during testing, may not be able to hold against maximum tester resistance and thus break the muscle contraction, indicating that the patient has a muscle test grade of 4 rather than 5. Criteria for Assigning a Muscle Test Grade The grade given on a manual muscle test comprises both subjective and objective factors. Subjective factors include the therapist's impression of the amount of resistance given during the actual test and then the amount of resistance the patient actually holds against during the test. Objective factors include the ability of the patient to complete a full range of motion or to hold the test position once placed there, the ability to move the part against gravity, or an inability to move the part at all. All these factors require clinical judgment, which makes manual muscle testing a skill that requires considerable practice and experience to master. An accurate test grade is important not only to establish the presence of an impairment but also to assess the patient's longitudinal status over time. Clinical reasoning is necessary for the therapist to determine the causes for the lack of ability to complete the full range or hold the position, ascertain which is most applicable, and decide whether manual muscle testing is appropriate. Consistent with a typical orthopedic exam, the patient is first asked to perform the active movement of the muscle to be tested. Active movement is performed by the patient without therapist or mechanical assistance. This active movement informs the therapist of the patient's willingness and ability to move the body part, of the available range in the related joint(s), and whether there are limitations to full range, such as pain, excess tone, or weakness. Active movement without resistance is the equivalent of a Grade 3. Active movement is also called active range of motion and begins every muscle test to help determine the appropriate test position and amount of resistance to apply. Grade 5 Muscle A grade of 5 is assigned when a patient can complete full active range of motion (active movement) against gravity and hold the test position against maximum resistance. If the therapist can break a patient's hold, a grade of 5 should not be assigned. Overgrading will prevent the differentiation of a weak from a strong muscle and the identification of muscles that do, versus do not, get stronger over time. The wide range of “normal” muscle performance typically leads to a considerable underestimation of a muscle's capability.6 If the therapist has no experience in examining people who are free of disease or injury, it is unlikely that there will be any realistic or accurate assessment of what is Grade 5 and how much normality can vary. In general, a student learns manual muscle testing by practicing on classmates, but this provides only minimal experience compared with what is needed to master the skill. It should be recognized, for example, that the average therapist cannot “break” knee extension in a reasonably fit young man, even by doing a handstand on his leg! A therapist may not be aware of underestimation of a muscle contraction unless quantitative measures of strength are also used, such as in a sit-to-stand test. In addition, contributing to an underestimation of weakness is the inability of some therapists, particularly those who are women, to apply adequate resistance.7 Grade 4 Muscle 50 Grade 4 is assigned when the patient can complete the full active range of motion (active movement) against gravity but is not able to hold the test position against maximum resistance. The Grade 4 muscle “gives” or “yields” to some extent at the end of its test range with maximal or submaximal resistance. When maximal resistance results in a break or give, irrespective of age or disability, the muscle is assigned a grade of 4. However, if pain limits the ability to maximally resist the force applied by the therapist, evaluation of actual strength may not be realistic and should be documented as such. An example might be, “Elbow flexion appeared strong but painful.” The grade of 4 represents the true weakness in manual muscle testing procedures (pun intended). Sharrard counted remaining alpha motor neurons in the spinal cords of individuals with poliomyelitis at the time of autopsy.8 He correlated the manual muscle test grades in the patient's chart with the number of motor neurons remaining in the anterior horns. His data revealed that more than 50% of motor neurons of a muscle group were absent when the muscle test grade was 4. Thus, when the muscle could withstand considerable but less than “normal” resistance, it had already been deprived of at least half of its innervation. Appropriate stabilization is critical to determine the true difference between a Grade 5 and Grade 4 muscle. Grade 3 Muscle The Grade 3 muscle test is based on an objective measure. The muscle or muscle group can complete a full range of motion against the resistance of gravity. This is also called “active range.” Even if a tested muscle can move through the full range against gravity and tolerate a small or “mild” amount of resistance, the muscle is assigned a grade of 3. Direct force measurements have demonstrated that the force level of the Grade 3 muscle is quite low (less than 5% of normal for knee extension), so that a much greater span of functional loss exists between Grades 3 and 5 than between Grades 3 and 1.9 Beasley, in a study of children ages 10 to 12 years, reported the Grade 3 in 36 muscle tests as no greater than 40% of Grade 5 (one motion), the rest being 30% or below normal “strength,” with the majority falling between 5% and 20% of a Grade 5.10 A grade of 3 may represent a functional threshold for some muscle actions tested (e.g., elbow flexion during feeding); however, a grade 3 may fall far short of the functional requirements of many lower extremity muscles during weight-bearing activities, particularly for such muscle groups as the hip abductors and the ankle plantar flexors. The therapist must be sure that muscles given a grade of 3 are not in the joint “locked” position during the test (e.g., locked elbow when testing elbow extension). Grade 2 Muscle The Grade 2 is assigned to a muscle group that can move the body segment when gravity is minimized. This position is typically described as the horizontal plane of motion. Movement in this plane may be eased by use of a powder board or other such friction-eliminating surface. Grade 1 Muscle The Grade 1 is assigned when the therapist can detect visually or by palpation some contractile activity in one or more of the muscles that participate in the action being tested (provided that the muscle is superficial enough to be palpated). The therapist also may be able to see or feel a tendon pop up or tense as the patient tries to perform the movement. However, there is no movement of the part as a result of this contractile muscle activity. Patient positioning is less important in Grade 1 testing because a Grade 1 muscle can be detected in almost any position. When a Grade 1 muscle is suspected, the therapist should passively move the part into the test position and ask the patient to hold the position and then relax; this will enable the therapist to palpate the muscle or tendon, or both, during the patient's attempts to contract the muscle and also during relaxation. Care should be taken to avoid substitution of other muscles. Grade 0 Muscle The Grade 0 muscle is assigned when palpation or visual inspection fail to provide evidence of contraction. This does not mean there is no muscle activation. In fact, electromyography may demonstrate that some activation is present. Thus the phrase “no discernable contraction” defines a Grade 0 in this text. 51 Plus (+) and Minus (−) Grades Use of a plus (+) or minus (−) addition to a manual muscle test grade is discouraged. Avoiding the use of plus or minus signs restricts manual muscle test grades to those that are meaningful, defendable, and reliable. The use of pluses and minuses adds a level of subjectivity that lacks reliability, especially for grades of 3 or greater. However, in the case of Grade 2, described above, there is a considerable difference between the muscle that can complete full range in a gravity- minimized position (horizontal position) and the one that cannot complete full range but can achieve some joint movement. Therefore the grade of 2- is acceptable when the muscle can complete partial range of motion in the horizontal plane, gravity minimized. The difference between Grade 2 and Grade 1 muscles represents such a broad functional difference that a minus sign may be important in assessing even minor improvements in function. The therapist is encouraged to supplement the grade with descriptive documentation of the quality of movement. Grade 4 Muscle Revisited Historically, manual muscle testing has used two grading systems, one using numbers (5-0) and the other using descriptors (normal to zero). Although both systems convey the same information, the authors favor the numeric system because it avoids use of the vague and subjective term “good.” As noted previously, there is no other term in muscle testing that is more problematic. Too often clinical practitioners, including therapists and physicians, construe the term in the literal sense, interpreting “good” to mean totally adequate. The assumption is that if strength is adequate, then the patient is not in need of rehabilitation. However, an abundance of evidence demonstrates unequivocally that once the therapist discerns that strength is no longer normal, but “good” instead, the muscle being tested has already lost approximately half its strength. Evidence of this has already been presented.11 More recently, Bohannon found that force values for muscles that were graded as “normal” ranged from 80 to 625 Newtons,6 an astronomic difference, further demonstrating how difficult it is to distinguish a “good” muscle from a “normal” muscle. It is unclear how a grade of “good” became synonymous with achievement of a satisfactory end point of treatment. Certainly, the pressure from third-party payers to discharge patients as soon as possible does not help the therapist to fulfill the minimum goal of reaching “prior level of function.” Nonetheless, the opportunity for patients to recover muscle forces to the fullest extent possible is a primary goal of an intervention. If this goal is not met, patients (especially aging individuals) may lose their independence or find themselves incapable of returning to a desired sport or activity because their weak muscles fatigue too quickly. Athletes who have not fully recovered their strength before returning to a sport are far more likely to suffer a reinjury, potentially harming themselves further. There are numerous instances in which a Grade 4 muscle cannot meet its functional demands. When the gluteus medius is Grade 4, a patient will display a positive Trendelenburg sign. When the soleus is Grade 4, the heel rise fails to occur during the latter portion of the stance phase of gait, which reduces gait speed.12 When the abdominals are Grade 4, there is difficulty stabilizing the pelvis while arising from bed or when sitting up, and this often results in back pain. Calling a muscle “good,” rather than Grade 4 is simply is not “good” enough. Repeatedly there is a disconnect between what patients can functionally accomplish and the manual muscle strength grade the therapist assigns, particularly in older adults. By the time a person reaches the age of 80 years, approximately 50% of their muscle mass and strength may be lost due to natural decline,13 and yet therapists often assign a manual muscle test grade of “normal” or “within normal limits” to an 80-year-old, even though the individual's strength is half of what it used to be. Functionally, these same older adults with “normal strength” cannot get out of a chair without pushing on the arms or ascend stairs without pulling on the railing. Therefore assigning “within functional limits” is discouraged. Muscle grades that are inaccurate based on the patient's age, gender, and presumed strength or because the therapist cannot apply adequate resistance must be avoided. In summary, a “good” muscle is not always “good.” Everything must be done to ensure accuracy in manual muscle test grading and to provide the intervention necessary to fully restore strength and function to “normal.” Substituting the numerical system of 5-0 for the subjective terms “good” or “normal” in manual muscle testing assessment is a start in the right direction. 52 Available Range of Motion When muscle shortness (“tightness”), a contracture, or fixed joint limitation (e.g., total knee replacement) limits joint range of motion, the patient performs only within the range available. In this circumstance, the available range is the full passive range of motion for that patient at that time, even though it is not “normal.” This is the range used to assign a muscle testing grade. For example, the normal knee extension range is 135° to 0°. A patient with a 20° knee flexion contracture is tested for knee extension strength at the end of available range or 20°. If this range (in sitting) can be completed with maximal resistance, the grade assigned would be a 5. If the patient cannot actively complete that range, the grade assigned MUST be less than 3. The patient then should be repositioned in the side-lying position to ascertain the correct grade. Screening Tests In the interests of time and cost-efficient care, it is often unnecessary to perform a muscle test on each muscle of the body. As the strength of various muscle actions tend to be correlated and internally consistent,6 a systematic testing of a limited number of muscle actions often will suffice. Three screening indexes warrant mentioning. Each was developed with a specific diagnostic group in mind and allows for the calculation of a total score. The first, the Motricity Index, was developed for patients with stroke and includes three muscle actions of the upper limb (shoulder elevation, elbow flexion, and hand grasp) and three muscle actions of the lower limb (hip flexion, knee extension, and ankle dorsiflexion).9 The second, the Motor Index Score, was developed for patients with spinal cord injury and includes muscle actions representative of key nerve root levels in the upper and lower limbs (elbow flexion [C5], wrist extension [C6], elbow extension [C7], finger flexion [C8], small finger abduction [T1], hip flexion [L2], knee extension [L3], ankle dorsiflexion [L4], great toe extension [L5], ankle plantarflexion [S1]).14 The final test, the Medical Research Council Sum Score, was produced to capture weakness in patients with Guillain-Barré but has since been used with other patients with dispersed weakness. It includes most of the actions included in the Motricity Index (shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, ankle dorsiflexion).15 Never should the therapist use phrases such as “within normal limits” or “within functional limits” for a screening exam. If a nonspecific strength exam is performed (e.g., through observation of tasks), documentation is better served with terms like “patient demonstrated no difficulty performing task,” rather than making a judgment about the degree of strength present. To screen for muscles that need definitive testing, the therapist can use a number of maneuvers to identify movements that do and do not need testing. Observation of the patient before the examination will provide valuable clues to muscular weakness and performance deficits. For example, the therapist can do the following: Observe the patient as he or she enters the treatment area to detect gross abnormalities of gait or other aspects of mobility. Observe the patient doing other everyday activities such as rising from a chair, completing admission or history forms, or removing street clothing. Ask the patient to walk on the toes and then on the heels. Ask the patient to grip the therapist's hand. Perform gross checks of bilateral muscle groups: reaching toward the floor, overhead, and behind the back. If evidence from the previous “quick checks” suggests a deficit in movement, manual muscle testing can quickly be focused to the region observed to be weak, in the interest of time and to optimize the patient's clinic visit. Preparing for the Muscle Test 53 The therapist and the patient must work in harmony if the test session is to be successful. This means that some basic principles and inviolable procedures should be second nature to the therapist. 1. The patient should be as free as possible from discomfort or pain for the duration of each test. It may be necessary to allow some patients to move or be positioned differently between tests. 2. The environment for testing should be quiet and nondistracting. The ambient temperature should be comfortable for the partially disrobed patient. 3. The testing surface must be firm to help stabilize the part being tested. The ideal is a firm surface, minimally padded or not padded at all. The firm surface will not allow the trunk or limbs to “sink in.” Friction of the surface material should be kept to a minimum. When the patient is reasonably mobile, a plinth is fine, but its width should not be so narrow that the patient is afraid of falling or sliding off. Sometimes a low mat table is the more practical choice. The height of the table should be adjustable to allow the therapist to use proper leverage and body mechanics. 4. Patient position should be carefully organized so that position changes in a test sequence are minimized. The patient's position must permit adequate stabilization of the part or parts being tested by virtue of body weight or with help provided by the therapist. 5. All materials needed for the test must be at hand. This is particularly important when the patient is anxious for any reason or is too weak to be safely left unattended. Materials needed include the following: Manual muscle test documentation forms (Fig. 1.1) 54 55 56  FIGURE 1.1 Documentation of manual muscle examination. Pen, pencil, or computer terminal Pillows, towels, pads, and wedges for positioning Sheets or other draping linen Goniometer Stopwatch Specific equipment for specific functional tests Test forms for functional tests Interpreter (if needed) Assistance for turning, moving, or stabilizing the patient Emergency call system (if no assistant is available) Reference material Exercises Specific exercises have been included in the text where there is electromyographic evidence of isometric maximal voluntary contraction (MVC). Clinically, motions that evoke higher electromyographic activities (%MVC) have been interpreted to be more challenging to a muscle.16 The following scale is used when interpreting %MVC: Low 0%–20% Moderate 21%–40% High 41%–60% Very high >60% An MVC of greater than 40% is considered necessary for strengthening.17,18 We have included higher-tier exercises as suggested exercises. These exercises should be considered challenging and used later in the rehabilitation process. The therapist should also be aware of the different types of contractions applied in muscle testing and exercise. See Box 1.1. Box 1.1 57 Types of Contractions Concentric contraction refers to the shortening of a muscle as it contracts, as in the bending flexion portion of a biceps curl or extension of the elbow when lifting an object overhead. Concentric activity is generally the primary motion of the muscle. Eccentric contraction refers to the lowering phase of an exercise, when the muscle lengthens, as in lowering the weight to the chest during the bench press or lowering oneself into a chair. Eccentric muscle activity is seen in many mobility-related functional tasks such as stepping down a curb or in gait. Isometric contraction refers to the creation of muscle tension without joint movement. Isometric contractions are often used when the limb is immobilized, such as post surgery. Isometric contractions are used with handheld dynamometry, discussed in Chapter 9. Prime Movers Within each chapter are tables indicating the muscles involved in the action that is tested (e.g., shoulder flexion). When prime movers have been identified for a particular action, they are in boldface type. For example, the prime mover of shoulder flexion is the anterior deltoid muscle and therefore this muscle is bolded. In other instances, there is no distinct prime mover and thus no bolding. The movement of back extension, for example, involves a dozen muscles, none of which is a prime mover, and therefore there are no muscle names bolded. Our intent in highlighting the prime movers is to help the student more readily understand which muscles are critical for many important movements and to have a better understanding of which muscles to strengthen when weakness is present. Summary From the foregoing discussion, it should be clear that manual muscle testing is an exacting clinical skill. Practice, practice, and more practice on a variety of patient types create the experience essential to building the skill to an acceptable level of clinical proficiency, to say nothing of clinical mastery. 58 References 1. Bohannon RW. Measuring knee extensor muscle strength. Am J Phys Med Rehabil. 2001;80:13–18. 2. LeVeau BF. Williams and Lissner's Biomechanics of Human Motion. 3rd ed. WB Saunders: Philadelphia; 1992. 3. Soderberg GL. Kinesiology: Application to Pathological Motion. Williams & Wilkins: Baltimore; 1997. 4. Resnick JS, Mammel M, Mundale MO, et al. Muscular strength as an index of response to therapy in childhood dermatomyositis. Arch Phys Med Rehabil. 1981;62:12–19. 5. Magnusson SP, Geismar RA, Gleim G, et al. The effect of stabilization on isokinetic knee extension and flexion torque production. J Athlet Train. 1993;28:221–225. 6. Bohannon RW, Corrigan D. A broad range of forces is encompassed by the maximum manual muscle test grade of five. Percept Mot Skills. 2000;90:747–750. 7. Mulroy SJ, Lassen KD, Chambers SH, et al. The ability of male and female clinicians to effectively test knee extension strength using manual muscle testing. J Orthop Sports Phys Ther. 1997;26:192–199. 8. Sharrard WJW. Muscle recovery in poliomyelitis. J Bone Joint Surg Br. 1955;37:63–69. 9. Demeurisse G, Demol O, Roboye E. Motor evaluation in hemiplegia. Eur Neurol. 1980;19:382–389. 10. Beasley WC. Normal and fair muscle systems: Quantitative standards for children 10 to 12 years of age. [Presented at 39th Scientific Session of the American Congress of Rehabilitative Medicine, Cleveland, Ohio] August 1961. 11. Beasley WC. Influence of method on estimates of normal knee extensor force among normal and post-polio children. Phys Ther Rev. 1956;36:21–41. 12. Perry J. Gait Analysis: Normal and Pathological Function. 2nd ed. Slack, Inc.: Thorofare, NJ; 2010. 13. Piering AW, Janowski AP, Moore MT, et al. Electromyographic analysis of four popular abdominal exercises. J Athl Train. 1993;28:120–126. 14. Lazar RB, Yarkony GM, Ortolano D, et al. Prediction of functional outcome by motor capability after spinal cord injury. Arch Phys Med Rehabil. 1989;70:819–822. 15. Hough CL, Lieu BK, Caldwell ES. Manual muscle strength testing of critically ill patients: feasibility and interobserver agreement. Crit Care. 2011;15(1):R43. 16. Smith J, Padgett DJ, Kaufman KR, et al. Rhomboid muscle electromyography activity during 3 different manual muscle tests. Arch Phys Med Rehabil. 2004;85(6):987–992. 17. Ayotte NW, Stetts DM, Keenan G, et al. Electromyographical analysis of selected lower extremity muscles during 5 unilateral weight-bearing exercises. JOSPT. 2007;37:48–55. 18. Escamilla RF, Lewis C, Bell D, et al. Core muscle activation during Swiss ball and traditional abdominal exercises. JOSPT. 2010;40:265–276. 59 CHAPTER 2 60 Relevance and Limitations of Manual Muscle Testing Introduction The Examiner and the Value of the Muscle Test Influence of the Patient on the Test Use of Manual Muscle Testing in Various Clinical Settings Limitations of Manual Muscle Testing 61 Relevance and Limitations Introduction Manual muscle testing (MMT) is well recognized as the most common strength-testing technique in physical therapy and other health professions, having first appeared during the poliomyelitis epidemic in New England before World War I. A brief history of MMT is described elsewhere in this text. MMT serves unique purposes that can vary according to the setting in which it is practiced. Although MMT is an essential and foundational skill in a therapist's examination techniques, it also has its limitations. Appreciating these limitations and learning how to compensate for them helps to make MMT as relevant nowadays as it was when first conceptualized during the polio era. The Examiner and the Value of the Muscle Test The knowledge and skill of the examiner determine the accuracy and defensibility of a manual muscle test. Specific aspects of these qualities include the following: Knowledge of the location and anatomic features of the muscles in a test. In addition to knowing the muscle attachments, the examiner should be able to visualize the location of the tendon and its muscle in relationship to other tendons and muscles and other structures in the same area (e.g., the tendon of the extensor carpi radialis longus lies on the radial side of the tendon of the extensor carpi radialis brevis at the wrist). Knowledge of the direction of muscle fibers and their alignment in each muscle. Knowledge of the function of the participating muscles (e.g., synergist, prime mover, agonist, and antagonist). Consistent use of a standardized method for each test procedure. Consistent use of proper positioning and stabilization techniques for each test procedure. Stabilization of the proximal segment of the joint being tested is achieved in several ways. These include patient position (via body weight), the use of a firm surface for testing, patient muscle activation, manual fixation by the examiner, or external fixation such as with a belt. Ability to identify patterns of substitution in a given test and how they can be detected based on a knowledge of which other muscles can be substituted for the one(s) being tested. Ability to detect contractile activity during both contraction and relaxation, especially in the minimally active muscle. Sensitivity to differences in contour and bulk of the muscles being tested in contrast to the contralateral side or to normal expectations based on such things as body size, occupation, or leisure work. 62  Awareness of any deviation from normal values for range of motion and the presence of any joint laxity or deformity. Understanding that the muscle belly must not be grasped at any time during a manual muscle test except specifically to assess muscle mass. Ability to identify muscles with the same innervation that will ensure a comprehensive muscle evaluation and accurate interpretation of test results (because weakness of one muscle in a myotome should require examination of all muscles within that myotome). Relating the diagnosis to the sequence and extent of the test (e.g., the patient with C7 complete tetraplegia will require definitive muscle testing of the upper extremity but only confirmatory tests in the trunk and lower extremities). Ability to modify test procedures when necessary while understanding the influence of the modification on the result and thus not compromising the accuracy of the test result. Knowledge of fatigue on the test results, especially muscles tested late in a long testing session, and a sensitivity to fatigue in certain diagnostic conditions such as myasthenia gravis or multiple sclerosis. Understanding of the effect of sensory and perceptual loss on movement. The examiner also may inadvertently influence the test results and should be especially alert when testing in the following situations: The patient with open wounds or other conditions requiring gloves, which may blunt palpation skills. The patient who must be evaluated under difficult conditions such as in an intensive care unit with multiple tubes and monitors or immediately after surgery, the patient in traction, the patient for whom turning is contraindicated, the patient on a ventilator, and the patient in shackles or restraints. The patient with limited understanding of the test, such as in the presence of delirium or dementia. The patient who cannot assume test positions, such as the prone position. The previous situations require careful documentation of the assessment of strength and any limitations encountered. The therapist must avoid the temptation to use shortcuts or “tricks of the trade” before mastering the basic procedures, lest 63  such shortcuts become an inexact personal standard. One such pitfall for the novice tester is to inaccurately assign a lower muscle grade when the patient could not successfully perform a test at a higher grade without actually testing in the position required for the lower grade. For example, when testing trunk flexion, a patient just partially clears the scapula from the surface, with the hands resting lightly on the side of the head (the position for the Grade 5 test), thus not earning a Grade 5. The temptation may exist to assign a grade of 4 to this test because the patient could not achieve a Grade 5, but this may “overrate” the true strength of trunk flexion unless the patient is actually tested with the arms across the chest to confirm Grade 4. The good clinician never ignores a patient's comments and must be a good listener, not just to the patient's questions but also to the meaning of the words the patient uses. This quality is an essential element of good communication and is the primary means of encouraging understanding and respect between therapist and patient. The patient is the best guide to a successful muscle test. Early Kendall Examination Accuracy in giving examinations depends primarily on the examiner's knowledge of the isolated and combined actions of muscles in individuals with normal muscles, as well as in those with weak or paralyzed muscles. The fact that muscles act in combination permits substitution of a strong muscle for a weaker one. For accurate muscle examinations, no substitutions should be permitted; that is, the movement described as a test movement should be done without shifting the body or turning the part to allow other muscles to perform the movement for the weak or paralyzed group. The only way to recognize substitution is to know normal function and realize the ease with which a normal muscle performs the exact test movement. Kendall HO, Kendall FP From Care During the Recovery Period in Paralytic Poliomyelitis. Public Health Bulletin No. 242. Washington, DC: U.S. Government Printing Office; 1939: 26. Influence of the Patient on the Test The intrusion of a living, breathing, feeling person into the testing situation may distort scoring for the unwary examiner. The following circumstances should be recognized: There may be variation in the assessment of the true effort expended by a patient in a given test (reflecting the patient's desire to do well or to seem more impaired than is actually the case). The patient's willingness to endure discomfort or pain may vary (e.g., the stoic, the complainer, the high competitor). The patient's ability to understand the test requirements may be limited in some cases because of cognitive impairments, comprehension, and language barriers. The motor skills required for the test may be beyond those possessed by some patients, making it impossible for them to perform as requested. Lassitude and depression may cause the patient to be indifferent to the test and the examiner. 64  Cultural, social, and gender issues may be associated with palpation and exposure of a body part for testing. Size and available force differences between big and small muscles can cause considerable differences in grading, although not an individual variation (e.g., the gluteus medius versus a finger extensor). There is a huge variability in maximum torque between such muscles, and the examiner must use care not to assign a grade that is inconsistent with muscle size and architecture. Use of Manual Muscle Testing in Various Clinical Settings MMT is used in many different types of health care settings. In this section, we will discuss some of the more common applications of MMT in various clinical and therapeutic settings, with emphasis on the specific challenges often seen in each. The reader should be aware that the examples provided here are not limited to these settings only. Acute Care Facilities Often patients seen in acute care facilities are either acutely ill or are seen postoperatively. In the acutely ill patient, MMT may be used to assess the patient's mobility status to inform a discharge plan. A manual strength exam performed as part of a general assessment may provide information concerning the amount of assistance the patient requires and whether the patient will need an assistive device. Assessing the patient's strength to help ensure safe transfers from bed to chair, to a standing position, or on and off the toilet is an essential part of the acute-care patient management process. A strength assessment may also inform the therapist of the patient's ability to follow directions and/or to verbalize concerns such as following a stroke or in the presence of delirium or other cognitive loss.1,2 Strength assessment may also indicate the presence of pain. Identifying painful muscles before asking a patient to do an activity, such as transfers, will save time in the long run (and potential embarrassment). Strength assessment can take the form of active movement followed by resistance, such as in a manual muscle test or in a 10-repetition maximum such as in a seated shoulder dip. Strength assessment in the postoperative patient informs the therapist of the integrity of the patient's nervous system. The therapist may be the first person requiring the patient to move actively after surgery and thus may be the first one to observe the patient's ability to contract a muscle. Although this scenario is rare, clearly the consequences of assuming an attitude of “all is well” and finding out during a transfer that the patient cannot use part of an extremity would have avoidable consequences. Strength testing in this scenario might take the form of isometric contractions, especially if there are contraindications to joint movement, suspected postsurgical pain as in a newly repaired fractured hip, or in restricted range of motion such as in a total hip arthroplasty. If testing is done in a manner that differs from the published directions, documentation should describe how the test was performed. For example, if isometric testing was done at the hip because the patient was not permitted to move the hip through full range after a hip arthroplasty, the therapist should document the test accordingly: “Patient's strength at the hip appeared to be under volitional control, but pain and postsurgical precautions prevented thorough assessment.” Key movements that should be assessed for viability and for the strength necessary to perform transfers or gait include elbow extension, grip, shoulder depression, knee extension, hip abduction, ankle plantar, and dorsiflexion. Functional tests that might be useful in assessing the patient include gait speed, chair stand, timed transfer, or the timed up-and-go test (see Chapter 8). Special considerations for the acute care setting may include the patient's rapid fluctuations in response to medications, illness, or pain. Reassessment may be necessary when any changes in strength are documented along with therapist's insights into why the changes are occurring. Clearly, strength gains are not possible in the short time a typical patient is in acute care but rather should be attributed to increased confidence in moving, less pain, better understanding of the 65 movement to be performed, motor learning, and so forth. Acute Rehabilitation Facilities Strength assessment in the acute rehabilitation setting may be performed as a baseline assessment to determine progress over time and to identify key impairments that affect the patient's mobility- related and other functional goals. Knowledge of community-based norms for mobility such as chair stands, distance walked, stair climbing speed, floor transfer ability, and gait speed will inform the therapist's clinical decision-making. (See Chapter 8 for a more complete description of these tests.) A standard manual muscle test and/or a 10-repetition maximum strength assessment are other methods used to assess relevant strength abilities. As in the acute care setting, assessment of strength for mobility tasks is critical in the acute rehabilitation setting. Recognition of the importance of key muscle groups in specific mobility tasks, such as the plantar-flexors in gait speed, is key to informed clinical decision-making. Special considerations for the acute rehabilitation setting often include rapid change over a short period. Positive changes may be attributed to increased comfort and less pain, less apprehension, neuroplasticity, and a change in medications. Negative changes may be attributed to, for example, a decline in medical status, pain, or depression. Muscle fatigue resulting from an extended inpatient stay, poor fitness, and excessive sedentary behavior or general body fatigue related to frailty or post–acute care implications may affect the perception of strength. The patient may not be able to assume a proper test position because of postsurgical restrictions or a lack of range of motion, requiring the therapist to do a strength-screen rather than a strength test. Although a screen may be appropriate, the screen cannot serve as an accurate baseline because of the lack of standardization. Functional testing may be more informative and accurate in these situations. The therapist should take special care to document any deviations from the standardized manual muscle test. Long-Term Care Facilities Strength testing and assessment approaches used in long-term care settings are similar to those used in acute rehabilitation. Strength assessment can serve as a baseline to identify key impairments that impact a patient's fall risk, mobility, and other functional goals as well as to determine the patient's progress over time. Strength screening can be part of a required annual assessment for long-term residents. Strength in the form of a chair stand test or grip strength is a key component of the diagnosis of frailty and therefore can inform prognosis.3 Frailty is a common geriatric syndrome, characterized by decreased reserve and increased vulnerability to adverse outcomes, including falls, hospitalization, institutionalization, and death.4 The majority of residents in long-term care are considered frail.5 A profound loss of strength is a significant cause of frailty and serves as a diagnostic criterion. Box 2.1 lists the diagnostic criteria for frailty. Based on these criteria, strength assessment and functional testing are essential in the examination and intervention of nursing home residents.4 Box 2.1 Diagnostic Criteria for Frailty Diagnostic criteria for frailty include the presence of three or more of the following4,10: 1. Unintentional weight loss (>10 lb in past year) 2. General feeling of exhaustion on 3 or more days/week (self-report) 3. Weakness (grip strength in lowest 20%; 40% MVIC)7 , 1 6 Exercises are listed in order from least to greatest MVIC Lateral step up Quadruped with contralateral arm and leg lift Forward step up Unilateral bridge Transverse lunge Wall squat Side-bridge to neutral spine position Standing erect pelvic drop Single-limb deadlift Single-limb squat Side-bridge with hip abduction Side-lying hip abduction MVIC, Maximum voluntary isometric contraction. 396 Hip Abduction From Flexed Position (Tensor fasciae latae) FIGURE 6.44 397  FIGURE 6.45 FIGURE 6.46 Arrow indicates level of cross section. Range of Motion Two-joint muscle. No specific range of motion can be assigned solely to the tensor. Table 6.5 HIP ABDUCTION FROM FLEXION I.D. Muscle Origin Insertion Function 185 Tensor fasciae latae Iliac crest (outer lip) Iliotibial tract (between its two layers, ending of the way down) Hip flexion Fasciae latae (deep) Hip internal (medial) rotation Anterior superior iliac spine (lateral surface) Others 183 Gluteus medius 184 Gluteus minimus The tensor fascia lata (TFL) helps to stabilize and steady the hip and knee joints by putting tension on the iliotibial band of fascia. It helps to maintain one foot in front of the other as in walking. It is tiny muscle, inferior to the iliotibial band. Grade 5, Grade 4, and Grade 3 Position of Patient: 398 Side-lying. Uppermost limb (test limb) is flexed to 45° and lies across the lowermost limb with the foot resting on the table (Fig. 6.47). FIGURE 6.47 Instructions to Therapist: Stand behind patient at level of pelvis. Ask patient to flex hip and lift leg to 30°. If successful, place hand for resistance on lateral surface of the thigh just above the knee. Hand providing stabilization is placed on the crest of the ilium (Fig. 6.48). FIGURE 6.48 Test: Patient abducts hip through approximately 30° of motion. Resistance is given downward (toward floor) from the lateral surface of the distal femur. Instructions to Patient: “Lift your leg and hold it. Don't let me push it down.” Grading 399 Grade 5: Holds test position against maximum resistance. Grade 4: Holds test position against strong to moderate resistance. Grade 3: Completes movement; holds test position but without resistance (Fig. 6.49). FIGURE 6.49 Grade 2 Position of Patient: Patient is in long-sitting position, supporting trunk with hands placed behind body on table. Trunk may lean backward up to 45° from vertical (Fig. 6.50). FIGURE 6.50 Instructions to Therapist: Stand at side of limb to be tested. (Note: Fig. 6.50 deliberately shows therapist on wrong side to avoid obscuring test positions.) One hand supports the limb under the ankle; this hand will be used 400 to reduce friction with the surface as the patient moves but should neither resist nor assist motion. The other hand palpates the tensor fasciae latae on the proximal anterolateral thigh where it inserts into the iliotibial band. Test: Patient abducts hip through 30° of range. Instructions to Patient: “Bring your leg out to the side.” Grading Grade 2 Completes hip abduction motion to 30°. Grade 1 and Grade 0 Position of Patient: Long sitting. Instructions to Therapist: One hand palpates the insertion of the tensor at the lateral aspect of the knee. The other hand palpates the tensor on the anterolateral thigh (Fig. 6.51). FIGURE 6.51 Test: Patient attempts to abduct hip. Instructions to Patient: “Try to move your leg out to the side.” Grading Grade 1: Palpable contraction of tensor fibers but no limb movement. Grade 0: No discernable palpable contractile activity. 401 402 Hip Adduction (Adductors magnus, brevis, and longus; Pectineus and Gracilis) FIGURE 6.52 403 FIGURE 6.53 404  FIGURE 6.54 FIGURE 6.55 Arrow indicates level of cross section. Range of Motion 0°–15°–20° Table 6.6 HIP ADDUCTION I.D. Muscle Origin Insertion Function 181 Adductor Ischial tuberosity (inferolateral) Femur (linea aspera via aponeurosis, medial Hip adduction magnus Ischium (inferior ramus) supracondylar line, and adductor tubercle on medial Hip extension from a position of hip flexion Pubis (inferior ramus) condyle)