Manual Muscle Testing (MMT) PDF

Manual Muscle Testing (MMT): Elbow, Wrist & Hand OT 217 Dr. Qussai Obiedat  ELBOW FLEXION Prime Movers: Biceps, brachialis, and brachioradialis. Against-Gravity Position: Start Position: Sitting in a chair with the arm at the side....

Manual Muscle Testing (MMT): Elbow, Wrist & Hand OT 217 Dr. Qussai Obiedat  ELBOW FLEXION Prime Movers: Biceps, brachialis, and brachioradialis. Against-Gravity Position: Start Position: Sitting in a chair with the arm at the side. The position of the forearm determines which muscle is working primarily: forearm in supination, biceps brachii; forearm in pronation, brachialis; forearm in midposition, brachioradialis. Stabilize: Stabilize the distal end of the humerus during the action. While applying resistance, provide counterpressure at the front of the shoulder. Instruction: While the patient is in each of the three forearm positions, say, “Bend your elbow to touch your shoulder, and do not let me pull it back down.” Resistance: For each of the three positions, the therapist’s hand is placed on the distal end of the forearm and pulls out toward extension. 2  ELBOW FLEXION Gravity-Eliminated Position: Start Position: Sitting with the arm supported by the therapist in 90° of abduction and elbow extension. The position of the forearm determines which muscle is working, as described earlier. Stabilize: Distal humerus. Instruction: “Try to move your hand toward your shoulder.” Palpation: The biceps is easily palpated on the anterior surface of the humerus. With the biceps relaxed and the forearm pronated, palpate the brachialis just medial to the distal biceps' tendon. With the forearm in midposition, palpate the brachioradialis along the radial side of the proximal forearm. Substitution: In a gravity-eliminated plane, the wrist flexors may substitute. 3  ELBOW FLEXION Against gravity Gravity eliminated 4  ELBOW EXTENSION Prime Mover: Triceps. Against-Gravity Position: Start Position: Prone with humerus abducted to 90° and supported on the table. The elbow is flexed, and the forearm is hanging over the edge of the table. Stabilize: Support the arm under the anterior surface of the distal humerus. Instruction: “Straighten your arm, and do not let me push it back down.” Resistance: Apply resistance with the elbow at 10°–15° less than full extension so that the elbow does not lock into position, which may indicate greater strength than the patient actually has. The therapist’s hand, placed on the dorsal surface of the patient’s forearm, pushes toward flexion. 5  ELBOW EXTENSION Gravity-Eliminated Position: Start Position: Sitting, with the humerus supported by the therapist in 90° of abduction. The elbow is fully flexed. Stabilize: The humerus is supported and stabilized. Instruction: “Try to straighten your elbow.” Palpation: The triceps are easily palpated on the posterior surface of the humerus. Substitutions: In the gravity-eliminated position, no external rotation of the shoulder is permitted, so as to avoid letting the assistance of gravity produce extension. On a supporting surface, finger flexion may be used to inch the forearm across the surface. 6  ELBOW EXTENSION Against gravity Gravity eliminated 7  PRONATION Prime Movers: Pronator teres and pronator quadratus. Against-Gravity Position: Start Position: Sitting with the humerus adducted, elbow flexed to 90°, and forearm supinated. The wrist and fingers are relaxed. Stabilize: The distal humerus is stabilized to keep it adducted to the body. Instruction: “Turn your palm to the floor, and do not let me turn it back over.” Resistance: The therapist’s hand encircles the patient’s volar wrist with the therapist’s index finger extended along the forearm. The therapist applies resistance in the direction of supination. 8  PRONATION Gravity-Eliminated Position: Start Position: Sitting with the humerus flexed to 90° and supported. The elbow is flexed to 90°, and the forearm is in full supination. The wrist and fingers are relaxed. Stabilize: The humerus is stabilized. Instruction: “Try to turn your palm away from your face.” Palpation: The pronator teres is palpated medial to the distal attachment of the biceps tendon on the volar surface of the proximal forearm. Pronator quadratus is too deep to palpate. Substitutions: Shoulder abduction or wrist and finger flexion may substitute. 9  PRONATION Against gravity Gravity eliminated 10  SUPINATION Prime Movers: Supinator and biceps. Against-Gravity Position: Start Position: Sitting, with the humerus adducted, elbow flexed to 90°, and forearm pronated. The wrist and fingers are relaxed. To differentiate the supinator from the supination function of the biceps, isolate the supinator by extending the elbow. The biceps does not supinate the extended arm unless resisted. Stabilize: The distal humerus is stabilized. Instruction: “Turn your palm up toward the ceiling, and do not let me turn it back over.” Resistance: Same as for pronation except that resistance is in the direction of pronation. 11  SUPINATION Gravity-Eliminated Position: Start Position: Sitting with the humerus flexed to 90° and supported. The elbow is flexed to 90°, and the forearm is in full pronation. The wrist and fingers are relaxed. Stabilize: The humerus is stabilized and supported. Instruction: “Try to turn your palm toward your face.” Palpation: The supinator is palpated on the dorsal surface of the proximal forearm just distal to the head of the radius. Palpation of the biceps was described earlier. Substitutions: The wrist and finger extensors may substitute. 12  SUPINATION Against gravity Gravity eliminated 13  WRIST AND HAND MEASUREMENT Because many tendons of the wrist and hand cross more than one joint, test positions for individual muscles must include ways to minimize the effect of other muscles crossing the joint. As a general rule, to minimize the effect of a muscle, place it opposite the prime action. For example, to minimize the effect of the extensor pollicis longus (EPL) on extension of the proximal joint of the thumb, flex the distal joint. 14  WRIST EXTENSION Prime Movers: Extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), and extensor carpi ulnaris (ECU). Against-Gravity Position: Start Position: The forearm is supported on a table in full pronation with fingers and thumb relaxed or slightly flexed. Stabilize: The forearm is stabilized on the table. Instruction: “Lift your wrist as far as you can, and do not let me push it down.” Resistance: To test the ECRL, which extends and radially deviates, apply resistance to the dorsum of the hand on the radial side in the direction of flexion and ulnar deviation. To test the ECRB, apply resistance on the dorsum of the hand and push into flexion. To test the ECU, which extends and ulnarly deviates, apply resistance to the dorsum of the hand on the ulnar side and push in the direction of flexion and radial deviation. 15  WRIST EXTENSION Gravity-Eliminated Position: Start Position: The forearm is supported on the table in midposition with the wrist in a slightly flexed position. Instruction: “Try to bend your wrist backward.” Palpation: Palpate the tendon of the ECRL on the dorsal surface of the wrist at the base of the second metacarpal. The muscle belly is on the dorsal proximal forearm adjacent to the brachioradialis. Palpate the tendon of the ECRB on the dorsal surface of the wrist at the base of the third metacarpal adjacent to the ECRL. The muscle belly of the ECRB is distal to the belly of the ECRL on the dorsal surface of the proximal forearm. Palpate the ECU on the dorsal surface of the wrist between the head of the ulna and the base of the fifth metacarpal. The muscle belly is approximately 2 inches distal to the lateral epicondyle of the humerus. Substitutions: EPL and extensor digitorum (ED). 16  WRIST EXTENSION Resistance applied to the extensor carpi radialis Resistance applied to the extensor carpi ulnaris. 17  WRIST FLEXION Prime Movers: Flexor carpi radialis (FCR), palmaris longus, and flexor carpi ulnaris (FCU). Against-Gravity Position: Start Position: The forearm is supinated, the wrist is extended, and the fingers and thumb are relaxed. Stabilize: The forearm is stabilized on the table with the back of the hand raised off the table to allow the wrist to go into slight extension. Instruction: “Bend your wrist all the way forward, and do not let me push it back.” Resistance: To test the FCR and palmaris longus, the therapist applies resistance over the heads of the metacarpals on the volar surface of the hand toward extension. To test for the FCU, the therapist applies resistance over the head of the fifth metacarpal on the volar surface of the hand toward wrist extension and radial deviation. 18  WRIST FLEXION Gravity-Eliminated Position: Start Position: Forearm in midposition, wrist extended, and fingers and thumb relaxed. Stabilize: The forearm rests on the table. Instruction: “Try to bend your wrist forward.” Palpation: Palpate the FCR on the volar surface of the wrist in line with the second metacarpal and radial to the palmaris longus (if present). Palpate the FCU on the volar surface of the wrist just proximal to the pisiform bone. The palmaris longus is a weak wrist flexor. The tendon crosses the center of the volar surface of the wrist. It is not tested for strength and may not even be present; if it is present, it will stand out prominently in the middle of the wrist when wrist flexion is resisted or the palm is cupped with the thumb and fifth digit opposed to one another. Substitutions: Abductor pollicis longus, flexor pollicis longus, flexor digitorum superficialis (FDS), and flexor digitorum profundus (FDP). 19  WRIST FLEXION Resistance applied to the flexor carpi radialis Resistance applied to the flexor carpi longus ulnaris 20 PALMARIS LONGUS Tendon of the palmaris longus as the patient cups her hand in an effort to make her tendon stand out 21  FINGER METACARPOPHALANGEAL (MCP) EXTENSION Prime Movers: ED, extensor indicis proprius, and extensor digiti minimi. Against-Gravity Position: Start Position: The forearm is pronated and supported on the table. The wrist is supported in neutral position, and the finger MP and IP joints are in a relaxed flexed posture. Stabilize: Wrist and metacarpals. Instruction: “Lift this knuckle straight as far as it will go [touch the finger that is to be tested]. Keep the rest of your fingers bent. Do not let me push your knuckle down.” ( Note: Be sure to demonstrate this action.) Resistance: Using one finger, the therapist pushes the head of each proximal phalanx toward flexion, one at a time. 22  FINGER METACARPOPHALANGEAL (MCP) EXTENSION Gravity-Eliminated Position: Start Position: Forearm supported in midposition, wrist in neutral position, and fingers flexed. Stabilize: Wrist and metacarpals. Instruction: “Try to move your knuckles back as far as they will go, one at a time. Keep the rest of your fingers bent.” Palpation: Palpate the muscle belly of the ED on the dorsal–ulnar surface of the proximal forearm. Often the separate muscle bellies are discernible. The tendons of this muscle are readily seen and palpated on the dorsum of the hand. The extensor indicis proprius tendon is ulnar to the ED tendon. Palpate the belly of this muscle on the mid- to distal dorsal forearm between the radius and ulna. Palpate the extensor digiti minimi tendon ulnar to the ED. Actually, it is the tendon that looks as if it were the ED tendon to the little finger because the ED to the little finger is only a slip from the ED tendon to the ring finger. Substitution: Apparent extension of the fingers can result from the rebound effect of relaxation following finger flexion. Flexion of the wrist can cause finger extension through tenodesis action. 23  FINGER MCP EXTENSION Finger metacarpophalangeal extension. The tendons of the extensor digitorum can be seen on the back of the patient’s hand. 24  FINGER INTERPHALANGEAL (IP) EXTENSION Prime Movers: Lumbricals, interossei, ED, extensor indicis proprius, and extensor digiti minimi. Against-Gravity Position for the Lumbricals: There is no reliable test for lumbrical function. Test 1 is traditional. Test 2 is suggested in accordance with electromyographic evidence. Start Position: The forearm is supinated and supported. The wrist is in neutral position. Test 1: MPs are extended with the IPs flexed. Test 2: MPs are flexed with the IPs extended. Stabilize: Metacarpals and wrist. Instruction: Test 1: “Bend your knuckles and straighten your fingers at the same time.” ( Note: Be sure to demonstrate this movement.) Test 2: “Straighten your knuckles and keep your fingers straight at the same time.” Resistance: Test 1: The therapist holds the tip of the finger being tested and pushes it toward the starting position. Test 2: The therapist places one finger on the patient’s fingernail and pushes toward flexion. 25  FINGER INTERPHALANGEAL (IP) EXTENSION Substitution: Nothing substitutes for DIP extension in the event of the loss of lumbrical function when the MP joint is extended. Other muscles of the dorsal expansion can substitute for DIP extension when the MP joint is flexed. Palpation: Lumbrical muscles lie too deep to be palpated. Resistance is given to the lumbricals as described for test 2 26  FINGER DISTAL INTERPHALANGEAL (DIP) FLEXION Prime Mover: FDP. Against-Gravity Position: Start Position: Forearm supinated and supported on a table; wrist and IP joints relaxed. Stabilize: Firmly support the middle phalanx of each finger as it is tested to prevent flexion of the proximal IP joint; the wrist should remain in neutral position. Instruction: “Bend the last joint on your finger as far as you can.” Resistance: The therapist places one finger on the pad of the patient’s finger and applies resistance toward extension. 27  FINGER DISTAL INTERPHALANGEAL (DIP) FLEXION Gravity-Eliminated Position: Start Position: The forearm is in midposition, resting on the ulnar border on a table. The wrist and IP joints are relaxed in neutral position. Stabilize: Same as previously described. Instruction: Same as previously described. Palpation: Palpate the belly of the FDP just volar to the ulna in the proximal third of the forearm. The tendons are sometimes palpable on the volar surface of the middle phalanges. Substitutions: Rebound effect of apparent flexion following contraction of extensors. Wrist extension causes tenodesis action. 28  FINGER PROXIMAL INTERPHALANGEAL (PIP) FLEXION Prime Movers: FDS and FDP. Against-Gravity Position for the Flexor Digitorum Superficialis: Start Position: Forearm supinated and supported on the table; wrist and MP joints relaxed and in zero position. To rule out the influence of the FDP when testing the FDS, hold all IP joints of the fingers not being tested in full extension to slight hyperextension. Because the FDP is essentially one muscle with four tendons, preventing its action in three of the four fingers prevents it from working in the tested finger. In fact, the patient cannot flex the distal joint of the tested finger at all. In some people, the FDP slip to the index finger is such that this method cannot rule out its influence on the PIP joint of the index finger. This should be noted on the test form. Stabilize: All IP joints of the other digits of the hand. Instruction: Point to the PIP joint and say, “Bend just this joint.” Resistance: Using one finger, the therapist applies resistance to the head of the middle phalanx toward extension. 29  FINGER PROXIMAL INTERPHALANGEAL (PIP) FLEXION Gravity-Eliminated Position: Start Position: Forearm supported in midposition, with the wrist and MP joints relaxed in neutral position. Again, rule out the influence of the FDP by holding all the joints of the untested fingers in extension. Stabilize: Proximal phalanx of the finger being tested as well as all IP joints of the other digits of the hand. Instruction: Point to the PIP joint and say, “Try to bend just this joint.” Palpation: Palpate the FDS on the volar surface of the proximal forearm toward the ulnar side. Palpate the tendons at the wrist between the palmaris longus and the FCU. Substitutions: FDP. Wrist extension causes tenodesis action. 30  FINGER PROXIMAL INTERPHALANGEAL (PIP) FLEXION The flexor profundus is prevented from substituting because the therapist is holding in extension all fingers not being tested. 31  FINGER METACARPOPHALANGEAL (MCP) FLEXION Prime Movers: FDP, FDS, dorsal interossei (DI), volar (palmar) interossei, and flexor digiti minimi. The tests for the first four muscles are discussed under their alternative actions. The flexor of the little finger has no other action and is described here. Against-Gravity Position for the Flexor Digiti Minimi: Start Position: Forearm supported in supination. Stabilize: Other fingers in extension. Instruction: “Bend the knuckle of your little finger toward your palm while you keep the rest of the finger straight.” Resistance: Using one finger, the therapist pushes the head of the proximal phalanx toward extension. The therapist must be sure the IP joints remain extended. 32  FINGER METACARPOPHALANGEAL (MCP) FLEXION Gravity-Eliminated Position: Start Position: Forearm supported in midposition. Stabilize: Other fingers in extension. Instruction: “Try to bend the knuckle of your little finger toward your palm while you keep the rest of the finger straight.” Palpation: The flexor digiti minimi is found on the volar surface of the hypothenar eminence. Substitutions: The FDP, FDS, or third volar interosseus may substitute. 33 FINGER METACARPOPHALANGEAL (MCP) FLEXION The therapist is pointing to the belly of the flexor digiti minimi 34  FINGER ABDUCTION Prime Movers: DI (4) and abductor digiti minimi. Gravity-Eliminated Position: Start Position: The pronated forearm is supported with the wrist neutral. The fingers are extended and adducted. Be sure the MP joints are in neutral or slight flexion. Stabilize: The wrist and metacarpals are gently supported. Instruction: “Spread your fingers apart, and do not let me push them back together.” Action: Because the midline of the hand is the third finger and abduction is movement away from midline, the action of each finger is different. It is important to know which DI you are testing: The first DI abducts the index finger toward the thumb. The second DI abducts the middle finger toward the thumb. The third DI abducts the middle finger toward the little finger. The fourth DI abducts the ring finger toward the little finger. The abductor digiti minimi abducts the little finger ulnarly. 35  FINGER ABDUCTION Resistance: Using the thumb and index finger to form a pincer, the therapist applies resistance at the radial or ulnar side of the head of the proximal phalanx in an attempt to push the finger toward midline. Applying resistance to the radial side of the heads of the index and middle fingers tests the first and second DI. Applying resistance to the ulnar side of the middle, ring, and little fingers tests the third and fourth DI and the abductor digiti minimi. Substitutions: ED. Palpation: The first DI fills the dorsal web space and is easy to palpate there. Palpate the abductor digiti minimi on the ulnar border of the fifth metacarpal. The other interossei lie between the metacarpals on the dorsal aspect of the hand, where they may be palpated; on some people, the tendons can be palpated as they enter the dorsal expansion near the heads of the metacarpals. When the DI are atrophied, the spaces between the metacarpals on the dorsal surface appear sunken. 36  FINGER ABDUCTION Grading: Normal finger abductors do not tolerate much resistance. Grade 5: If the fingers give way to resistance but spring back when the resistance is removed. Grade 4: if the muscle takes some resistance. Grade 3: when there is full AROM. Grade 2: if there is partial AROM. Grade 1: when contraction is felt with palpation. Grade 0: when no contractile activity is palpable. 37  FINGER ADDUCTION Prime Movers: Volar (palmar) interossei (3). Gravity-Eliminated Position: Start Position: The forearm is pronated, and the MPs are abducted and in extension. Stabilize: Both of the therapist’s hands are needed for resistance. The forearm and wrist can be supported on a table. Instruction: “Bring your fingers together and hold them. Do not let me pull them apart.” Action: Because the midline of the hand is the third finger and adduction is movement toward midline, the action of each finger is different. The first palmar interosseus (PI) adducts the index finger toward the middle finger. The second adducts the ring finger toward the middle finger, and the third adducts the little finger toward the middle finger. 38  FINGER ADDUCTION Resistance: The therapist holds the heads of the proximal phalanx of two adjoining fingers and applies resistance in the direction of abduction to pull the fingers apart. For the index and middle finger pair, the first PI is tested. For the middle and ring finger pair, the second PI is tested. For the ring and little finger pair, the third PI is tested. Substitutions: Extrinsic finger flexors. Grading: Same as with the finger abductors. Palpation: The PI are usually too deep to palpate with certainty. When these muscles are atrophied, the areas between the metacarpals on the volar surface appear sunken. 39  FINGER ADDUCTION Grading: Grade 5: If the fingers give way to resistance but spring back when the resistance is removed. Grade 4: if the muscle takes some resistance. Grade 3: when there is full AROM. Grade 2: if there is partial AROM. Grade 1: when contraction is felt with palpation. Grade 0: when no contractile activity is palpable. 40  THUMB INTERPHALANGEAL (IP) EXTENSION Prime Mover: EPL. Against-Gravity Position: Start Position: Forearm supported in midposition, wrist flexion of 10°–20°, and thumb MP and IP flexion. Instruction: “Straighten the end of your thumb.” Stabilize: Proximal phalanx into MP flexion. Resistance: The therapist places one finger over the dorsum of the distal phalanx (thumbnail) and pushes only the DIP toward flexion. 41  THUMB INTERPHALANGEAL (IP) EXTENSION Gravity-Eliminated Position: Start Position: Forearm supinated, thumb flexed. Instruction: “Try to straighten the end of your thumb.” Palpation: The tendon of the EPL may be palpated on the ulnar border of the anatomical snuffbox and on the dorsal surface of the proximal phalanx of the thumb. Substitutions: Relaxation of the flexor pollicis longus produces apparent extensor movement as a result of rebound effect. Because the abductor pollicis brevis, adductor pollicis, and flexor pollicis brevis insert into the lateral aspects of the dorsal expansion, they may produce thumb IP extension when the EPL is paralyzed. To prevent this, the position of maximal flexion of CMC and MP joints, wrist flexion of 10°–20°, and full forearm supination are used to put these synergists in a shortened, disadvantaged position while testing the EPL. 42 THUMB INTERPHALANGEAL (IP) EXTENSION The therapist is resisting the extensor pollicis longus, whose tendon is prominent. Against gravity position 43  THUMB METACARPOPHALANGEAL (MCP) EXTENSION Prime Movers: Extensor pollicis brevis (EPB) and EPL. Against-Gravity Position for the Extensor Pollicis Brevis: Start Position: Forearm supported in midposition, MP and IP joints flexed. Stabilize: Firmly support the first metacarpal in abduction. Instruction: “Straighten the knuckle of your thumb while keeping the end joint bent.” ( Note: You may have to move the thumb passively a few times for the patient to get the kinesthetic input regarding the movement.) Resistance: The therapist’s index finger, placed on the dorsal surface of the head of the proximal phalanx, pushes toward flexion. 44  THUMB METACARPOPHALANGEAL (MCP) EXTENSION Gravity-Eliminated Position: Start Position: Forearm supinated, MP and IP joints flexed. Stabilize: First metacarpal in abduction. Instruction: “Try to straighten the knuckle of your thumb while keeping the end joint bent.” Palpation: Palpate the tendon of the EPB on the radial border of the anatomical snuffbox medial to the tendon of the abductor pollicis longus. The EPB may not be present. Substitution: EPL. 45 THUMB METACARPOPHALANGEAL (MCP) EXTENSION The therapist is resisting the extensor pollicis brevis, whose tendon can be seen. 46  THUMB ABDUCTION Prime Movers: Abductor pollicis longus and abductor pollicis brevis. Against-Gravity Position for the Abductor Pollicis Longus: Start Position: Forearm supinated, wrist in neutral position, thumb adducted. Stabilize: Support the wrist on the ulnar side and hold it in neutral position. Instruction: “Bring your thumb away from your palm. Do not let me push it back in.” Action: Patient abducts the thumb halfway between thumb extension and palmar abduction. The therapist may have to demonstrate this action while giving the instructions. Resistance: The therapist’s finger presses the head of the first metacarpal toward adduction. Substitutions: Abductor pollicis brevis and EPB. 47  THUMB ABDUCTION Gravity-Eliminated Position the Abductor Pollicis Longus: Start Position: Forearm in midposition, wrist in neutral position, thumb adducted. Stabilize: Support the wrist on the ulnar side and hold it in neutral position. Instruction: “Try to bring your thumb away from your palm.” Palpation: Palpate the tendon of the abductor pollicis longus at the wrist joint just distal to the radial styloid and lateral to the EPB. 48  THUMB ABDUCTION Against-Gravity Position for the Abductor Pollicis Brevis: Start Position: Forearm is supported in supination, wrist in neutral position, and thumb adducted. Stabilize: Support the wrist in neutral position by holding it on the dorsal and ulnar side. Instruction: “Lift your thumb directly out of the palm of the hand. Do not let me push it back in.” Resistance: The therapist’s finger presses the head of the first metacarpal toward adduction. Substitution: Abductor pollicis longus. 49  THUMB ABDUCTION Gravity-Eliminated Position for the Abductor Pollicis Brevis: Start Position: Forearm is supported in midposition, wrist in neutral position, thumb adducted. Stabilize: Support the wrist in neutral position by holding it on the dorsal and ulnar side. Instruction: “Try to move your thumb away from the palm of your hand.” Palpation: Palpate the abductor pollicis brevis over the center of the thenar eminence. 50  THUMB INTERPHALANGEAL (IP) FLEXION Prime Mover: Flexor pollicis longus. Against-Gravity Position: Start Position: Elbow flexed and supported on a table. Forearm supinated so that the palmar surface of the thumb faces the ceiling; thumb extended at the MP and IP joints. Stabilize: Proximal phalanx, holding MP joint in extension. Instruction: “Bend the tip of your thumb as far as you can, and do not let me straighten it.” Resistance: The therapist’s finger pushes the head of the distal phalanx toward extension. Substitution: Relaxation of the EPL causes apparent rebound movement. 51  THUMB INTERPHALANGEAL (IP) FLEXION Gravity-Eliminated Position: Start Position: Forearm supinated to 90° so that the thumb can flex across the palm. Stabilize: Proximal phalanx, holding MP joint in extension. Instruction: “Try to bend the tip of your thumb as far as you can.” Palpation: Palpate the fl exor pollicis longus on the palmar surface of the proximal phalanx. 52  THUMB METACARPOPHALANGEAL (MCP) FLEXION Prime Movers: Flexor pollicis brevis and flexor pollicis longus. Against-Gravity Position for the Flexor Pollicis Brevis: Start Position: Elbow flexed and supported on the table. Forearm supinated so that the palmar surface of the thumb faces the ceiling; thumb is extended at both the MP and IP joints. Stabilize: Firmly support the first metacarpal. Instruction: “Bend your thumb across your palm, keeping the end joint of your thumb straight. Do not let me pull it back out.” Resistance: The therapist’s finger pushes the head of the proximal phalanx toward extension. 53  THUMB METACARPOPHALANGEAL (MCP) FLEXION Gravity-Eliminated Position: Start Position: Forearm supinated to 90° so that the thumb can flex across the palm. Stabilize: First metacarpal. Instruction: “Try to bend your thumb into your palm, keeping the end joint of your thumb straight.” Palpation: Palpate the flexor pollicis brevis on the thenar eminence just proximal to the MP joint and medial to the abductor pollicis brevis. 54  THUMB METACARPOPHALANGEAL (MCP) FLEXION Substitution: Flexor pollicis longus; the abductor pollicis brevis and the adductor pollicis through insertion into the extensor hood. To rule out the effect of the flexor pollicis longus when testing the flexor pollicis brevis, a test position of maximal elbow flexion, maximal pronation, and maximal wrist flexion. 55  THUMB ADDUCTION Prime Mover: Adductor pollicis. Against-Gravity Position: Start Position: Forearm pronated, wrist and fingers in neutral position, thumb abducted, and MP and IP joints of the thumb in extension. Stabilize: Metacarpals of fingers, keeping the MP joints in neutral. Instruction: “Lift your thumb into the palm of your hand, and do not let me pull it out.” Resistance: The therapist grasps the head of the proximal phalanx and tries to pull it away from the palm toward abduction. 56  THUMB ADDUCTION Gravity-Eliminated Position: Start Position: Same except forearm is in midposition. Stabilize: Metacarpals of fingers, keeping the MP joints in neutral. Instruction: “Try to bring your thumb into the palm of your hand.” Palpation: Palpate the adductor pollicis on the palmar surface of the thumb web space. Substitutions: The EPL, flexor pollicis longus, or flexor pollicis brevis may substitute. 57  OPPOSITION Prime Movers: Opponens pollicis and opponens digiti minimi. Against-Gravity Position: Start Position: Forearm supinated and supported, wrist in neutral position, thumb adducted and extended. Stabilize: Hold the wrist in a neutral position. Instruction: “Touch the pad of your thumb to the pad of your little finger. Do not let me pull them apart.” Resistance: The therapist holds along the first metacarpal and derotates the thumb or holds along the fifth metacarpal and derotates the little finger. These can be resisted simultaneously using both hands. Substitutions: The abductor pollicis brevis, flexor pollicis brevis, or flexor pollicis longus may substitute. 58 OPPOSITION Gravity-Eliminated Position: Start Position: Elbow resting on the table with forearm perpendicular to the table, wrist in neutral position, thumb adducted and extended. Stabilize: Hold the wrist in a neutral position. Instruction: “Try to touch the pad of your thumb to the pad of your little finger.” Palpation: Place fingertips along the lateral side of the shaft of the first metacarpal where the opponens pollicis may be palpated before it becomes deep to the abductor pollicis brevis. The opponens digiti minimi can be palpated volarly along the shaft of the fifth metacarpal. 59 Thank You!