Manual Muscle Test of the Lower Limb PDF

MANUAL MUSCLE TEST OF THE LOWER LIMB Test and Measurement I Dr. MARWA MAHFOUZ Lecturer of Basic Science  MANUAL MUSCLE TESTING Definition Manual muscle testing is a procedure for the evaluation of the function and strength of individual muscles and muscles group based...

MANUAL MUSCLE TEST OF THE LOWER LIMB Test and Measurement I Dr. MARWA MAHFOUZ Lecturer of Basic Science  MANUAL MUSCLE TESTING Definition Manual muscle testing is a procedure for the evaluation of the function and strength of individual muscles and muscles group based on effective performance of a movement in relation to the forces of gravity and manual resistance through the available ROM.  TERMINOLOGY Prime Mover or agonist: A muscle or muscle group that makes the major contribution to movement at the joint. Antagonist: A muscle or a muscle group that has an opposite action to the prime mover's. The antagonist relaxes as the agonist moves the part through a ROM. Synergist: A muscle that contracts and works a long with the agonist to produce the desired movement. Three types of synergists are described.  1-Neutralizing or counter acting synergists Muscles contracted to prevent unwanted movements produced by the prime mover. For example, when the long finger flexors contract to produce finger flexion the wrist extensors contract to prevent wrist flexion from occurring.  2-Conjoint synergists Two or more muscles that work together to produce the desired movement. The muscles contracting alone would be unable to produce the movement. For ex.: Wrist extension is produced by contraction of extensor carpi radialis longus and brives and extensor carpi ulnaris. If the extensor carpi radialis longus or brevis contract a lone the wrist extends and radially deviates, if the extensor carpi ulnaris contracts alone the wrist extends and ulnar deviates. When the muscles contract as a group the deviation actions cancel out and the common action of wrist results (extension).  3-Stabilizing or Fixating Synergists Muscle that prevent movement or control the movement at joints proximal to the moving joint to provide a fixed or stable base from which the distal moving segment can effectively work. For ex.: If the elbow flexors contract to lift an object off a table anterior to the body, the muscles of the scapula and glenohumeral joint must contract to either allow slow controlled movement or no movement to occur at the scapula and glenohumeral joint to provide the elbow flexors with a fixed origin from which to pull. If the scapular muscles did not contract the object could not be lifted as the elbow flexors would act to pull the shoulder girdle downward toward the table top.  GRADING Zero (0): Paralyzed (no palpable or visible contraction) Trace (1): Flicker or visible or palpable contraction. Poor (2): Full ROM with gravity eliminated. Fair (3): Full ROM against gravity. Good (4): Full ROM against gravity + moderate resistance. Normal (5): Full ROM against gravity + maximum resistance + hold at the end of ROM.  MANUAL MUSCLE TEST Factors affecting muscle strength Age Sex Type of muscle contraction Muscle size Speed of muscle contraction Previous training effect  Contraindications Inflammation Pain Osteoporosis (contraindicated for resistance)  Explanation and Instruction Assessment of normal muscle strength Patient position Stabilization & fixation Reliability is the confidence or consistency over time. Subjectivity is against reliability. To increase the reliability of the assessment of muscle strength: MMT should be conducted at 1-the same time of day each time to avoid varying levels of fatigue. 2-The same therapist should repeat MMT in the same environment 3- using the same patient position.  Substitution and trick movements When muscles are weak or paralyzed, other muscles may take over or gravity may be used to perform the movements normally carried out by the weak muscles. To prevent substitutions and trick movements making by the patient, the therapist should use the following: – Use of normal muscles to fix the proximal parts of the body. – The patient's body weight is used to help fix the shoulder or pelvis girdles. – The patient position should be ensure fixation of other parts of body except the tested part. – External forces (e.g. external pressure applied directly by the therapist, or belt may be used). MMT for Hip Flexors 1.ORIGIN ………………………… 2.INSERTION…………………… 3.NERVE Supply………………… 4.ACTION………………………… 5.EFFECT of WEAKNESS…… 6.EFFECT OF CONTRUCTURE 7.SUBSTITUTIONS …………… 8.PALPATION POINT …………  Hip Flexion Agonist / Prim mover : Psoas major and iliacus Origin: Psoas major: transverse processes of L1-L5 and the vertebral bodies of T12-L5 Iliacus: anterior 2/3 of iliac fossa Insertion: Psoas major: lesser trochanter of the femur Iliacus: lesser trochanter of the femur Nerve Supply: Psoas major: lumbar plexus , nerve root from L2-L4 Iliacus: lumbar plexus, Femoral nerve L2L3 Action: powerful hip flexion Synergist / Accessory Muscles: Rectus Femoris (RF), Sartorius, Tensor fasciae latae (TFL). 2- Range of motion: 0 to 115 -125 3- Stabilization: 1. contraction of anterior abdominal muscles to fix lumbar spine and pelvis. 2. weight of trunk. 4- Effect of weakness: 1 - Difficulty in: climbing stair, walking up or down the incline, getting up from a reclined position. 2- In marked weakness: walking is difficult because the leg must brought forward by pelvic motion. 5- Effect of contracture: Bilateral– Increased lumbar lordosis. Unilateral–hip abduction combined with external rotation. 6- Factor Limiting of motion - With knee flexed, contact of thigh on abdomen. - With knee extended, tension of Hamstring Muscles. 7- Substitution: *Sartorius: external rotation and abduction of the hip *Tensor fasciae latae: internal rotation and abduction of the hip 8-Procedures: a- Position of Patient: b- Position of Therapist : inner hand, Outer hand, Direction of Resistance c- Test d- Instruction to patient Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair) Position of Patient: Short sitting with thighs fully supported on table and legs hanging over the edge. Patient may use arms to provide trunk stability by grasping table edge or with hands on table at each side. Position of Therapist: Standing next to limb to be tested. Contoured hand to give resistance over distal thigh just proximal to the knee joint.  Test: Patient flexes hip to end of range, clearing the table and maintaining neutral rotation, holding that position against the examiner's resistance, which is given in a downward direction toward the floor. Instructions to Patient: "Lift your leg off the table and don't let me push it down."  Grade 5: Thigh clears table. Patient tolerates maximal resistance. Grade 4: Hip flexion holds against strong to moderate resistance. There may be some "give" at the end position. Grade 3: Patient completes test range and holds the position without resistance.  Helpful Hints Knowledge of the ROM of the hip is essential before manual tests of hip strength are conducted. If the examiner does not have a clear idea of hip joint ranges, especially tightness in the hip flexor muscles, test results will be contaminated. For example, in the presence of a hip flexion contracture, the patient must be standing and leaning over the edge of the table to test hip extension strength. This position will decrease the influence of the flexion contracture and will allow the patient to move against gravity through the available range.  Grade 2 (Poor) Position of Patient: Side-lying with limb to be tested uppermost and supported by examiner. Trunk in neutral alignment. Lower most limb may be flexed for stability. Position of Therapist: Standing behind patient. Cradle test limb in one arm with hand support under the knee. Opposite hand maintains trunk alignment at hip. Test: Patient flexes supported hip. Knee IS permitted to flex to prevent hamstring tension. Instructions to Patient: "Bring your knee up toward your chest." Grade 2: Patient completes the range of motion in sidelying position.  Helpful Hints When the trunk is weak the test will be more accurate from a supine position. Hip flexion is not a strong motion, so experience is necessary to appreciate what constitutes a normal level of resistance. Hip Flexion, Abduction, and External Rotation with Knee Flexion  Sartorius muscle - Origin : from the anterior superior iliac spine and part of the notch between the anterior superior iliac spine and anterior inferior iliac spine. - Insertion: into the superomedial surface of the tibia Nerve supply: by the femoral nerve. Action: hip flexion, abduction, and external rotation. -Others: Hip and knee flexors Hip external rotators Hip abductors  Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair) Position of Patient: Short sitting with thighs supported on table and legs hanging over side. Arms may be used for support. Position of Therapist: Standing lateral to the leg to be tested. Place one hand on the lateral side of knee; the other hand grasps the medial-anterior surface of the distal leg. Hand at knee resists hip flexion and abduction. Hand at the ankle resists hip external rotation and knee flexion.  Test: Patient flexes, abd., and ER the hip and flexes the knee. Instructions to Patient: Therapist may demonstrate the required motion passively and then ask the patient to repeat the motion, "Hold it! Don't let me move your leg or straighten your knee." Alternate instruction: "Slide your heel up the shin of your other leg." Grade 5: Holds end point against maximal resistance. Grade 4: Tolerates moderate to heavy resistance. Grade 3: Completes movement and holds end position but takes no resistance  Grade 2 (Poor) Position of Patient: Supine. Heel of limb to be tested is placed on contralateral shin. Position of Therapist: Standing at side of limb to be tested. Support limb as necessary to maintain alignment. Test: Patient slides test heel upward along shin to knee. Instructions to Patient: "Slide your heel up to your knee." Grade 2: Completes desired movement Grade 1 (Trace) and Grade 0 (Zero) Position of Patient: Supine. Position of Therapist: Standing on side to be tested. Cradle test limb under calf with hand supporting limb behind knee. Opposite hand palpates sartorius on medial side of thigh where the muscle crosses the femur. Examiner may prefer to palpate near the muscle origin just below the ASIS. Test: Patient attempts to slide heel up shin toward knee. Instructions to Patient: "Try to slide your heel up to your knee." Grade 1: Therapist can detect slight contraction of muscle; no visible movement. Grade 0: No palpable contraction  Substitution Substitution by the iliopsoas or the rectus femoris results in pure hip flexion without abduction and external rotation. Helpful Hints The therapist is reminded that failure of the patient to complete the full range of motion in the Grade 3 test is not an automatic Grade 2. The patient should be tested in the supine position to ascertain whether the correct grade is Grade 2 or less. Never grasp the belly of a muscle (the calf in this instance) during Poor and Trace tests. THANK YOU