Evaluation of Muscle Strength

1. Position: The client is seated erect with arms resting at sides of body. The OT practitioner stands behind the client toward the side to be tested.

2. Stabilize: A chair back can offer stabilization to the trunk, if necessary.

3. Palpate: Palpate the upper trapezius parallel to the cervical vertebrae, near the shoulder-neck curve.¹⁰

4. Observe: Observe the elevation of the scapula as the client shrugs the shoulder toward the ear and rotates and laterally flexes the neck toward the side being tested at the same time (Figure 22-2, A).¹⁴

5. Resist: Provide resistance by placing one hand on top of the shoulder toward the scapula depression and the other hand on the side of the head toward derotation and lateral flexion to the opposite side (Figure 22-2, B).¹⁴

1. Position: The client should be prone with head in midposition. The OT practitioner stands opposite the side being tested.

2. Stabilize: The weight of the trunk on the supporting surface provides adequate stabilization.

3. Palpate: Palpate the upper trapezius, as described in the previous procedure, while observing the client elevating the shoulder being tested. Because of positioning, the neck rotation and lateral flexion components are omitted for these grades (Figure 22-2, C).

4. Grade: The standard definitions of muscle grades should be used.

1. Position: The client is prone with the arm positioned overhead in 130 to 165 degrees of abduction and resting on the supporting surface. The forearm is in midposition with the thumb toward the ceiling.^12,13 The therapist stands next to the client on the opposite side^7,10 or on the same side.^12,13

2. Stabilize: The weight of the body provides adequate stabilization. This test is given in the gravity-minimized position, because it is not feasible to position the client for the against-gravity movement (head down). If the deltoid is weak, the arm may be supported and passively raised by the therapist while the client attempts the motion.¹⁰

3. Palpate: Palpate the lower trapezius distal to the medial end of the spine of the scapula and parallel to the thoracic vertebrae, approximately at the level of the inferior angle of the scapula.¹⁰

4. Observe: Observe the client while he or she lifts the arm off the supporting surface to ear level.¹² During this movement, there is strong downward fixation of the scapula by the lower trapezius (Figure 22-3, A).¹⁰

5. Resist: Provide resistance at the lateral angle of the scapula, toward elevation and abduction (Figure 22-3, B).¹⁰ Resistance may be applied on the humerus just above the elbow in a downward direction if shoulder and elbow strength are adequate.^12–14

1. Position and stabilize: Position and stabilize the client as described in the previous test. No stabilization is required. The therapist may support the client’s arm if the posterior deltoid muscles and triceps are weak.¹²

2. Palpate and observe: Palpate and observe the client in the same manner as described for the previous test (Figure 22-3, C).

3. Grade: The client receives a grade of P if he or she can complete full scapular ROM without the weight of the arm.¹²

1. Position: The client is supine with the shoulder flexed to 90 degrees and slightly abducted, elbow extended or fully flexed. The therapist stands next to the client on the side being tested.^6,7,10,13,14

2. Stabilize: Provide stabilization over the weight of the trunk or over the shoulder.⁶

3. Palpate: Palpate the digitations of the origin of the serratus anterior on the ribs, along the midaxillary line and just distal and anterior to the axillary border of the scapula.^6,10 Note that muscle contraction may be difficult to detect in women and overweight clients.

4. Observe: Observe the client reaching upward as if pushing the arm toward the ceiling, abducting the scapula (Figure 22-4, A).^6,10

5. Resist: Provide resistance at the distal end of the humerus, and push the client’s arm directly downward toward scapula adduction (Figure 22-4, B).^6,7,10,13 If there is shoulder instability, the therapist should support the arm and not apply resistance. In this instance, only a grade of F (3) can be tested.⁷

1. Position: The client is seated with the arm supported by the therapist in 90 degrees of shoulder flexion and the elbow extended.^6,10,13

2. Stabilize: Provide stabilization over the shoulder to be tested.

3. Palpate: The client is palpated in the same manner as described in the previous section.

4. Observe: The therapist should note any abduction of the scapula as the arm moves forward (Figure 22-4, C).¹⁰ Weakness of this muscle produces “winging” of the scapula.⁸

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is prone with the shoulder abducted to 90 degrees and externally rotated and the elbow flexed to 90 degrees, shoulder resting on the supporting surface. The therapist stands on the side being tested.^10,12–14

2. Stabilize: The weight of the trunk on the supporting surface usually provides adequate stabilization, or stabilization can be provided over the midthorax to prevent trunk rotation if necessary.

3. Palpate: Palpate the middle trapezius between the spine of the scapula and adjacent vertebrae in alignment with the abducted humerus.

4. Observe: Observe the client lifting the arm off the table, and note any movement of the vertebral border of the scapula toward the thoracic vertebrae (Figure 22-5, A).

5. Resist: Provide resistance at the vertebral border of the scapula toward abduction (Figure 22-5, B).^6,7,10,13

1. Position and stabilize: The therapist positions and stabilizes the client in the same way as described in the previous test but now supports the weight of the arm by cradling it under the humerus and forearm.¹⁴ The client may also be positioned sitting erect, with the arm resting on a high table and the shoulder midway between 90-degree flexion and abduction.¹⁰ The therapist stands behind the client in this instance.

2. Palpate and observe: Palpate and observe the middle trapezius. Ask the client to bring the shoulders together as if assuming an erect posture. Observe scapula adduction toward the vertebral column (Figure 22-5, C).

3. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is prone with the head rotated to the opposite side; the arm on the side being tested is placed in shoulder adduction and internal rotation, with the elbow slightly flexed and the dorsum of the hand resting over the lumbosacral area of the back.^6,12 The therapist stands opposite the side being tested.^7,8,10

2. Stabilize: The weight of the trunk on the supporting surface offers adequate stabilization.^7,14

3. Palpate: Palpate the rhomboid muscles between the vertebral border of the scapula and the second to fifth thoracic vertebrae.^10,14 (They may be more easily discerned toward the lower half of the vertebral border of the scapula, because they lie under the trapezius muscle.)

4. Observe: Observe the client raising the hand up off the back while maintaining the position of the arm.^7,12 During this motion, the anterior aspect of the shoulder must lift from the table surface. Observe scapula adduction and downward rotation while the shoulder joint is in some extension (Figure 22-6, A).¹⁰

5. Resist: Provide resistance over the scapula toward abduction and upward rotation⁶ (Figure 22-6, B).

1. Position: The client sits erect with the arm positioned behind the back in the same manner described for the previous test. The therapist stands behind the client, slightly opposite the side being tested.¹⁰

2. Stabilize: The trunk is stabilized by placing one hand over the shoulder, opposite the one being tested, to prevent trunk flexion and rotation.

3. Palpate: The rhomboids are palpated as described previously.

4. Observe: Scapula adduction and downward rotation are observed as the client lifts the hand away from the back (Figure 22-6, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated with the arm relaxed at the side of the body and the hand facing backward.¹² A straight-backed chair may be used to offer trunk support. The therapist stands on the side being tested and slightly behind the client.^7,10,20

2. Stabilize: Provide stabilization over the shoulder being tested, but allow the normal abduction and upward rotation of the scapula that occurs with this movement.^10,13

3. Palpate: Palpate the anterior deltoid just below the clavicle on the anterior aspect of the humeral head.⁷

4. Observe: Observe the client flexing the shoulder joint to 90-degree flexion (parallel to the floor; Figure 22-7, A).^6,10,12

5. Resist: Provide resistance at the distal end of the humerus downward toward shoulder extension (Figure 22-7, B).^6,7,8,12

1. Position: The client is placed in a side-lying position. The side being tested is superior. If the client cannot maintain the weight of the arm against gravity, the therapist can support it.^6,12 If the side-lying position is not feasible, the client may remain seated, and the test procedure described above can be performed with the grading modified.¹⁰

2. Palpate and observe: The therapist should palpate and observe the client in the same manner as described in the previous test. The arm is moved toward the face to 90-degree shoulder flexion (Figure 22-7, C).

3. Grade: The client is graded according to standard definitions of muscle grades. If the seated position was used for tests of grades poor to zero, partial ROM against gravity should be graded poor.^10,13

1. Position: The client is prone, with the shoulder joint adducted and internally rotated so that the palm of the hand is facing up.^6,7,12 The therapist stands on the opposite side or on the test side.

2. Stabilize: Provide stabilization over the scapula on the side being tested.

3. Palpate: Palpate the teres major along the axillary border of the scapula. The latissimus dorsi may be palpated slightly below this point or closer to its origins parallel to the thoracic and lumbar vertebrae.^7,10 The posterior deltoid may be found over the posterior aspect of the humeral head (Figure 22-8, A).

4. Observe: Observe the client extending the shoulder joint.

5. Resist: Provide resistance at the distal end of the humerus in a downward and outward direction, toward flexion and slight abduction (Figure 22-8, B).^{6,7,10,12–14}

1. Position: The client is placed in the side-lying position; the therapist stands behind the client.⁶

2. Stabilize: Provide stabilization over the scapula. If the client cannot maintain the weight of the part against gravity, the therapist should support the client’s arm.⁶ If the side-lying position is not feasible, the client may remain in the prone position, and the test may be performed as described for the previous test with modified grading.¹⁰

3. Palpate: Palpate the teres major or latissimus dorsi as described for the previous test.

4. Observe: Observe the client extending the arm backward in a plane parallel to the floor (Figure 22-8, C).

5. Grade: Grade the client according to standard definitions of muscle grades. If the tests for grades poor to zero were done in the prone-lying position, completion of partial ROM should be graded poor.¹⁰

1. Position: The client is seated, with arms relaxed at the sides of the body. The elbow on the side to be tested should be slightly flexed and the palms facing toward the body. The therapist stands behind the client.^6,7,12

2. Stabilize: Provide stabilization over the scapula on the side to be tested.^6,10,14

3. Palpate: Palpate the middle deltoid over the middle of the shoulder joint from the acromion to the deltoid tuberosity.^6,10,14,15 The supraspinatus is too deep to palpate.⁶

4. Observe: Observe the client abducting the shoulder to 90 degrees. During movement, the client’s palm should remain down, and the therapist should observe that there is no external rotation of the shoulder nor elevation of the scapula^6,10,12–15 (Figure 22-9, A).

5. Resist: Provide resistance at the distal end of the humerus toward adduction (Figure 22-9, B).¹²

1. Position: The client is in the supine position, lying with the arm to be tested resting at the side of the body, palm facing in and the elbow slightly flexed. The therapist stands in front of the supporting surface toward the side to be tested.^10,12

2. Stabilize: Provide stabilization over the shoulder to be tested.

3. Palpate and observe: Follow the technique described for the previous test. The therapist asks the client to bring the arm out and away from the body, while abducting the shoulder to 90 degrees (Figure 22-9, C).

4. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is prone, with the shoulder abducted to 90 degrees and the humerus in neutral (0-degree) rotation, elbow flexed to 90 degrees. The forearm is in neutral rotation, hanging over the edge of the table, perpendicular to the floor.^6–8,12 The therapist stands in front of the supporting surface, toward the side to be tested.^10,14

2. Stabilize: Provide stabilization at the distal end of the humerus by placing a hand under the arm on the supporting surface to prevent shoulder abduction.^7,14

3. Palpate: Palpate the infraspinatus muscle just below the spine of the scapula on the body of the scapula⁶ or the teres minor along the axillary border of the scapula.¹⁰

4. Observe: Observe the client rotating the humerus so that the back of the hand is moving toward the ceiling (Figure 22-10, A).^{6,7,10,12–14}

5. Resist: Provide resistance on the distal end of the forearm toward the floor in the direction of internal rotation (Figure 22-10, B).^6,10,12–14 Apply resistance gently and slowly to prevent injury to the glenohumeral joint, which is inherently unstable.¹²

1. Position: The client is seated, with arm adducted and in neutral rotation at the shoulder. The elbow is flexed to 90 degrees, with the forearm in neutral rotation. The therapist stands in front of the client toward the side to be tested.^6,7

2. Stabilize: Provide stabilization on the arm against the trunk at the distal end of the humerus to prevent abduction and extension of the shoulder, and over the shoulder to be tested.^5,7,20 The hand stabilizing over the shoulder can be used to palpate the infraspinatus simultaneously.

3. Palpate: Palpate the infraspinatus and teres minor as described for the previous test.

4. Observe: Observe the client moving the forearm away from the body by rotating the humerus while maintaining neutral rotation of the forearm (Figure 22-10, C).^6,20

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is prone, with the shoulder abducted to 90 degrees, the humerus in neutral rotation, and the elbow flexed to 90 degrees. A rolled towel may be placed under the humerus. The forearm is perpendicular to the floor. The therapist stands on the side to be tested, just in front of the client’s arm.^6–8,12

2. Stabilize: Provide stabilization at the distal end of the humerus by placing a hand under the arm and on the supporting surface, as for external rotation.^6,7,10,14

3. Palpate: Palpate the teres major and latissimus dorsi along the axillary border of the scapula toward the inferior angle.

4. Observe: Observe the client internally rotating the humerus, moving the palm of the hand upward toward the ceiling (Figure 22-11, A).^6,10

5. Resist: Provide resistance at the distal end of the volar surface of the forearm anteriorly toward external rotation (Figure 22-11, B).^7,10,12–14

1. Position: The client is seated, with the shoulder adducted and in neutral rotation, elbow flexed to 90 degrees with the forearm in neutral rotation. The therapist stands on the side to be tested.^6,20

2. Stabilize: Provide stabilization on the arm at the distal end of the humerus against the trunk to prevent abduction and extension of the shoulder.

3. Palpate: Palpate the teres major and latissimus dorsi, as described for the previous test.

4. Observe: Observe the client moving the palm of the hand toward the chest, while internally rotating the humerus (Figure 22-11, C).

1. Position: The client is prone, with the shoulder abducted to 90 degrees and in slight external rotation, elbow flexed to 90 degrees, and forearm perpendicular to the floor. The therapist stands on the side being tested.^14,15

2. Stabilize: Provide stabilization over the scapula.^6,10

3. Palpate: Palpate the posterior deltoid below the spine of the scapula and distally toward the deltoid tuberosity on the posterior aspect of the shoulder.¹⁰

4. Observe: Observe the client horizontally abducting the humerus, lifting the arm toward the ceiling (Figure 22-12, A).¹²

5. Resist: Provide resistance just proximal to the elbow obliquely downward toward horizontal adduction (Figure 22-12, B).^6,12–14

1. Position: The client is seated, with the arm in 90-degree abduction, the elbow flexed to 90 degrees, and the palm down, supported on a high table or by the therapist.^6,12 If a table is used, powder may be sprinkled on the surface to reduce friction.

2. Stabilize: Provide stabilization over the scapula.

3. Palpate: Palpate the posterior deltoid, as described for the previous test.

4. Observe: Observe the client pulling the arm backward into horizontal abduction (Figure 22-12, C).

5. Grade: Client is graded according to standard definitions of muscle grades.

1. Position: The client is supine, with the shoulder abducted to 90 degrees, elbow flexed or extended. The therapist stands next to the client on the side being tested or behind the head of C.^4,6,7,10,12

2. Stabilize: Stabilize the trunk by placing one hand over the shoulder on the side being tested to prevent trunk rotation and scapula elevation.

3. Palpate: Palpate over the insertion of the pectoralis major at the anterior aspect of the axilla.⁶

4. Observe: Observe the client horizontally adducting the humerus, moving the arm toward the opposite shoulder to a position of 90 degrees of shoulder flexion.¹⁴ If the client cannot maintain elbow extension, the therapist may guide the forearm to prevent the hand from hitting the client’s face (Figure 22-13, A).

5. Resist: Provide resistance at the distal end of the humerus, in an outward direction toward horizontal abduction (Figure 22-13, B).^6,7,10

1. Position: The client is seated next to a high table, with the arm supported in 90 degrees of shoulder abduction and slight flexion at the elbow.^4,12,20 Powder may be sprinkled on the supporting surface to reduce the effect of resistance from friction during movement, or the therapist may support the arm.⁶

2. Stabilize: Provide stabilization over the shoulder on the side being tested, simultaneously using the stabilizing hand to palpate the pectoralis major muscle.⁶

3. Palpate: Palpate the pectoralis major, as described for the previous test.

4. Observe: Observe the client horizontally adducting the arm toward the opposite shoulder, in a plane parallel to the floor (Figure 22-13, C).

1. Position: The client is seated, with the arm adducted at the shoulder and extended at the elbow and held against the side of the trunk. The forearm is supinated to test for the biceps primarily (forearm should be positioned in pronation to test for the brachialis primarily, and in midposition to test for the brachioradialis).^10,12,13 The therapist stands next to the client on the side being tested or directly in front of the client.

2. Stabilize: Provide stabilization at the humerus (in adduction).

3. Palpate: Palpate the biceps brachii over the muscle belly, on the middle of the anterior aspect of the humerus. Its tendon may be palpated in the middle of the antecubital space.^6,7,10 (Brachioradialis is palpated over the upper third of the radius on the lateral aspect of the forearm, just below the elbow. The brachialis may be palpated lateral to the lower portion of the biceps brachii if the elbow is flexed and in the pronated position.¹⁵)

4. Observe: Observe the client flexing the elbow, with hand toward the face. The therapist should observe for maintenance of forearm in supination (when testing for biceps) and for relaxed or extended wrist and fingers (Figure 22-14, A).^6,15

5. Resist: Provide resistance at the distal end of the volar aspect of the forearm, pulling downward toward elbow extension (Figure 22-14, B).^7,10,14

1. Position: The client is supine, with the shoulder abducted to 90 degrees and externally rotated, elbow extended, and forearm supinated. The therapist stands at the head of the table on the side being tested. (The client may also be seated, with the side being tested resting on the treatment table, which is at axillary height, the humerus in 90-degree abduction, the elbow extended, and the forearm in neutral position.⁷)

2. Stabilize: Provide stabilization at the humerus. The stabilizing hand can be used simultaneously for palpation here.

3. Palpate: Palpate the biceps as described for the previous test.

4. Observe: Observe the client flexing the elbow, with the hand toward the shoulder.¹⁰ Watch for maintenance of forearm supination and relaxation of the fingers and wrist (Figure 22-14, C).¹⁵

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is prone, with the humerus abducted to 90 degrees, the elbow flexed to 90 degrees, and the forearm in neutral rotation and perpendicular to the floor. The therapist stands next to the client, just behind the arm to be tested.^7,14,20

2. Stabilize: Provide stabilization at the humerus by placing one hand for support under it, between the client’s arm and the table.^12,14

3. Palpate: Palpate the triceps over the middle of the posterior aspect of the humerus or the triceps tendon just proximal to the olecranon process on the dorsal surface of the arm.^6,7,10,15

4. Observe: Observe the client extending the elbow to just less than maximal range. The wrist and fingers remain relaxed (Figure 22-15, A).

5. Resist: Provide resistance at the distal end of the forearm into elbow flexion. Before resistance is given, be sure that the elbow is not locked. Resistance to a locked elbow can cause joint injury (Figure 22-15, B).^6,10

1. Position: The client is supine, with the humerus abducted to 90 degrees and in external rotation, the elbow fully flexed, and the forearm supinated. The therapist is standing next to the client, just behind the arm to be tested.¹⁰ An alternate position is with the client seated, shoulder abducted to 90 degrees in neutral rotation, elbow flexed, and forearm in neutral position, supported by the therapist.^7,10,12

2. Stabilize: Provide stabilization at the humerus by holding one hand over the middle or distal end to prevent shoulder motion.

3. Palpate: Palpate the triceps as described for the previous test.

4. Observe: Observe the client extending the elbow, moving the hand away from the head (Figure 22-15, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated, with the humerus adducted, the elbow flexed to 90 degrees, and the forearm pronated. The therapist stands in front of the client or next to the client on the side to be tested.^6,7,10,12,13

2. Stabilize: Provide stabilization at the humerus just proximal to the elbow.^6,10

3. Palpate: Palpate the client over the supinator muscle on the dorsal-lateral aspect of the forearm, below the head of the radius. The muscle can be best felt when the radial muscle group (extensor carpi radialis and brachioradialis) is pushed up out of the way.⁴ The therapist may also palpate the biceps at the middle of the anterior surface of the humerus.^6,7

4. Observe: Observe the client supinating the forearm, turning the hand palm up. Because gravity assists movement, after the 0-degree neutral position is passed, the therapist may apply slight resistance equal to the weight of the forearm (Figure 22-16, A).^6,7

5. Resist: Provide resistance by grasping around the dorsal aspect of the distal forearm with the fingers and heel of the hand, while turning the arm toward pronation (Figure 22-16, B).⁶

1. Position: The client is seated, shoulder flexed to 90 degrees and the upper arm resting on the supporting surface, elbow flexed to 90 degrees; the forearm is in full pronation in a position perpendicular to the floor.^6,7,20 The therapist stands next to the client on the side to be tested.

2. Stabilize: Provide stabilization at the humerus just proximal to the elbow.⁶

3. Palpate: Palpate the supinator or biceps as described for the previous test.

4. Observe: Observe the client supinating the forearm, turning the palm of the hand toward the face (Figure 22-16, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated with the humerus adducted, the elbow flexed to 90 degrees, and the forearm in full supination. The therapist stands beside the client on the side to be tested.^6,7,10,13

2. Stabilize: Provide stabilization at the humerus just proximal to the elbow to prevent shoulder abduction.^6,7,10,14

3. Palpate: Palpate the pronator teres on the upper part of the volar surface of the forearm, medial to the biceps tendon and diagonally from the medial condyle of the humerus to the lateral border of the radius.^7,10,14,15

4. Observe: Observe the client pronating the forearm, turning the hand palm down (Figure 22-17, A).¹⁰ Slight resistance may be applied after the arm has passed midposition to compensate for the assistance of gravity after that point.⁶

5. Resist: Provide resistance by grasping over the dorsal aspect of the distal forearm, using the fingers and heel of the hand and turning toward supination (Figure 22-17, B).

1. Position: The client is seated, shoulder flexed to 90 degrees, elbow flexed to 90 degrees, and the forearm in full supination. The upper arm is resting on the supporting surface, and the forearm is perpendicular to the floor.²⁰ The therapist stands next to the client on the side to be tested.

2. Palpate: Palpate the pronator teres as described for the previous test.

3. Observe: Observe the client pronating the forearm, turning the palm of the hand away from the face (Figure 22-17, C).

4. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated or supine with the forearm resting on the supporting surface in pronation, the wrist at neutral, and the fingers and thumb relaxed. The therapist sits opposite to or next to the client on the side to be tested.^10,14

2. Stabilize: Provide stabilization over the volar or dorsal aspect of the distal forearm.^6,10,14

3. Palpate: Palpate the ECRL and ECRB tendons on the dorsal aspect of the wrist at the bases of the second and third metacarpals, respectively.^6,7,10 The tendon of the ECU may be palpated at the base of the fifth metacarpal, just distal to the head of the ulna (Figure 22-18, A).^4,6,10,15

4. Observe: Observe the client extending and radially deviating the wrist, while lifting the hand from the supporting surface and simultaneously moving it medially (to the radial side). The movement should be performed without finger extension, which could substitute for the wrist motion (Figure 22-18, B).^6,10,15

5. Resist: Provide resistance over the dorsum of the second and third metacarpals, toward flexion and ulnar deviation (Figure 22-18, C).^6,10,12–14

1. Position: The client is placed in the same manner as described for the previous test, except that the forearm is resting in midposition on its ulnar border.^10,20

2. Stabilize: Provide stabilization at the ulnar border of the forearm, supported slightly above the table surface.¹⁰

3. Palpate: Palpate radial wrist extensors as described for the previous test.

4. Observe: Observe client extending the wrist, moving the hand away from the body (Figure 22-18, D).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated, forearm pronated, wrist neutral, fingers and thumb relaxed, supported on a table. The therapist sits opposite or next to the client on the side to be tested.

2. Stabilize: Provide stabilization under the distal forearm.^10,12–14

3. Palpate: Palpate the ECU tendon at the base of the fifth metacarpal, just distal to the ulnar styloid,⁶ and the ECRL and ECRB tendons at the bases of the second and third metacarpals.

4. Observe: Observe the client extending the wrist and simultaneously moving it laterally (to the ulnar side). The therapist should observe that movement is not preceded by thumb or finger extension (Figure 22-19, A).^{6,10,12,13,15}

5. Resist: Provide resistance over the dorsal-lateral aspect of the fourth and fifth metacarpals toward flexion and radial deviation (Figure 22-19, B).^6,10,14

1. Position: The client is placed in the same manner as that described for the previous test, except that the forearm is in 45 degrees of pronation and is supported on a table. The wrist is flexed and radially deviated, and the thumb and fingers are flexed.⁶

2. Stabilize: Provide stabilization under the distal forearm, supporting it slightly above the supporting surface.^10,14

3. Palpate: Palpate the extensor tendons as described previously.

4. Observe: Observe client extending the wrist and moving it ulnarly at the same time (Figure 22-19, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated or supine, with the forearm resting in nearly full supination on the supporting surface, fingers and thumb relaxed.^7,12,15 The therapist is seated next to the client on the side to be tested.

2. Stabilize: Provide stabilization over the volar aspect of the midforearm.^6,10,14

3. Palpate: The FCR tendon can be palpated over the wrist at the base of the second metacarpal bone. The palmaris longus tendon is at the center of the wrist at the base of the third metacarpal, and the FCU tendon can be palpated at the ulnar side of the volar aspect of the wrist, at the base of the fifth metacarpal (Figure 22-20, A).⁴

4. Observe: Observe the client simultaneously flexing and radially deviating the hand. The therapist should observe that the fingers remain relaxed during the movement⁶ (Figure 22-20, B).

5. Resist: Provide resistance in the palm at the radial side of the hand, over the second and third metacarpals toward extension and ulnar deviation (Figure 22-20, C).⁶

1. Position: The client is seated with the forearm in midposition and the ulnar border of the hand resting on the supporting surface.^10,20 The therapist sits next to the client on the side to be tested.

2. Stabilize: Provide stabilization under the ulnar border of the forearm, supporting the wrist slightly above the supporting surface.

3. Palpate: Palpate the wrist flexor tendons as described for the previous test.

4. Observe: Observe the client flexing and radially deviating the wrist. Movement should not be initiated with finger flexion (Figure 22-20, D).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated or supine, with the forearm resting in nearly full supination on the supporting surface, fingers and thumb relaxed. The therapist is seated opposite or next to the client on the side to be tested.^10,14

2. Stabilize: Provide stabilization over the volar aspect of the middle of the forearm.^10,14

3. Palpate: Palpate the flexor tendons on the volar aspect of the wrist, the FCU at the base of the fifth metacarpal, the FCR at the base of the second metacarpal, and the palmaris longus at the base of the third metacarpal.⁴

4. Observe: Observe the client simultaneously flexing the wrist and deviating it ulnarly (Figure 22-21, A).

5. Resist: Provide resistance in the palm of the hand over the hypothenar eminence toward extension and radial deviation (Figure 22-21, B).^6,7,14

1. Position: The client is seated, with the forearm in neutral rotation and resting in 45 degrees of supination on the ulnar border of the arm and hand.¹⁰ The therapist sits opposite or next to the client on the side being tested.

2. Stabilize: The client’s arm can be supported slightly above the supporting surface and stabilized at the dorsal-medial aspect of the forearm to prevent elbow and forearm motion.

3. Palpate: Palpate the wrist flexor tendons as described for the previous test.

4. Observe: Observe the client simultaneously flexing and deviating the wrist toward ulnar side (Figure 22-21, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated, with forearm in supination, wrist at neutral, resting on the supporting surface.⁸ The metacarpophalangeal (MP) joints are extended, and the interphalangeal (IP) joints are flexed.^12,20 The therapist sits next to the client on the side being tested.

2. Stabilize: Provide stabilization over the metacarpals, proximal to the MP joints in the palm of the hand to prevent wrist motion.

3. Palpate: Palpate the first dorsal interosseous muscle just medial to the distal aspect of the second metacarpal on the dorsum of the hand. The remainder of these muscles are not easily palpable because of their size and deep location in the hand.^15,20

4. Observe: Observe the client flexing the MP joints and extending the IP joints simultaneously (Figure 22-22, A).^12,14

5. Resist: Provide resistance to each finger separately by grasping the distal phalanx and pushing downward on the finger into the supporting surface toward MP extension and IP flexion, or apply pressure first against the dorsal surface of the middle and distal phalanges toward flexion, followed by application of pressure to the volar surface of the proximal phalanges toward extension (Figure 22-22, B).¹⁴

1. Position: The client is seated or supine, with the forearm and wrist in midposition and resting on the ulnar border on the supporting surface. MP joints are extended, and IP joints are flexed.^10,13 The therapist sits next to the client on the side being tested.

2. Stabilize: Provide stabilization at the wrist and palm of the hand.

3. Palpate: Palpate the client as described for the previous test.

4. Observe: Observe the client flexing the MP joints and extending the IP joints simultaneously (Figure 22-22, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated, with the forearm pronated and the wrist in the neutral position, MP and IP joints relaxed in partial flexion.^7,10,12 The therapist sits opposite or next to the client on the side to be tested.

2. Stabilize: Provide stabilization at the wrist and metacarpals slightly above the supporting surface.^10,12–14

3. Palpate: Palpate the EDC tendons where they course over the dorsum of the hand.^6,7,10 In some individuals, the EDM tendon can be palpated or visualized just lateral to the EDC tendon to the fifth finger. The extensor indicis tendon can be palpated or visualized just medial to the EDC tendon to the first finger.⁶

4. Observe: Observe the client extending the MP joints but maintaining the IP joints in some flexion (Figure 22-23, A).^6,12

5. Resist: Provide resistance to each finger individually on the dorsum of the proximal phalanx toward MP flexion (Figure 22-23, B).^6,10,14

1. Position: The patient should be placed in a position similar to that described for the previous test, except that the client’s forearm is in midposition and the hand and forearm are supported on the ulnar border.^10,12

2. Stabilize: Provide stabilization in the same manner as described for the previous test.

3. Palpate: Palpate the patient in the same manner as described for the previous test.

4. Observe: Observe the client extending the MP joints while keeping the IP joints somewhat flexed (Figure 22-23, C).

5. Grade: The patient is graded according to standard definitions of muscle grades.

1. Position: The client is seated, with the forearm supinated, wrist at neutral, fingers extended, and hand and forearm resting on the dorsal surface.^6,10,12 The therapist sits opposite or next to the client on the side being tested.

2. Stabilize: Provide stabilization at the MP joint and the proximal phalanx of the finger being tested (Figure 22-24, A).^6,7,14 If it is difficult for the client to isolate PIP flexion, hold all of the fingers not being tested in MP hyperextension and PIP extension. This maneuver inactivates the flexor digitorum profundus so that the client cannot flex the distal joint (Figure 22-24, B).^4,6,12,20 Most individuals cannot perform isolated action of the PIP joint of the fifth finger, even with this assistance.¹⁵

3. Palpate: Palpate the FDS tendon on the volar surface of the proximal phalanx.⁶ A stabilizing finger may be used to palpate in this instance.¹⁵ The tendon supplying the fourth finger may be palpated over the volar aspect of the wrist between the flexor carpi ulnaris and the palmaris longus tendons, if desired.^4,6

4. Observe: Observe the client flexing the PIP joint while maintaining DIP extension (Figure 22-24, A).

5. Resist: Provide resistance with one finger at the volar aspect of the middle phalanx toward extension.^6,10,14 If the therapist uses the index finger to apply resistance, the middle finger may be used to move the DIP joint to and fro to verify that the flexor digitorum profundus (FDP) is not substituting (Figure 22-24, C).

1. Position: The client is seated, with the forearm in midposition and the wrist at neutral, resting on the ulnar border.^12,20 The therapist sits opposite or next to the client on the side to be tested.

2. Stabilize: Provide stabilization at the MP joint and proximal phalanx of the finger.^10,14 If stabilization during the motion is difficult in this position, the forearm may be returned to full supination because the effect of gravity on the fingers is not significant.

3. Palpate and observe: The therapist palpates and observes the client in the same manner as described for the previous test, except that movement is performed in the gravity-minimized position (Figure 22-24, D).

4. Grade: The client is graded according to standard definitions of muscle grades. If the test for grades poor and below is done with the forearm in full supination, partial ROM against gravity may be graded poor.¹⁰

1. Position: The client is seated, with the forearm supinated, the wrist at neutral, and the fingers extended.¹⁰ The therapist sits opposite or next to the client on the side being tested.¹²

2. Stabilize: Provide stabilization at the wrist in neutral and the PIP joint and middle phalanx of the finger being tested.^6,20

3. Palpate: Use the finger stabilizing the middle phalanx to simultaneously palpate the FDP tendon over the volar surface of the middle phalanx.^6,10,15

4. Observe: Observe the client flexing the DIP joint (Figure 22-25, A).

5. Resist: Provide resistance with one finger at the volar aspect of the distal phalanx toward extension (Figure 22-25, B).^6,7,10,14

1. Position: The client is seated, with the forearm in midposition and with the wrist at neutral, resting on the ulnar border.^12,20 The client may be positioned with the forearm supinated, if necessary.

2. Stabilize: The client is stabilized in the same manner as described for the previous test.

3. Palpate: The client is palpated in the same manner as described for the previous test.

4. Observe: Observe the client flexing the DIP joint (Figure 22-25, C).

5. Grade: The client is graded according to standard definitions of muscle grades, except that if the test for grades poor and below was done with the forearm in full supination, movement through partial ROM may be graded poor.¹⁰

1. Position: The client is seated or supine, with the forearm pronated, wrist at neutral, and fingers extended and adducted. The therapist is seated opposite or next to the client on the side to be tested.^10,13

2. Stabilize: Provide stabilization at the wrist and metacarpals slightly above the supporting surface.

3. Palpate: Palpate the first dorsal interosseous muscle on the radial side of the second metacarpal or of the abductor digiti minimi on the ulnar border of the fifth metacarpal. The remaining interossei are not palpable.^6,7,10

4. Observe: Observe the client spreading the fingers, with abduction of the little finger, the ring finger toward the little finger, the middle finger toward the ring finger, and the index finger toward the thumb (Figure 22-26, A).¹²

5. Resist: Provide the first dorsal interosseous by applying pressure on the radial side of the proximal phalanx of the second finger in an ulnar direction (Figure 22-26, B); the second dorsal interosseous on the radial side of the proximal phalanx of the middle finger in an ulnar direction; the third dorsal interosseous on the ulnar side of the proximal phalanx of the middle finger in a radial direction; the fourth dorsal interosseous on the ulnar side of the proximal phalanx of the ring finger in a radial direction; and the abductor digiti minimi on the ulnar side of the proximal phalanx of the little finger in a radial direction.^6,14 An alternative mode of resistance is to flick each finger toward adduction. If the finger rebounds, the grade is N (5).¹²

1. Grade: Because the test motions were not performed against gravity, the therapist must exercise professional judgment when grading. For example, partial ROM in the gravity-minimized position may be graded poor and full ROM graded fair.^10,13

1. Position: The client is seated, with forearm pronated, wrist in neutral, and fingers extended and abducted.^10,13

2. Stabilize: Provide stabilization at the wrist and metacarpals slightly above the supporting surface.⁶

3. Palpate: The condition is not palpable.⁶ The muscle cannot be palpated.

4. Observe: Observe the client adducting the first, fourth, and fifth fingers toward the middle finger (Figure 22-27, A).

5. Resist: Provide resistance at the index finger at the proximal phalanx by pulling it in a radial direction, with the ring finger at the proximal phalanx in an ulnar direction, and the little finger likewise (Figure 22-27, B).^6,14 These muscles are very small, and resistance must be modified to accommodate their comparatively limited power. Fingers can be grasped at the distal phalanx and flicked in the direction of abduction. If the finger snaps back to the adducted position, the grade is N (5).¹²

1. Position: The client is seated or supine, forearm in midposition, wrist at neutral, and hand and forearm resting on the ulnar border.^6,10,13 The thumb is flexed into the palm at the MP joint, and the IP joint is extended but relaxed. The therapist sits opposite or next to the client on the side to be tested.

2. Stabilize: Provide stabilization at the wrist and the thumb metacarpal.⁶

3. Palpate: Palpate the EPB tendon on the dorsoradial aspect of the base of the first metacarpal. It lies just medial to the abductor pollicis longus tendon on the radial side of the anatomical snuffbox, which is the hollow space created between the EPL and EPB tendons when the thumb is fully extended and radially abducted.^4,6,7

4. Observe: Observe the client extending the MP joint. The IP joint remains relaxed (Figure 22-28, A). It is difficult for many individuals to isolate this motion.

5. Resist: Provide resistance on the dorsal surface of the proximal phalanx toward MP flexion (Figure 22-28, B).^6,10,12–14

1. Position and stabilize: Positioning and stabilizing are the same as described for the previous test, except that the forearm is fully pronated and resting on the volar surface.²⁰ The therapist may stabilize the first metacarpal, holding the hand slightly above the supporting surface. The test may also be performed in the same manner as for grades normal to fair, with modified grading.¹⁰

2. Palpate and observe: The client is palpated and observed in the same way as described for the previous test. MP extension is performed in a plane parallel to the supporting surface (Figure 22-28, C).

3. Grade: The client is graded according to standard definitions of muscle grades. If midposition of the forearm was used, partial ROM is graded poor and full ROM is graded fair.^10,12

1. Position: The client is seated or supine, forearm in midposition, wrist at neutral, and hand and forearm resting on the ulnar border.^6,10,13 The thumb is adducted, the MP joint is extended or slightly flexed, and the IP is flexed.⁶ The therapist sits opposite or next to the client on the side being tested.

2. Stabilize: Provide stabilization at the wrist in neutral position, the first metacarpal, and the proximal phalanx of the thumb.⁶

3. Palpate: Palpate the EPL tendon on the dorsal surface of the hand medial to the EPB tendon, between the head of the first metacarpal and the base of the second on the ulnar side of the anatomical snuffbox.^4,6,10

4. Observe: C extends the IP joint (Figure 22-29, A).

5. Resist: Provide resistance on the dorsal surface of the distal phalanx, down toward IP flexion (Figure 22-29, B).^6,10,14

1. Position and stabilize: Positioning and stabilizing are the same as described for the previous test, except that the forearm is fully pronated.²⁰ The therapist may stabilize so that the client’s hand is held slightly above the supporting surface. The test may also be performed in the same position as for grades normal to fair with modification in grading.

2. Palpate and observe: The patient is palpated and observed in the same manner as described for the previous test. IP extension is performed in the plane of the palm, parallel to the supporting surface (Figure 22-29, C).

3. Grade: The client is graded according to standard definitions of muscle grades. If the test was performed with the forearm in midposition, partial ROM is graded P (2).¹⁰

1. Position: The client is seated or supine, the forearm supinated, the wrist in neutral position, and the thumb in extension and adduction.^6,12 The therapist is seated next to or opposite the client.^7,10,14

2. Stabilize: Provide stabilization at the first metacarpal and the wrist.¹²

3. Palpate: Palpate the client over the middle of the palmar surface of the thenar eminence just medial to the abductor pollicis brevis muscle.^6,10 The hand that is used to stabilize may also be used for palpation.

4. Observe: Observe the client flexing the MP joint while maintaining extension of the IP joint (Figure 22-30, A).⁶ It may not be possible for some individuals to isolate flexion to the MP joint. In this instance, both MP and IP flexion may be tested together as a gross test for thumb flexion strength and graded according to the therapist’s judgment.

5. Resist: Provide resistance on the palmar surface of the first phalanx toward MP extension (Figure 22-30, B).^6,7,10,14

1. Observe: Observe the client flexing the MP joint so that the thumb moves over the palm of the hand.

2. Grade: Full ROM is graded fair; partial ROM is graded poor.^10,13

1. Position: The client is seated, with the forearm fully supinated, wrist in neutral position, and thumb extended and adducted.^10,13 The therapist is seated next to or opposite the client.

2. Stabilize: Provide stabilization at the wrist, thumb metacarpal, and proximal phalanx of the thumb in extension.^6,7,10,14

3. Palpate: Palpate the FPL tendon on the palmar surface of the proximal phalanx.⁶ In this instance, the palpating finger may be the same one used for stabilizing the proximal phalanx.

4. Observe: Observe the client flexing the IP joint in the plane of the palm (Figure 22-31, A).^10,12

5. Resist: Provide resistance on the palmar surface of the distal phalanx, toward IP extension (Figure 22-31, B).^6,10,12–14

1. Position: The client is seated or supine, forearm in supination, wrist at neutral, thumb relaxed in adduction against the volar aspect of the index finger. The OT sits opposite or next to the client on the side to be tested.^{6,7,10,12–14}

2. Stabilize: Provide stabilization at the metacarpals and wrist.

3. Palpate: Palpate the APB muscle on the lateral aspect of the thenar eminence, lateral to the flexor pollicis brevis muscle.¹⁰

4. Observe: Observe the client raising the thumb away from the palm in a plane perpendicular to the palm (Figure 22-32, A).^6,14

5. Resist: Provide resistance at the lateral aspect of the proximal phalanx, downward toward adduction (Figure 22-32, B).^6,14

1. Position: The client is positioned in the same manner as described for the previous test, except that the forearm and hand are supported on the ulnar border.^12,20

2. Stabilize: Provide stabilization at the wrist and metacarpals.

3. Palpate: Palpate the APB muscle on the lateral aspect of the thenar eminence.

4. Observe: Observe the client moving the thumb away from the palm in a plane at right angles to the palm of the hand and parallel to the supporting surface (Figure 22-32, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated or supine, forearm in neutral rotation, wrist at neutral, thumb adducted and slightly flexed across the palm. Hand and forearm are resting on the ulnar border.¹⁴ The therapist sits opposite or next to the client on the side being tested.

2. Stabilize: Provide stabilization at the wrist and metacarpals of the fingers.^10,14

3. Palpate: Palpate the APL tendon on the lateral aspect of the base of the first metacarpal. It is the tendon immediately lateral (radial) to the EPB tendon.^4,6,10

4. Observe: Observe the client moving the thumb out of the palm of the hand, abducting away from the index finger at an angle of about 45 degrees (Figure 22-33, A).⁶

5. Resist: Provide resistance at the lateral aspect of the thumb metacarpal toward adduction (Figure 22-33, B).^6,10,14

1. Position: The client is positioned in the same manner as described for the previous test, except that the forearm is in supination.¹⁰

2. Stabilize: Provide stabilization at the wrist and palm of the hand.

3. Palpate: The client is palpated in the same manner as described for the previous test.

4. Observe: Observe the client moving the thumb out away from the palm of the hand in the plane of the palm (Figure 22-33, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated or supine, forearm pronated, wrist at neutral, thumb relaxed and in palmar abduction.^10,13,20 The therapist is sitting opposite or next to the client on the side to be tested.

2. Stabilize: Provide stabilization at the wrist and metacarpals by grasping the hand around the ulnar side and supporting it slightly above the resting surface.^10,13

3. Palpate: Palpate the AP on the palmar side of the thumb web space.^6,15

4. Observe: Observe the client adducting the thumb to touch the palm (Figure 22-34, A).^10,12 (The palm is turned upward in the illustration to show the palpation point.)

5. Resist: Provide resistance by grasping the proximal phalanx of the thumb near the metacarpal head and pulling downward, toward abduction (Figure 22-34, B).¹⁰

1. Position: The client is positioned in the same manner as described for the previous test, except that the forearm is in midposition and the forearm and hand are resting on the ulnar border.²⁰

2. Stabilize: Provide stabilization over the wrist and palm of the hand.

3. Palpate: Palpate the client in the same manner as described for the previous test.

4. Observe: Observe the client adducting the thumb to touch the radial side of the palm of the hand or the second metacarpal (Figure 22-34, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated or supine, with forearm supinated, wrist at neutral, thumb in palmar abduction, and fifth finger extended.^6,7,10,14 The therapist sits opposite or next to the client on the side to be tested.

2. Stabilize: Provide stabilization at the forearm and wrist.

3. Palpate: Palpate the opponens pollicis along the radial side of the shaft of the first metacarpal, lateral to the APB; the opponens digiti minimi on the shaft of the fifth metacarpal.^6,10,15

4. Observe: Observe the client opposing the thumb to touch the thumb pad to the pad of the fifth finger, which flexes and rotates toward the thumb (Figure 22-35, A).^6,7

5. Resist: Provide resistance at the distal ends of the first and fifth metacarpals toward derotation of these bones and flattening of the palm of the hand (Figure 22-35, B).^10,12

1. Position: The client is seated, with knees flexed over the edge of the table and feet above the floor.¹² The therapist stands next to the client on the side being tested.⁷

2. Stabilize: Provide stabilization at the pelvis at the iliac crest on the side being tested. The client may grasp the edge of the table or fold arms across chest.^{6,7,10,12–14}

3. Palpate: The psoas and iliacus are difficult to palpate.⁶ The rectus femoris may be palpated on the middle anterior aspect of the thigh, just lateral to the sartorius muscle.^4,15

4. Observe: Observe the client flexing the hip so that the femur rises above the table surface (Figure 22-36, A).

5. Resist: Provide resistance just proximal to the knee on the anterior surface of the thigh, down toward the table into hip extension (Figure 22-36, B).^{6,7,10,12–14}

1. Position: The client assumes a side-lying position. The therapist stands behind the client, supporting the upper leg in neutral rotation and slight abduction, with the knee extended.^10,12,13 The lower leg (to be tested) is extended at the hip and knee.

2. Stabilize: The weight of the trunk may provide adequate stabilization, or the therapist may stabilize the pelvis.¹⁰

3. Palpate: The client is palpated in the same manner as described for the previous test.

4. Observe: Observe the client bringing the lower leg up toward the trunk, flexing the hip and knee (Figure 22-36, C).¹⁰

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is prone, with the hip at neutral and the knee flexed to about 90 degrees. This position is used to isolate the gluteus maximus.^6,12 The client may also be prone with the knee extended.¹² The therapist stands next to the client on the opposite side.¹⁴ Two pillows may be placed under the pelvis to flex the hips.^6,7

2. Stabilize: Provide stabilization over the iliac crest on the side being tested.^10,12

3. Palpate: Palpate the gluteus maximus on the middle posterior surface of the buttock.¹⁵

4. Observe: Observe the client extending the hip while keeping the knee flexed to minimize action of the hamstring muscles on the hip joint (Figure 22-37, A).

5. Resist: Provide resistance at the distal end of the posterior aspect of the thigh, downward, toward flexion (Figure 22-37, B).^10,12–14

1. Position: The client assumes a side-lying position. The therapist stands in front of the client, supporting the upper leg in extension and slight abduction.¹⁰ The lower leg (to be tested) is flexed at the hip and knee.

2. Stabilize: Provide stabilization at the pelvis over the iliac crest.¹⁰

3. Palpate: The client is palpated in the same manner as described for the previous test.

4. Observe: Observe the client extending the hip, bringing the lower leg backward, while maintaining flexion of the knee (Figure 22-37, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client assumes a side-lying position, with the upper leg (to be tested) with the knee extended and hip extended slightly beyond the neutral position and slight forward rotation of the pelvis¹²; the lower leg is flexed at the hip and knee to provide a wide base of support.⁷ The therapist stands behind or in front of the client.^{6,7,10,12–14}

2. Stabilize: Provide stabilization at the pelvis over the iliac crest.^10,14

3. Palpate: Palpate the gluteus medius on the lateral aspect of the ilium above the greater trochanter of the femur.^6,10

4. Observe: Observe the client abducting the hip, lifting the leg upward (Figure 22-38, A).

5. Resist: Provide resistance at the point just proximal to the knee in a downward direction, toward adduction (Figure 22-38, B).^6,10,12

1. Position: The client is supine, with both legs extended and in neutral rotation. The therapist stands next to the client on the opposite side.¹⁰ The therapist may use one hand to support at the ankle and slightly lift the test leg off the surface, being careful to offer no resistance or assistance to the movement.¹²

2. Stabilize: Provide stabilization at the pelvis at the iliac crest on the side to be tested and at the opposite limb at the lateral aspect of the calf.¹⁰

3. Palpate: Use the hand stabilizing over the pelvis to palpate the gluteus medius muscle simultaneously by adjusting the position of the hand so that the fingers are touching the lateral aspect of the ilium, above the greater trochanter, as described for the previous test.

4. Observe: Observe the client abducting the hip, moving the free leg sideward, while maintaining neutral rotation during this movement (Figure 22-38, C).¹⁰

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client assumes a side-lying position, with the test limb lowermost; the therapist supports the uppermost limb in 25 degrees of abduction and stands behind the client.¹² This test may also be done with the client in the supine position.^6,8,10

2. Stabilize: Support the client’s upper leg in partial abduction while the client grasps the supporting surface for stability.^5,6,10,14

3. Palpate: Palpate any of the adductor muscles as follows: adductor magnus at the middle of the medial surface of the thigh; adductor longus at the medial aspect of the groin; gracilis on the medial aspect of the posterior surface of the knee, just anterior to the semitendinosus tendon.¹⁵

4. Observe: Observe the client adducting the hip by raising the lower leg from the table until it meets the upper leg. Observe that there is no rotation, flexion, or extension of the hip nor pelvic tilting (Figure 22-39, A).^12,14

5. Resist: Provide resistance over the medial aspect of the leg, just proximal to the knee, downward toward abduction or outward if tested in supine position (Figure 22-39, B).^{6,7,10,12–14}

1. Position: The client is supine; the limb to be tested is abducted to 45 degrees. The therapist stands next to the client on the opposite side.

2. Stabilize: Provide stabilization over the iliac crest on the side to be tested.¹⁰

3. Palpate: The client is palpated in the same manner as described for the previous test.

4. Observe: Observe the client adducting the leg toward midline (Figure 22-39, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated, with knees flexed over the edge of the table. A small pad or folded towel is placed under the knee on the side to be tested. The therapist stands in front of the client toward the side to be tested.^6,10,12–14

2. Stabilize: Provide stabilization at the lateral aspect of the knee on the side to be tested. The client may grasp the edge of the table to stabilize the trunk and pelvis.^6,10,14

3. Palpate: These deep muscles are difficult or impossible to palpate.⁶ Action of the external rotators may be detected by palpating deeply posterior to the greater trochanter of the femur.¹⁰

4. Observe: Observe the client rotating the thigh outwardly, moving the foot medially (Figure 22-40, A).

5. Resist: Provide resistance at the medial aspect of the lower leg, just proximal to the ankle in a lateral direction, toward internal rotation.^{6,7,10,12–14} Resistance should be given carefully and gradually, because use of the long lever arm can cause joint injury if sudden forceful resistance is given. Clients with knee instability should be tested in the supine position (Figure 22-40, B).^7,10

1. Position: The client is supine, with hips and knees extended; the hip to be tested is internally rotated. The therapist is standing next to the client on the opposite side.^10,12

2. Stabilize: Provide stabilization at the pelvis on the side to be tested.

3. Palpate: Action of the external rotators may be detected by palpating deeply posterior to the greater trochanter of the femur.¹⁰

4. Observe: Observe the client externally rotating the thigh (roll laterally). Gravity may assist this motion once the client has passed the neutral position. The therapist may use one hand to palpate and the other to offer slight resistance during the second half of the movement to compensate for the assistance of gravity. If the range can be completed with slight resistance, a grade of poor can be given (Figure 22-40, C).¹⁰

5. Grade: The client is graded according to standard definitions of muscle grades for fair to normal muscles. Muscles are graded poor if ROM in the gravity-minimized position can be achieved against slight resistance during the second half of the ROM. A grade of trace can be assigned if contraction of external rotators can be detected by deep palpation, as described for the previous test, when movement is attempted in the gravity-minimized position.¹⁰

1. Position: The client is seated on a table, with the knees flexed over the edge and with a small pad placed under the knee. The therapist stands in front of or next to the client on the side to be tested.^6,10 (The therapist is shown on the opposite side in the illustration so that palpation and stabilization will be apparent.)

2. Stabilize: Provide stabilization at the medial aspect of the knee. The client may grasp the edge of the table to stabilize the pelvis and trunk.^6,10,14

3. Palpate: Palpate the gluteus medius between the iliac crest and the greater trochanter.⁴

4. Observe: Observe the client internally rotating the thigh, moving the foot laterally. The therapist should observe that the client does not lift the pelvis on the side being tested (Figure 22-41, A).^6,10

5. Resist: Provide resistance at the lateral aspect of the lower leg, pushing the leg medially and, therefore, the thigh toward external rotation. Resistance is stressful to the knee joint. Clients with knee instability should be tested in the supine position as described for the next test (Figure 22-41, B).^7,10,14

1. Position: The client is supine, with hips and knees extended; the hip to be tested is in external rotation. The therapist stands on the opposite side.^10,12

2. Stabilize: Provide stabilization over the iliac crest on the side to be tested.¹⁰

3. Palpate: The client is palpated in the same manner as described for the previous test.

4. Observe: Observe the client rotating the thigh inwardly or medially. As in external rotation, gravity may assist the motion once the neutral position is passed but to a lesser degree than in the test for external rotation (Figure 22-41, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is prone, with knees and hips in extension and neutral rotation with the foot in midline and toes hanging over the end of the table.^{5,7,10,12–14} The therapist stands next to the client on the opposite side, or the same side, toward the lower end of the supporting surface.¹⁰

2. Stabilize: Provide stabilization firmly over the posterior aspect of the thigh, above the tendinous insertion of the knee flexors.^6,10

3. Palpate: For the biceps femoris tendon proximal to the knee joint, palpate on the lateral aspect of the popliteal fossa; for the semitendinosus tendon proximal to the knee joint, palpate medial to the popliteal fossa.^4,6,15

4. Observe: Observe the client flexing the knee to slightly less than 90 degrees (Figure 22-42, A).^13,15

5. Resist: Provide resistance over the posterior aspect of the ankle downward toward knee extension.^6,10,13 Note that not as much resistance can be applied to knee flexion in this position as when tested in sitting position with the hip flexed (Figure 22-42, B).¹⁴

1. Position: The client assumes a side-lying position, with knees and hips extended and in neutral rotation. The therapist stands next to the client and supports the upper leg in slight abduction to allow testing of the lower leg.¹⁰

2. Stabilize: Provide stabilization over the medial aspect of the thigh.

3. Palpate: Palpate the semitendinosus as described for the previous test.

4. Observe: Observe the client flexing the knee of the lower leg (Figure 22-42, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated, with knees flexed over the edge of the table and feet suspended off the floor. The client may lean backward slightly to release tension on the hamstrings and grasp the edge of the table for stability.^6,10,12 The therapist stands next to the client on the side to be tested.^6,12

2. Stabilize: Provide stabilization at the thigh by holding hand firmly over it, or place one hand under the client’s knee to cushion it from the edge of the table. The client may grasp the edge of the table.^7,10,12–14

3. Palpate: Any of the muscles in the quadriceps femoris group can be palpated as follows: the rectus femoris on the anterior aspect of the midthigh; the vastus medialis on the medial aspect of the distal thigh; and the vastus lateralis on the lateral aspect of the midthigh. The vastus intermedius cannot be palpated.^6,15

4. Observe: Observe the client extending the knee to slightly less than full ROM. Observe for hip movement that may betray evidence of substitutions (Figure 22-43, A).

5. Resist: Provide resistance on the anterior surface of the leg, just above the ankle, with downward pressure toward knee flexion.^6,10,14 The client should not be allowed to lock the knee joint at the end of the ROM when full extension is achieved.^7,10 Maintenance of a slight amount of knee flexion will prevent this condition. Resistance to a locked knee can cause joint injury (Figure 22-43, B).¹⁰

1. Position: The client assumes a side-lying position on the side to be tested. The lower leg is positioned with the hip extended and the knee flexed to 90 degrees. The therapist stands behind the client.

2. Stabilize: Provide stabilization at the upper leg in slight abduction with one hand, with the other hand over the anterior aspect of the thigh on the leg to be tested.¹⁰

3. Palpate: Any of the muscles can be palpated, as described for the previous test, with the same hand used to stabilize the client’s thigh. Then ask the client to straighten the leg, extending the knee. Observe for hip movements that may betray signs of substitution (Figure 22-43, C).

4. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is prone, with the hips and knees extended and the feet projecting beyond the edge of the table. The therapist stands at the lower end of the table, facing the client’s feet.^6,7,13,14

2. Stabilize: The weight of the leg is usually adequate stabilization. The client may stabilize the leg proximal to the ankle.⁶

3. Palpate: Palpate the gastrocnemius on the posterior aspect of the calf of the leg or the soleus, which is slightly lateral to and beneath the lateral head of the gastrocnemius.¹⁵ The gastrocnemius tendon above the calcaneus may also be palpated.¹⁰

4. Observe: Observe the client flexing the plantar portion of the ankle. Observe for flexion of the toes and forefoot before movement of the heel, which may indicate substitutions (Figure 22-44, A).^6,14,15

5. Resist: Provide resistance on the posterior aspect of the calcaneus as if pulling downward and on the forefoot as if pushing forward.¹² If there is considerable weakness, pressure to the calcaneus may be sufficient (Figure 22-44, B).¹⁴

1. Position: The client assumes a side-lying position on the side to be tested; the hip and knee of the lower limb are extended, and the ankle is in midposition. The upper limb may be flexed at the knee to keep it out of the way. The therapist stands at the lower end of the table.^6,10

2. Stabilize: Provide stabilization over the posterior aspect of the calf.¹⁰

3. Palpate: Palpate the client in the same manner as described for the previous test.

4. Observe: Observe the client pulling the heel upward, pointing the toes down. Observe for toe flexion and inversion or eversion of the foot, which may indicate substitutions (Figure 22-44, C).

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client is seated, with the legs flexed at the knees, over the edge of the table. The therapist sits in front of the client, slightly to the side to be tested.^6,10,12–14

2. Stabilize: Provide stabilization at the leg, just above the ankle. The client’s heel can rest in the therapist’s lap.^6,12

3. Palpate: Palpate the tibialis anterior tendon on the anterior medial aspect of the ankle joint.^6,7,10 Muscle fibers may be palpated on the anterior surface of the leg, just lateral to the tibia.¹⁵

4. Observe: Observe the client dorsiflexing and inverting the foot, keeping the toes relaxed.¹² Watch for extension of the great toe preceding the ankle motion, which may be a sign of muscle substitution (Figure 22-45, A).^12–14

5. Resist: Provide resistance on the medial dorsal aspect of the foot, toward plantar flexion and eversion (Figure 22-45, B).^6,10,14

1. Grade: If the against-gravity position is used in the procedure for grades P to 0, the therapist must exercise clinical judgment to determine muscle grades. Partial ROM against gravity can be graded poor.¹² If the test is performed in the supine position for these grades, standard definitions of muscle grades may be used.¹⁰

1. Position: The client assumes a side-lying position on the side to be tested, with the hip in neutral rotation, the knee slightly flexed, and the foot and ankle in a neutral position.⁶ The upper leg may be flexed at the knee to keep it out of the way. The therapist stands at the end of the table.

2. Stabilize: Provide stabilization at the leg to be tested above the ankle joint on the dorsal surface of the calf, being careful not to put pressure on the tibialis posterior muscle.^6,10

3. Palpate: Palpate the tendon of the tibialis posterior muscle between the medial malleolus and navicular bone, or above and just posterior to the medial malleolus.^6,7,10

4. Observe: C inverts the foot, keeping the toes relaxed. There normally will be some plantar flexion as well (Figure 22-46, A).^10,14

5. Resist: Provide resistance at the medial border of the forefoot toward eversion (Figure 22-46, B).^6,7,10,14

1. Position: The client is supine, with the hip extended and in neutral rotation, the knee extended, and the ankle in midposition.

2. Stabilize: The client is stabilized in the same manner as described for the previous test.

3. Palpate: The client is palpated in the same manner as described for the previous test.

4. Observe: Observe the client moving the foot inward (medially), inverting it while keeping the toes relaxed.

5. Grade: The client is graded according to standard definitions of muscle grades.

1. Position: The client assumes a side-lying position, with the lower leg flexed at the knee to keep it out of the way. The upper test leg is in hip extension with neutral rotation, knee extension, and ankle plantar flexion with foot inversion.⁶

2. Stabilize: Provide stabilization medially or laterally, above the ankle.⁶

3. Palpate: Palpate the peroneus longus over the upper half of the lateral aspect of the calf, just distal to the head of the fibula. Its tendon can be palpated on the lateral aspect of the ankle, above and behind the lateral malleolus. The peroneus brevis tendon may be palpated on the lateral border of the foot, proximal to the base of the fifth metatarsal.^6,10,15 Its muscle fibers can be found on the lower half of the lateral surface of the leg, over the fibula.¹⁰

4. Observe: Observe the client everting the foot. (Note that this movement is normally accompanied by some degree of plantar flexion.^14,15) Observe for dorsiflexion or toe extension, which may indicate substitutions (Figure 22-47, A).

5. Resist: Provide resistance against the lateral border and the plantar surface of the foot toward inversion and dorsiflexion (Figure 22-47, B).^6,14

1. Position: The client is supine, hip extended and in neutral rotation.¹⁰ The knee is extended, and the ankle is in midposition.

2. Stabilize: Provide stabilization at the leg, under the calf.

3. Palpate: The client is palpated in the same manner as described for the previous test.

4. Observe: Observe the client everting the foot (Figure 22-47, C).

5. Grade: Grade according to standard definitions of muscle grades.