LAB 3: UPPER EXTREMITY: PART II

1

• LAB 3 UPPER EXTREMITY PART II MUSCLE TESTING
  FOR SHOULDER, WRIST, AND HAND
• Group 4
• Tyler Hyvarinen
• Aaron Ruberto
• Allison Pruys
• Kelly Heikkila
• Dr. Tony Bauer
• Kinesiology 3015
• Lakehead University
• October 3, 2006

2
TENNIS ELBOW TEST(Lateral Epicondylitis)

• The major muscles that attach to the lateral
  epicondyle are extensor carpi radialis brevis,
  extensor carpi ulnaris, extensor digit minimi,
  extensor digitorum and the supinator
• Lateral epicondylitis is imflammation or
  irritation of these muscle attachments due to
  overuse or injury
• Steps to test for Tennis Elbow
• Therapist stabilizes the patients forearm,
  applying slight pressure on the lateral
  epicondyle
• Patient makes a fist and extends the wrist
• The therapist will then apply pressure to the
  patients wrist, trying to gently force the wrist
  into flexion
• Observations should include if there is sudden,
  severe pain at the lateral epicondyle where the
  extensor muscles attach

3
(No Transcript)
4
MUSCLE TEST FOR WRIST FLEXION

• Primary Flexors
• Flexor Carpi Radialis Innervated by Median
  Nerve (C7)
• Flexor Carpi Ulnaris Innervated by Ulnar Nerve
  (C8,T1)
• TESTING (While sitting or standing)
• 1) Instruct the patient to make a fist (this
  eliminates wrist flexion assistance from the
  finger flexors)
• 2) Stabilize the wrist with your hand (as
  illustrated in the next slide)
• 3) Tell patient to flex his or her closed hand at
  the wrist
• 4) While wrist is in flexion place your hand over
  the patients flexed fist and offer resistance by
  trying to pull the patients wrist out of flexion
  
  
  
  

5
MUSCLE TEST FOR WRIST EXTENSION

• Primary Extensors
• Extensor Carpi Radialis Longus Innervated by
  Radial Nerve (C6, C7)
• Extensor Carpi Radialis Brevis Innervated by
  Radial Nerve (C6, C7)
• Extensor Carpi Ulnaris Innervated by Radial
  Nerve (C7)

• TESTING
• ) Use the same methods as described in the
  muscle test for wrist flexion, but get patient to
  put closed fist in an extended position and offer
  resistance by trying to push the patients hand
  out of extension

6
MUSCLE TEST FOR WRIST SUPINATION

• Primary Supinators
• Biceps Innervated by Musculocutaneous Nerve
  (C5,C6)
• Supinator Innervated by Radial Nerve (C6)

• Secondary Supinator
• Brachioradialis

• TESTING
• 1) Position yourself in front of the patient with
  your hand supporting the patients elbow at the
  side (the support will aid in eliminating
  shoulder abduction and external rotation of the
  forearm in place of forearm supination)
• 2) Place the thenar eminence of your hand on the
  dorsal surface of the patients radius (distal)
• 3) Wrap your finger around the ulna (medially)
• 4) Tell patient to begin supination from a
  position of pronation
• 5) As the patient further progresses the
  supination of his/her forearm, increase your
  resistance against the radius this will
  determine the maximum resistance the patient can
  overcome

7
MUSCLE TEST FOR WRIST PRONATION

• Primary Pronators
• Pronator Teres Innervated by Median Nerve (C6)
• Pronator Quadratus Innervated by Anterior
  Interosseous Branch of Median Nerve (C8,T1)

• Secondary Pronator
• Flexor Carpi Radialis

• TESTING
• )Use the same procedures as described in the
  muscle test for wrist supination, but adjust your
  resisting hand so that the thenar eminence
  presses against the frontal-distal surface of the
  radius. Get the patient to begin forearm
  pronation from a position of supination. Offer
  increased resistance as patient increases
  pronation of his/her forearm.

8
MUSCLE TEST FOR FINGER EXTENSION

• Primary Extensors
• Extensor Digitorum Communis Innervated by
  Radial Nerve (C7)
• Extensor Indicis Innervated by Radial Nerve
  (C7)
• Extensor Digiti Minimi Innervated by Radial
  Nerve (C7)

• TESTING
• 1)Stabilize the patients wrist in a neutral
  position
• 2)Get patient to extend his/her
  metacarpophalangeal joints, while flexing the
  proximal interphalangeal joints (this prevents
  the aid the intrinsic muscles of the hand may
  make in place of the long finger extensors)
• 3)Place your hand on the dorsum of the proximal
  pahalanges and try to force them into flexion

9
MUSCLE TEST FOR FINGER FLEXION

• Primary DIJ Flexor
• Flexor Digitorum Profundus Innervated by Ulnar
  Nerve and Anterior Interosseous branch of Median
  Nerve (C8,T1)

• Primarty PIJ Flexor
• Flexor Digitorum Superficialis Innervated by
  Median Nerve (C7,C8,T1)

• Flexors of Metacarpophalangeal Joint
• Lumbricals Medial 2 Innervated by Ulnar Nerve
  (C8)
• Lumbricals Lateral 2 Innervated by Median
  Nerve (C7)

• TESTING
• 1)Have patient flex his/her fingers st all
  phalangeal joints
• 2)Curl and lock your fingers into the patients
  and try to pull his/her finger out of flexion
• 3)All joints should remain flexed Make note of
  those specific joints that fail to hold against
  your resistance

10
MUSCLE TEST FOR FINGER ABDUCTION

• Primary Abductors
• Dorsal Interossi Innervated by Ulnar Nerve
  (C8,T1)
• Abductor Digiti Minimi Innervated by Ulnar
  Nerve (C8,T1)

• TESTING
• 1)Have your patient abduct his or her extended
  fingers away from the axial midline of the hand
• 2)Try to force each pair of the patients fingers
  together
• Pinch index finger to the middle, ring, and
  little fingers
• Pinch the middle finger to the ring and little
  fingers
• Pinch the ring finger to the little finger

11
MUSCLE TEST FOR FINGER ADDUCTION

• Primary Adductors
• Palmar Interossei Innervated by Ulnar Nerve
  (C8,T1)

• TESTING
• 1)Have your patient keep his/her fingers extended
  together
• 2)See muscle test for finger abduction instead
  of pinching the fingers together, pull the same
  pairs of fingers apart
• Alternate Method
• 1)Place a piece of paper between two of the
  patients fingers
• 2)Get the patient to hold the piece of paper
  between his fingers while you try to pull it out
  from between

ON ALL TESTS The strength of the patients grasp
on one hand should be compared to the opposite
12
THUMB EXTENSION

• Muscles primarily involved in thumb extension
  include the extensor pollicis brevis
  (metacarpophalangeal joint) and extensor pollicis
  longus (interphalangeal joint), which are both
  innervated by radial nerve, C7
• Steps for thumb extension muscle testing
• Patient extends thumb
• Therapist will press upon the distal phalanx
  which will push the thumb into flexion
• Observations should include if either joint of
  the thumb flex with little pressure applied,
  indicating muscle weakness
• Weakness will be apparent if the patient uses
  thumb abductors in order to perform the extension

13
THUMB FLEXION

• Muscles primarily involved in thumb flexion
  include the flexor pollicis brevis
  (metacapophalangeal joint) which is innervated
  medially by the ulnar nerve (C8) and laterally by
  the median nerve (C6, C7) and also the flexor
  pollicis longus (metacapophalangeal joint) which
  is innervated by the median nerve (C8, T1)
• Steps for testing thumb flexion
• Patient flexes thumb toward his hypothenar
  eminence
• Therapist will now hook his thumb into patients
  and try to pull thumb out of flexion
• Observe if thumb is easily pulled out of flexion,
  indicating muscle weakness or malfunction

14
THUMB ABDUCTION (Palmar abduction)

• Primary muscles involved in thumb abduction are
  the abductor pollicis brevis which is innervated
  by the median nerve (C6, C7) and the abductor
  pollicis longus which is innervated by the radial
  nerve (C7)
• Steps for thumb abduction
• Therapist will stabilize patients metacarpals
  along the ulnar border with one hand and hold the
  patients thumb with the other hand
• Patient will attempt to abduct the thumb fully as
  the therapist attempts to push thumb toward the
  palm
• Note that if the patient attempts to substitute
  the movement with thumb extensor muscles, the
  abductor pollicis brevis and longus may be weak
  or damaged

15
THUMB ADDUCTION

• The primary muscles for thumb adduction is the
  adductor pollicis (obliquus and transverus) which
  is innervated by the ulnar nerve (C8)
• Steps for testing thumb adduction
• Therapist will stabilize patients metacarpals
  along the ulnar border with one hand and hold the
  patients thumb with the other hand
• Patient will attempt to adduct the thumb while
  the therapist applies gradual resistance
• Observations should include the maximum
  resistance the patient can overcome while
  adducting

16
PINCH MECHANISM(Thumb and index fingers)

• The main muscles responsible for creating an O
  shape between the thumb and index fingers are the
  long flexors and extensors, which stabilize the
  interphalangeal, metacarpophalangeal and
  carpometacarpal joints.
• Also included in the pinching motion are the
  lumbricals and interossus membrane
• Steps for testing the pinch mechanism
• Patient touches the tips of their thumb and index
  finger together
• Therapist will curl their index finger around the
  union of the patients finger and thumb and
  attempt to pull them apart
• Observations should include the strength of the
  pull required if there is injury in the
  muscles, the O shape will collapse with little
  force

17
OPPOSITION OF THUMB AND LITTLE FINGER

• The primary muscles involved in opposition are
  the opponens pollicis, which is innervated by the
  median nerve (C6, C7) and the opponens digiti
  minimi, which has innervation from the ulnar
  nerve (C8)
• Steps for testing opposition
• Patient will touch the tips of his little finger
  and thumb together
• Therapist will grasp the thenar eminence with one
  hand and the hypothenar eminence with the other
  hand, palpating for the underlying metacarpals
• Therapist will then attempt to separate the tips
  of the patients fingers by pushing the metacapals
  away from each other

18
TESTING MUSCLE SENSATIONWrist Hand

• Sensation in the wrist and hand should be tested
  in two ways
• Testing each Neurologic Level involved in the
  hand
• Testing the major Peripheral Nerves that
  innervate the hand

19
PROCEDURES AND EQUIPMENT FOR TESTING HAND
NEUROLOGIC LEVELS (DERMATOMES) PERIPHERAL
NERVES

• Muscle sensation is evaluated using a Wartenberg
  Pinwheel as pictured. Tests of sensitivity of
  peripheral nerves or neurologic levels may also
  be done using a cotton ball, paperclip, pads of
  fingers or fingernails.
• (http//www.sagewoodwellness.com/Doc0004.htm)
• The pins on the Wartenberg Pinwheel may also be
  used as a single point mechanism for peripheral
  nerve testing.
• TESTING HAND NEUROLOGIC LEVELS (Dermatomes)
• Ask patient to sit or lie down in a comfortable
  position.
• Make sure the patient is aware that he/she should
  not feel any pain or discomfort.
• Using the Wartenberg Pinwheel, roll it gently
  over the specified dermatome in the hand.
• Have the patient provide you with feedback
  regarding sensation.
• TESTING PERIPHERAL NERVES
• Ask the patient to first sit or lie down in a
  comfortable postion.
• Make sure the patient is aware that at no point
  in time should they feel any discomfort or pain.
• Gently apply pressure with the point tool (as
  listed above) to the area specified for
  particular nerve sensation. Table 2
• Have the patient give you feedback on the type of
  sensation present. The patient should have
  feeling in the area tested, however sensation
  should not be excessive

Note Dermatomes are always tested before
Specific Peripheral Nerves
20
TESTING HAND NEUROLOGIC LEVELS

• The sensation in the hand is provided by 3
  neurologic levels found in the cervical spine
• C6
• C7
• C8

21
DERMATOME FOR NERVE ROOT C6

• Spinal nerve root C6 provides sensation to the
  lateral forearm, innervating most of the forearm
  extensors.
• Distally C6 fibers form the Median Nerve.
• To test sensation of the C6 nerve root, roll the
  Wernberg Pinwheel gently over the lateral aspect
  of the palm to the index (2nd digit) finger and
  over the thumb.
• The muscles innervated by C6 fibers are Serratus
  anterior, Deltoid, Infraspinatus, Teres minor,
  Supraspinatus, Teres major, Pectoralis major,
  Latissimus dorsi, Biceps, Brachialis,
  Brachioradialis, Supinator, Pronator teres,
  Flexor carpi radialis, Extensor carpi radialis,
  Extensor digitorum communis.

22
DERMATOME FOR NERVE ROOT C7

• Spinal nerve root C7 provides sensation to the
  proximal forearm and hand muscles, mainly the
  wrist flexors and finger extensors.
• Distally C7 fibers form the median and radial
  nerves.
• To test sensation of the C7 nerve root, gently
  roll the pinwheel over the dorsal and ventral
  (palm) hand over the 3rd and 4th digits.
• The muscles innervated by C7 fibers are
  Latissimus dorsi, Pectoralis major, Triceps,
  Pronator teres, Flexor carpi radialis, Extensor
  carpi radialis, Palmaris longus, Extensor
  digitorum communis, Extensor indicis proprius,
  flexor digitorum superficialis, Abductor policis
  longus, Extensor policis brevis, Extenosr policis
  longus, Extensor carpi ulnaris, and Flexor carpi
  ulnaris.

23
DERMATOME FOR NERVE ROOT C8

• Spinal nerve root C8 provides sensation to both
  the proximal and distal muscles. Distally, C8
  fibers innervate the finger flexors and form the
  median, ulnar and radial nerves.
• To test sensation of the C8 nerve root in the
  hand, gently roll the pinwheel over the medial
  aspect of the dorsal and ventral hand up the
  4th and 5th digits.
• The muscles innervated by C8 fibers are
  Latissimus dorsi, Pectoralis major, Triceps,
  Palmaris longus, Flexor digitorum superficialis,
  Flexor policis longus, Abductor policis longus,
  Extensor policis brevis, Extensor policis longus,
  Extensor carpi ulnaris, Flexor carpi ulnaris,
  Flexor digitorum profundus, Lumbricals, and
  Interossei.

24
TESTING PERIPHERAL NERVE SENSATION

• The hand is supplied by 3 major peripheral
  nerves
• Radial Nerve
• Median Nerve
• Ulnar Nerve

25
THE RADIAL NERVE TEST

• The radial nerve supplies the dorsal surface of
  the hand on the radial side of the third
  metacarpal, as well as the dorsal surfaces of the
  thumb, index and middle fingers.
• The area most fully innervated by the radial
  nerve, and used in testing radial nerve
  sensation, is the web space on the dorsal surface
  of the hand, found between the thumb and index
  fingers.
• The muscles innervated by the radial nerve are
  the triceps, brachialis, brachioradialis,
  anconeus, supinator, extensor carpi radialis
  longus, extensor carpi radialis brevis, extensor
  carpi ulnaris, extensor digitorum communis,
  extensor digiti minimi, abductor pollicis longus,
  extensor pollicis brevis, extensor pollicis
  longus, the extensor indicis.

http//classes.kumc.edu/sah/resources/handkines/ne
rves/radial.htm
26
THE MEDIAN NERVE TEST

• The median nerve innervates the radial side of
  the palm. The ventral surfaces of the thumb,
  index and middle fingers are also supplied by the
  median nerve.
• Strongest sensation from the median nerve can be
  found on the ventral/palmar skin of the tip of
  the index finger (2nd digit). This is where
  median nerve sensation is tested.
• The muscles innervated by the median nerve are
  the pronator teres, palmaris longus, flexor
  carpi radialis, flexor digitorum superficialis,
  flexor digitorum profundus (lateral portion),
  pronator quadratus, flexor pollicis longus,
  abductor pollicis brevis, opponens pollicis,
  the flexor pollicis brevis.

http//classes.kumc.edu/sah/resources/handkines/ne
rves/median.htm
27
THE ULNAR NERVE TEST

• The ulnar nerve innervates both the dorsal and
  ventral/palmar surfaces of the ulnar side of the
  hand. It also supplies the same surfaces on the
  4th and 5th digits.
• Sensation is strongest on the lateral tip of the
  5th digit. This is were sensation testing
  occurs.
• The muscles innervated by the ulnar nerve are
  the Flexor carpi ulnaris, Flexor digitorum
  profundus, Palmaris brevis, Adductor pollicis,
  Flexor pollicis longus, Abductor digiti minimi,
  Opponens digiti minimi, the Flexor digiti
  minimi.

http//classes.kumc.edu/sah/resources/handkines/ne
rves/ulnar.htm
28
FINGER FLEXION(Special Tests)

• Muscles Involved
• Lumbricles at the Metacarppohalangeal joint
• Flexor digitorum superficialis at the Proximal
  Interphangeal joint
• Flexor digitorum profundas at the Distal
  Interphangeal joint

• Joints Involved
• Metacarpo-phalangeal Joints
• Proximal Interphalangeal Joints
• Distal Interphalangeal Joints
• Nerve Supply
• Lumbricales Lateral 2 by Median Nerve, Medial 2
  by Ulnar Nerve
• Flexor Digitorum Superficialis Median Nerve
• Flexor Digitorum Profundus Ulnar Nerve

29
FLEXOR DIGITORUM SUPERFICIALIS TEST

• The Flexor Digitorum Superficialis tendon is the
  only functioning tendon at the proximal
  interphalangeal joint
• The distal interphalangeal joint powered by the
  flexor digitorum profundus has no power of
  flexion when the other fingers are held in
  extension, and the finger tip is loose and beyond
  the patients control.
• Steps for Testing
• Hold the patients fingers in extension except
  for the finger being tested. This isolates the
  flexor digitorum superficialis.
• Instruct the patient to flex the finger being
  tested at the proximal interphalangeal joint.
• Note whether or not the patient is able to flex
  their finger. If they can flex their finger, the
  FDS tendon is in tact. If they cannot flex their
  finger at the specified joint, the tendon is
  either cut or absent.

30
FLEXOR DIGITORUM PROFUNDUS TEST

• Note that the flexor digitorum profundus tendons
  work only in unison, therefore if the patient is
  unable to individually flex at any given
  interphalangeal joint
• Steps for test
• Therapist will isolate the distal interphalangeal
  joint by stabilizing the metacarpphalangeal and
  interphalangeal joints in extension
• Have the patient flex his finger at the distal
  interphalangeal joint
• If the patient cannot flex his finger at the
  distal interphalangeal joint, the tendon may be
  cut or the muscle denervated

31
RETINACULAR TEST

• This tests function is to determine whether
  flexion limitations at the distal interphalangeal
  joints are due to tightness of the retinacular
  ligaments or to joint capsule contractures
• Steps for retinacular test
• Therapist will hold the proximal interphalangeal
  joint in a neutral position and try to move the
  distal interphalangeal joint into flexion
• If the joint does not flex, there are two
  conclusions to be made there is either joint
  capsule contraction or retinacular tightness
• To test if it is retinacular tightness, the
  therapist will flex the proximal interphalangeal
  joint slightly to relax the retinaculum. If the
  proximal interphalangeal joint flexes, the
  patient is positive for retinacular tightness
• If the proximal interphalangeal joint does not
  flex then the interphalangeal joint capsule is
  probably contracted

32
(No Transcript)
33
ALLEN TEST

• Evaluates
• This test makes its possible to see I the radial
  and ulnar nerves are supplying the hand.

• TESTING
• Instruct the patient to open and close their fist
  quickly several times, then to close their fist
  tightly so that the venous blood is forced out of
  the palm.
• Place your thumb over the radial artery and your
  index and middle fingers over the ulnar artery,
  and press them against the underling bone to
  occlude them.
• With the vessels still occluded, instruct the
  patient to open their hand. The palm of the hand
  should be pale.
• Then release one of the arteries at the wrist,
  while maintaining pressure on the other one.
• Normally blood will return to the hand
  immediately. If it does not react of blood comes
  back slowly, then the released artery is
  partially or completely occluded.
• The opposite artery should also be checked the
  same way.

34

• Allen test for fingers
• Follow the same procedure for the Allen test,
  except..
• With the hand still in a fist lace your index and
  middle finger on the sides of the finger being
  tested, pressing them o the bone to occlude the
  digital arteries.
• When the patient opens their hand the test finger
  should be pale.
• The blood normally returns to the finger when
  pressure is released. If it does not the flow of
  the digital arteries is in question.

35
BUNNEL-LITTLER TEST

• Evaluates
• Tightness of the intrinsic muscles of the hand
• Whether flexion limitation in the proximal
  interphalangeal joint is due to tightness of
  intrinsic muscles of the hand or to joint capsule
  contractures (prevents the finger from curling
  into the palm)

• TESTING
• 1) Hold the patients metacarpophalangeal joint
  in slight (few degrees) extension (fig.112)
• 2) Try to move the proximal interphalangeal joint
  into flexion (fig.113)
• 3) If proximal interphalangeal joint can be
  flexed, the intrinsics are not tight (not
  limiting flexion)
• 4) If proximal interphalangeal joint cant be
  flexed, the intrinsics are tight or there are
  Joint Capsule Contractures

• Distinguishing between intrinsic muscle tightness
  and Joint Capsule Contractures
• Let the patients finger (one being tested) flex
  a few degrees at the metacarpophalangeal joint
  (this relaxes the intrinsic muscles and moves the
  proximal interphalangeal joint into flexion)
• If the joint is capable of full flexion
  Intrinsics are most likely tight (fig.114)
• If the joint does not flex Limitation is
  probably due to proximal interphalangeal joint
  capsule contractures (fig.115)

36
(No Transcript)
37
REFERENCES

• All material unless otherwise noted retrieved
  from
• Hoppenfield. S. Physical Examination of Spine and
  Extremities. Appleton Croft. 1972.