PT Measurement: - multiple choice (45-50), cumulative, similar to quiz

Quiz:When examining leg length you have your client lie down on a plinth with both knees flexed & feet flat (hooklying). You are viewing the client from the bottom (foot end) of the plinth & you notice the clients right knee is higher than the left knee. What does this indicate? true leg length discrepancy: left tibia shorter than right

A PT takes a tape measure & measures the distance from umbilicus to medial malleolus? What are you measuring? apparent leg length

Most valid & reliable method for measuring true leg length discrepancy? radiographic X-ray

Patient whose proximal femur & distal tibia are excessively angled inward, toward midline (bowlegged): genu varum

Patient has 17 degrees of hyperextension: genu recurvatum

Reliability of goni? intra is higher than inter

Which of the following correctly ranks instruments in order of accuracy for evaluation of lumbar flexion & extension (from most to least) radiograph, dual inclinometer, visual estimation

evaluating patient from lateral view, note that acromion process lies anterior to plumb line, scapula abducted? common cause: tightness of upper abdominals, shoulder adductors & pect minor

assessing posture from anterior view, right foot pointing outward (toe out/laterally rotated) more than the left? tightness of glut max & piriformis

patient can flex their shoulders through less than normal range against gravity, to determine true ROM you.. perform PROM screening

evaluating elbow ext, patient can actively extend elbow against gravity of normal range, unchanged with PROM. Patient able to hold this position against gravity with moderate resistance. Muscle grade: 4/5 in available ROM

following goni measurement, 0-83 of shoulder flexion most difficult brushing hair

UE motion to fasten bra from behind?- wrist flex, IR & ext of shoulder

Gross Screening Of Posture:- Looking for asymmetries from all sides, give analysis from all 3 viewsA. Anterior View Head: lateral or rotatory deviation? Neck: lateral or rotatory deviation? Face: mandible (symmetry), nose (aligned with sternum?) Shoulder: UT muscles symmetry (unilateral hypertrophy or atrophy could be due to dominance) shoulder level: should roughly be equal, AC & SC joint symmetry, clavicles, step deformity Elbow: carrying angle (5-10 degrees in males & 10-15 degrees in female) Hip: ASIS symmetry Knees: patella (rotated toward/away), tibial torsion (excess of 25 degrees) Ankle & foot: malleoli, toe out angle (5-7 degrees), hammer toe/claw toe, hallux valgus, pronation/supination, arch height

B. Posterior View Head: upright (deviated right or left), torticollis or wry neck Shoulder height: symmetry (dominant UE is usually lower) Scapulae: Positional symmetry (by looking at the spines of the scapulae and the inferior angles) Abducted/protraction or Adducted/retraction (by evaluating distance between T-Spine and Medial Scapular borders: this is affected by muscle imbalance, traps, stretch pectoralis Major & minor), note winging (weak serratus anterior) Spine: Scoliosis? Functional Scoliosis: straightens during forward trunk flexion. Muscle imbalance or disease. Structural Scoliosis: Does not reverse during flexion. Bony deformity. Rib protrusions may indicate scoliosis. Acute lumbar scoliosis Lateral Shift as per McKenzie Hip: symmetry of iliac crests, ASIS/PSIS, gluteal folds, greater trochanter (variety of causes), leg length Knee: varus/valgus Ankle/foot: deviation of Achilles tendon, calcaneal valgum/varum (pronation/sup)

C. Lateral View Head: forward head posture? (Will decrease cervical lordosis) Cervical spine: cervical lordosis (excessive, reduced, or normal) Shoulders: forward shoulder posture (can result from tight pec. minor, weak retractors (Serratus anterior) could be one sided, or normal Chest region: thoracic kyphosis (excessive: respiration issues, compression of discs anteriorly, weak thoracic extensors, tightness of ALL ligament), reduced or normal, Pectus Excavatum (Funnel chest depressed chest), Barrel Chest (increased AP diameter), Pectus Cavinatum (Pigeon Chest anterior and downward projection of the chest) Abdomen: flat, protruding (how does this effect spine) Lumbar spine: lumbar lordosis (excessive/reduced/normal), a/p pelvic tilt, sway/flat back: reduced lumbar lordosis: anterior muscles weak, posterior muscles tight (gluts & HS), posterior pelvic tilt can cause this Knee joint: genu recurvatum (hyper-extension), flexed knee posture (too much) Ankle joint: slightly anterior to lateral malleolus (obvious deviations/deformities)

Gross Screening Of Spine (remember to look at actual spine)A. Cervical: seated Protrusion: lower mid c-spine flexion with upper c-spine extension Retraction: lower mid c-spine extension with upper c-spine flexion Flexion*: bring chin all the way to chest Extension*: look up to the ceiling as high as you can Rotation*: turn all the way to one side (watch jaw during overpressure) Lateral flexion*: bring ear twrd shoulder (bring shoulder down w/ overpressure)B. Thoracic: seated in backless chair (overpressure: sandwich chest w/ hands) Flexion*: bring chest toward belly Extension*: bring chest up toward ceiling (look for reverse of kyphotic curve) Rotation*: hands across chest, turn body to side (overpressure on shoulders)C. Lumbar: standing (no overpressure, just touch spine) Flexion: bend down towards feet (look for lordosis to reverse) Extension: hands on buttock, feet apart, back-bend Lateral Flexion: hands on side, run fingers towards knee (looking at sides & from behind to see spine/skin folds) **Apply gentle overpressure to check end feel

1. Cervical Goniometric Measurement: seated Expected ROM Flexion: 50 degreesExtension: 60 degrees (look up to ceiling 40-50 degrees)Lateral Flexion: 45 degreesRotation: 80 degrees (rotation to look over shoulder 60-70 degrees)

A. Flexion: Fulcrum: external auditory meatus Proximal arm (fixed arm): perpendicular or parallel to ground Distal arm (moving arm): base of nose

B. Extension: same as flexion*Flexion/Extension are not typically measured with a goniometer in clinical situations

C. Lateral Flexion Fulcrum: C7 Proximal Arm (fixed arm): spinous processes of thoracic perpendicular to ground Distal arm (moving arm): dorsal midline of head

D. Rotation Fulcrum: cranial aspect of head Proximal Arm (fixed arm): imaginary line between 2 acromial processes Distal arm (moving arm): tip of nose

2. Measuring Lumbar Spine (goniometer or tape) Expected ROM:Flexion: 5-7 cm (tape), 80 degreesExtension: 3-4 cm (tape), 25 degreesLateral Flexion: 35 degrees(Values are for combined thoracic & lumbar motions)**

Flexion With Tape Measure: Mark S2 & C7 with tape (S2: lined up with PSIS) Stabilize pelvis, measure distance (tape measure touching skin entire time) Patient flexes re-measure Remember: estimating total thoracic & lumbar ROM (normal is about 5-7cm)

Extension With Tape Measure: Mark S2 & C7 with tape Stabilize pelvis, measure distance Patient extends re-measure Remember: estimating total thoracic & lumbar ROM (normal is about 3-4cm)

Lateral Flexion With Tape Measure: Measure tip of middle finger to floor Patient side bends re-measure Change in distance should be roughly 21-23cm Make sure not compensating by rotating; compare both sides & norms Best used for repeated measures over time rather than compared to norms, 2 degrees to variations in body proportion (ex: arm length)

Lateral Flexion With Goniometer: Fulcrum: S1 Proximal arm (fixed arm): perpendicular to ground Distal Arm (moving arm): aligned with C7 (follow C7, not curvature of the spine)

Leg Length Testing: True leg length discrepancy: actual shortening/lengthening of skeletal system between had of femur & ankle Functional/Apparent leg length discrepancy: factors other than actual bone length cause the shortening/lengthening (ex: scoliosis, foot pronation, pelvic obliquity) Visual Method: patient supine with knees flexed (look at femur from side & tibia from front) Clear with bridge, then straightening legs out Measure true first (ASIS medial malleolus) Measure apparent second (Umbilicus medial malleolus)

Manual Muscle Testing

Cervical Spine A. Extension (combined motion, upper and lower)Primary muscles: KNOW* Splenius Capitus, Longisssimus cervicis, semispinalis cervicis, Iliocostalis cervicis, splenius cervicis, upper trapezius Patient lies prone with head off table (for grades 5,4,3), Arms by side, head off tableResistance: OcciputStabilization: Under chin ready to catch head if necessaryDirection is extension: look up at ceilingStart with grade 3 lift head up hold it there a few secondsIf full ROM is possible (should see ext. in rest of spine too) apply resistanceIf full ROM is not possible put fully onto table

B. Flexion (combined capital and lower cervical) Primary muscles: SCMs, anterior scalenes, longus coli (lower), rectus capitus, longus capitus (upper) - Patient lays supine, head supported by table for all grades Resistance: applied to forehead (2 fingers), other hand support back of headDirection is flexion: bring your chin towards your chestStart with grade 3 see if they can hold it thereIf full ROM is possible apply resistance (tell them before you do so)If full ROM is not possible grade 2, partial range

Deep neck flexors: stabilizers during capitol flexion Can be tested with a pressure bladder and measured Ex) 10 sec at 10mm/hg for stabilization; 10x for endurance

Manual Muscle Testing Continued: Trunk (do not give resistance, ignore half grades) Trunk Flexion Muscles used: Rectus abdomens (obliques assist) Legs extended stabilize at the pelvis (curl up), patient is supine Start with grade 3 can hold it up and clear angles Clears inferior angles of scapula Does not clear inferior angles of scapula Grade 5No assist, hand behind head, clear inferior angles Grade 4No assist, hands crossed, clear inferior angles Grade 3No assist, hands straight forward, clear inf. Angles (shoulders up)Grade 2Raise head and palpate abdominals knees bent (shoulders dont clear)Grade 1Cough or perform an assisted forward lean (palpate, cough & abs tighten)Grade 0Zero (palpate: cough & feel no contraction)

Trunk Extension Muscles used: multifidi, Longissimus/Iliocostalis/Spinalis thoracis, Iliocostalis lumborum- Patient prone with hands clasped behind head (grades 5,4,3 off the table to xiphoid process) use pillow right under pelvis, stabilize at hips with your hands- Start with grade 3 lift chest all the way up, hold for 3 seconds (arms by side)- Can rise up hands behind head - Cannot raise up fully xiphoid still touching table put fully on table try grade 2Grade 5Raises up and locks without effort or lagGrade 4Raises up but yields slightlyGrade 3Raises up with arms at sideGrade 2Partial range of motion arm at sideGrade 1Trace contraction (palpate back to feel, will feel contraction)Grade 0Zero (palpate back to feel, feel no contraction)

Truck Rotation Muscles used: Internal & External obliques Patient position: Supine, legs straight, stabilize pelvis & hand in back to protect Start with grade 3 lift this shoulder toward that side of the room Can clear inferior angle of scapula hands behind head, make sure not pulling on neck Cannot clear inferior angle of scapula grade 2 if lifting up at allDiagonal curl-up perform movements bilaterallyGrade 5Hands behind headelbow towards opposite knee. Must clear scapula.Grade 4Arms crossedGrade 3Arms straight out can raise scapula off tableGrade 2Arms straight unable to clear inferior angleGrade 1Trace contraction (not lifting off table but you feel obliques contracting)Grade 0Zero (palpate obliques, feel no contraction)

Elbow Range of Motion

Active screen/gross screen first: standing Look from front/side Flexion, Extension

Have patient lay supine to do PROM Flexion: stabilize shoulder, end feel: firm/soft Extension: hand under elbow, end feel: hard

FlexionPatient position Supine with towel under upper armFulcrumLateral epicondyleProximal ArmLateral midline of humerus, landmark acromion process Distal ArmLateral midline of the radius, landmark radial styloid AAOS normal range150 degreesEnd FeelSoft. Approximation with muscle bulk of biceps. Most commonFirm. Posterior Capsule of Elbow joint or Triceps Hard. Bony contact between ulnar coronoid process and coronoid fossa of humerus. (Can only occur is bicep has very little bulk).ExtensionPosition and goniometer placement same as for flexion (& supine)AAOS normal range0 degreesEnd feelHard. Contact between olecranon process and olecranon fossa. Can be firm, Due to tension in biceps or brachialis, collateral ligaments and anterior joint capsule. Dont get to 0 degrees? Ex: 150-5 degrees or -5 degrees of elbow extension (start from flexion) Hyperextension: 0 degrees - ? degrees

Elbow Manual Muscle Testing

First take patient through full ROM, if they can grade 3Then take them to half way & perform resistance:Break 3+, little give 4, strong 5

Elbow Flexion(biceps brachii, brachialis, brachioradialis)PositionPatient is sitting with arm close to side of body. Therapist stands close to side.ResistanceDistal forearm proximal to wrist (hold position, dont let me push you down)StabilizationLateral/anterior arm (by shoulder)GM positionSL or supine (can also do sitting, bring forearm to chest, shoulder at 90 degrees)

Elbow Extension(triceps)PositionSupine with 90 degrees of shoulder flexion. Neutral pron/sup at wristResistanceDistal ulnaStabilizationPosterior upper arm just proximal to elbow jointAlternate positionPatient sitting. Examiner resists elbow extensionGM positionSitting with 90 degrees of flexion, full shoulder IR, elbow supported by examiner

Muscle LengthBiceps brachii PositionSittingMovementShoulder extension, forearm pronation, extend elbowMeasurementNote whether patient can get to full elbow extension- Overpressure at wrist & shoulder (compare both sides)

Triceps brachiiPositionSupine or sitting with full shoulder flexionMovementElbow flexion while stabilizing shoulderMeasurementShould get to full elbow flexion. Note limitations. (Passive insufficiency?)- Overpressure at hand & below elbow (compare both sides)

Shoulder

ROM- Quick screen fore posture then a gross screening sitting (view from front & back to watch scapula)Functional Screen: Flexion, Abduction, Internal Rotation. External Rotation, ExtensionAply scratch test or reach behind back or IR- Overpressure once on table

MeasurementProcedure1.Position and drape the patient 2.Explain to the patient what the motion is and what you are going to do.3.Check passive range of motion and end feel4. Proceed slowly and gently. Give the patient confidence5.Measure starting position if necessary6.Measure ending position (active or passive)- Always measure both sides

Flexion: 180*Patient positionSupineFulcrumClose to Acromion process (humeral head)Proximal ArmMid-Axillary line of thoraxDistal Armlateral midline of humerus lateral humeral epicondyle Lats can limit if tight AROM first then passive, make sure no compensation (Ex: arching back)

Extension 60*Patient PositionProne with head turned or forehead on towelFulcrumClose to acromion (humeral head)Proximal ArmMid-Axillary line of thoraxDistal ArmLateral midline of humerus lateral epicondyle Measure AROM, then lift for PROM Avoid compensation, stabilize shoulder & lift above elbow, should be firm end feel

Abduction 180*Patient PositionSupine close to the edge of the table (differs from book)FulcrumAnterior aspect of acromion process (humeral head)Proximal ArmParallel to midline of the anterior aspect of the sternumDistal ArmMedial midline of humerus- Thumb up to clear, AROM then PROM at elbow

Internal Rotation 70*Patient PositionSupine with towel under upper arm, elbow just over edge of table. 90 degrees Abduction (if limited/contraindications bring wherever he can)FulcrumOlecranon process (elbow)Proximal ArmParallel or perpendicular to floorDistal armUlna. Aligned with Olecranon and ulnar styloidNoteWhat carefully for substitution. As soon as humeral head rises noticeably, motion is complete. (if you push too much, shoulder will pop out)- Ask to bring arm forward for IR

External Rotation 90* Same as for Internal Ask patient to bring arm back instead of forward

Muscle Length Testing

Muscle length must be looked at because it can limit ROM Take them into the motion opposite of what the muscle does to lengthen muscle ALWAYS assessed passively with over pressure There are no norms, comparing sides

Latissimus Dorsi & Teres Major Teres major is the synergist, but has no attachment to pelvis

Patient positionSupine on table. Hips and knees flexedMovementFlex both upper limbs with low back flat on table. When back arches, amount of flexion is noted (back pop up & movement is done, look at one side to compare to other, if it is tight stretch patient in that position)- Flex, abduction of UEs & apply overpressure

Pectoralis Major(remember there are 2 heads & apply overpressure!)

Patient positionSupine on table. Hips and knees flexedMovementSternocostal Head (scaption w/ER), attaches to sternumShoulder lateral rotation and flexion about way between frontal and sagittal planes. Shoulders should achieve full flexion to the table. Costoclavicular Head, attaches to clavicleHorizontal Abduction at 90 degrees of shoulder flexion. Upper limb should reach the tablePectoralis MinorSupine on table with hips and knees flexed.Assess for asymmetrical shoulder height from table.Can be measured with a tape measure to compare both sides (table to shoulder height). Will be tight with round shoulders, view & gently press on shoulders to see if they come down closer to table

Scapulothoracic MMT (no grav min!)

Scapular Depression and Adduction (lower trapezius)PProne. Elbow extended. Thumb up. 145 degrees of abduction (a little more than scaption). Therapist stands at test side inferior to arm. RDistal humerusSUse other hand to palpate lower trap

Scapular Adduction (middle trap)PProne. Therapist at side and inferior to armArm abducted and externally rotated (thumb toward ceiling)RDistal forearmSScapular area (palpating the fibers of middle trapezius)Note:Look for scapular adduction (are you pulling scaps together), not horizontal abduction of the humerus.

Scapular Adduction and medial rotation (Rhomboid major/minor)PProne with dorsum of hand placed over the buttock opposite the test side- raises the arm away from the back (make sure scapula is adducted and IR). (90,90 & push to ceiling)Rapplied over the scapula (vertebral border) in the direction of abduction and ERSthrough the weight of the trunk assess for substitutions (tipping of scapula forward through pec minor)

Scapular Abduction (Serratus anterior)PSupine. Shoulder flexed to 90, elbow flexed to 90ROn top of elbowSPec major

Alternate PositionElbow extended. Patient makes a fist. Resistance applied to top of fist. No stabilization required unless elbow is weak.

Quick Clinical Test - Wall push up Weakness is demonstrated by winging of the scapula.

SHOULDER /GH MMT Always apply max resistance, but relative to the joint & individual patient PROM first to see range & end feel if can pull arm all the way up grade 3 Then take patient halfway through ROM & stabilize shoulder/upper trap 3+ can break, 4 little give, 5 cant budge Cant go all the way through PROM GM positioned: 3- can PROM in GM position (strength in an issue), 2 full ROM in GM 2+ partial ROM against gravity, 2- cant go through full ROM 1 trace (touch & feel contraction), 0 no contraction at all

Flexion (anterior deltoid, Coracobrachialis & long head of the biceps)Position Sitting. Elbow extended & thumb up.Resistance Distal HumerusStabilizationDistal upper trapGM position: side lying (cant lift half way, support arm, take through PROM, grade is less than 3)

Abduction (middle deltoid and supraspinatus)PSitting. Elbow extended, thumb up. Therapist in front of patient. RDistal HumerusSDistal upper trap(Follow the same principles as for flexion)GM position supine (not full ROM, support, arm overhead) Scaption (deltoid and supraspinatus): Arm elevation in the plane of the scapula.PShort Sitting elevate arm to 90 deg, halfway between Abduction and FlexionRDistal humerusSDistal Upper Trap

Extension (Latissimus Dorsi, Teres Major, Posterior Deltoid)PProne with head turned or forehead on towelRDistal HumerusSScapulaGM position: sidelying

Horizontal Adduction (Pec major)PSupine. 90 degrees of elbow flexion, full shoulder internal rotation, Therapist stands on the cranial side of the arm. RDistal humerusSPec majorGM position - sitting

External Rotation (teres minor and Infraspinatus)PProne with head turned or forehead on towel. 90 degrees of ABD and 90 degrees of elbow flexion. Can use a towel or pad under upper arm. Therapist stands superior to arm. RDistal forearm use mild or two-finger resistance (half way)SElbowGM position arm straight

Internal Rotation (Subscapularis, pec major, lat. dorsi, teres major)PProne with head turned or forehead on towel. Towel under upper arm. Therapist stands inferior to arm. RDistal forearm. Resistance is stronger than for ER. SElbowGM position arm straight

Wrist and Hand ROM and Muscle Testing LAB

Gross exam: AROM screeningFlexion/ExtensionUlnar/radial deviationSupination/pronationDigit abduction/adductionThumb flexion/extensionFist (make full fist)Opposition (thumb to each finger)If all can fully be achieved, strength is the issue

Passive Range of Motion AssessmentSupine or sitting

Goniometry1. PronationPosition Arm at side of body with elbow at 90 degrees, STANDING, Forearm neutral Fulcrumproximal ulnar headProximal armdorsal or volar surface of forearm just proximal to styloid processStationary armPerpendicular to floorExpected ROM0-90 degrees

1. SupinationPosition Arm at side of body with elbow at 90 degrees, STANDING Forearm neutralFulcrumexact opposite of ulnar headProximal armdorsal or volar surface of forearm just proximal to styloid processStationary armPerpendicular to floorExpected ROM0-90 degrees

1. Wrist FlexionPosition Sitting with arm supported on table. Wrist just over edge of table. FulcrumLateral Aspect of wrist. Triquetrum (ulnar side)Proximal armOlecranonStationary armLateral midline of 5th MC.Expected ROM80 degreesEnd feelFirm

2. Wrist Extension: same positions & end feelExpected ROM70 degrees

3. Radial DeviationPositionSameFulcrumCapitateProximal armDorsal Midline of forearmDistal armThird MCEnd feelFirm or hardExpected ROM20 degrees

4. Ulnar DeviationPositionSameFulcrumSameProximal armSameDistal armSameEnd feelfirmExpected ROM30 degrees*** Wrist Capsular Pattern Equal limitations of flexion and extension

5. MCP FlexionPositionSitting. Neutral pronation/supinationFulcrumPlace axis on the dorsal surface of the MCP jointProximalDorsal midline of MCDistalDorsal midline of proximal phalanxEnd feelFirm or hardExpected ROM90 degrees

6. MCP ExtensionSame as for flexionEnd feelFirmExpected Rom45 degrees

7. Thumb CMC FlexionPositionSitting. Full supinationFulcrum Palmer first CMC jointProximalVentral midline of radius radial styloidDistalVentral midline of first MCEnd feelSoftExpected ROM15 degrees

8. Thumb CMC ExtensionSame as for FlexionEnd feelFirmExpected ROMNot listed. Roughly 25 degrees

9. Thumb CMC AbductionPositionSitting. Neutral Pronation/SupFulcrumLateral aspect of radial styloid processProxCenter of 2nd MCDistalCenter of 1st MCP jointEnd feelFirmExpected ROM70 degrees

10. Thumb MCP FlexionPositionSitting. Full SupinationFulcrumDorsal aspect of MCPProxDorsal midline of MCDistalDorsal midline of prox phalanxEnd feelHard or firmExpected ROM50 degrees

11.Thumb MCP ExtensionSame as MCP flexionEnd feelFirmExpected ROMNot listed

12. Thumb OppositionPositionSitting. Full supinationRuler positionTip of thumb and tip of fifth finger.

13. PIP and DIP Flexion and ExtensionDemonstration only

Muscle Length Testing

Flexor carpi ulnaris, flexor carpi radialis, and palmaris longus

Extensor carpi radialis longus and brevis, extensor carpi ulnaris

Flexor digitorum superficialis

Extensor digitorum and digiti minimi

Manual Muscle Testing

Please note that there is no gross strength screening for the wrist and hand.

1. Wrist Flexion (flexor carpi radialis, flexor carpi ulnaris)

Position:Sitting, full supinationStabilization:Proximal to wristResistance:Distal to wristGM:Neutral pron/sup

2. Wrist Extension (extensor carpi radialis longus and brevis, extensor carpi ulnaris)

Position:Sitting, full pronationStabilizationProx to wristResistance:Distal to wristGM:Neutral Pronation/supination3. Wrist Radial Deviation (flexor carpi radialis brevis/longus, extensor carpi radialis)

Position:Sitting, neutral sup/pronStabilizationProx to wristResistanceDistal to wrist. Radial side of handGMNeutral pron/sup

4. Wrist Ulnar Deviation (flexor carpi ulnaris and extensor carpi unlnaris)

PositionSitting. Full pronationStabilizationProx to wrist. ResistanceUlnar side of wristGMNone. Main test position is GM

Finger MMT

Please note that there are no grades given for finger MMTs. Gravity has very little effect so you will not be asked to learn GM positions for the following tests. .

1. PIP Flexion (Flexor digitorum superficialis)Position Sitting. Full supinationStabilizeProx phalanxResistanceMiddle Phalanx

2.DIP Flexion (Flexor digitorum profundus)PositionSameStabilizeMiddle phalanxResistanceDistal phalanx

3. MCP Extension (Extensor digitorum, extensor indices, extensor digiti minimi (depending on finger tested)

PositionSitting. Full pronation. MCP flexion. Finger flexionStabilizeWristResistanceProx phalanx

Thumb motions

The thumb is positioned in a rotated position. Therefore flexion, extension, abduction and adduction may appear counterintuitive when viewed in the anatomical plane.

4. Thumb Extension (extensor pollicis longus) PositionSitting. Neutral pron/supStabilizeProx phalanxResistancedistal phalanx

5.Thumb Abduction (abductor pollicis longus)PositionSitting. Neutral. StabilizeHandResistanceProx phalanx

6.Thumb Adduction (adductor pollicis)PositionSitting. NeutralStabilizeHand, digits 2-5ResistanceInner aspect of prox phalanx

Hip and Knee ROM and Muscle Testing Lab

Range of motion screening Hip: Look at symmetry & full ROM from multiple planes Flexion: march leg up (both sides) any pain? Extension: lift leg back, very little motion, no leaning forward Abduction: leg out to side, toe straight Adduction: bring leg out in front, cross over then bring back *All standing, hold on to table or hold their hand- IR: bring foot out to side (avoid knee movement)- ER: bring leg in & up shin towards knee*Both sitting, some hip flexion can occur with normal range Knee extension:- sitting, kick knee up totally straight, look for symmetry & full ROMKnee flexion: standing, hold onto something stable, bend knee back, bring heel towards bottomAnkle: (performed in short sitting), hold leg, get a stool Dorsiflexion (guide with finger) Plantarflexion (guide with finger) Inversion Eversion Flexion, Abduction, Extension of 1st MT

Goniometric Measurement: 1. Passive Range of Motion AssessmentSupine (Hip extension can be done in prone or side-lying; Hip adduction can be assessed by moving both legs together (one adducting the other abducting), say end feel2. AROM & get measurement3. give overpressure, obtain PROM measurement (should be 5-10* more)*Test effected side first!!!1. Hip FlexionPositionSupine (fully relax, lift hip toward belly, bend knee, any pain?)FulcrumGTProx armLateral midline of trunkDistal armLateral femoral epicondyleAAOS ROM120 degreesEnd FeelUsually soft, can be firm

2.Hip Extension (side-lying is cant lay prone)PositionProne (feet off table, stabilize hip, keep leg straight & lift to ceiling)Goni Same as flexionAAOS ROM20 degreesEnd feelFirm

3.Hip AbductionPositionSupine (bring leg out to side, support around knee, stabilize pelvis)FulcrumASISProx ArmLine between ASISs (straight across stomach), patient can hold goniDistal armMidline of PatellaAAOS ROM45 degreesEnd FeelFirm

4. Hip Adduction: Same as abduction(abduct other leg, bring leg toward other leg, keep knee straight)AAOS ROM30(come closer to that side of table & abduct other leg away)

5.Hip Internal (Medial) RotationPositionSitting, knee flexed to 90 degrees (stabilize gently at knee, leg to ankle)FulcrumAnterior aspect of patellaProx armPerpendicular to floorDistal armmidpoint between malleoliAAOS ROM45 degreesEnd feelFirm, do PROM & end feel in supine first!!

6.Hip External (Lateral) RotationPositionSame (stabilize knee, bring leg in toward other foot)Goni SameAAOS ROM45 degreesEnd feelfirm, do PROM & end feel in supine first!!

7.Knee Flexion (Supine)PositionSupine, can flex hip also if necessaryFulcrumLateral epicondyleProx armGTDistal armlateral malleolusAAOS ROM135 degreesEnd feelSoft (apply overpressure on tibia)

8.Knee Extension (Supine)PositionSupine with towel under ankle, knee straight, quad set (squeeze knee & push into my hand), do not give resistance (just a cue), Same as knee flexionAAOS ROM10 degrees of hyperextensionEnd feel Firm (overpressure on femur & support back of calf)

Muscle Length Testing

1. Hip Flexors - Thomas Test psoas & rectus femoris- will be tight with anterior pelvic tilt- sitting at edge of table, lie them back & support back, bring both knees toward chest- drop one leg down & tell pt to pull other leg in as tight as possible- is leg hitting table or not? Angle of knee should be 90, positive psoas if tight- COMPARE BOTH SIDES!

2. Rectus Femoris Thomas test. Watch for knee extension- rule rectus out by extending the leg (can help but dont hold it up), back is flat- if it is rectus that is tight thigh should go down, if not psoas is tight- if rectus is issue turn over to prone for elys test

3. Ely - Prone Knee Flexion - stabilize hip, bend knee if angle is 90 or more, it is a positive test- can measure flexibility with goni to compare both sides, but not measuring the true angle in this position (due to passive insufficiency)

4. TFL Ober test:- side-lying, bend knee & support hip- lift pt into abduction & extension (body in neutral so hips don't roll back)- let go, should fall back slowly..if hanging in air positive test (of TFL)- then extend knee & redo to figure out if ITB is involved (pos IT band)

5. Hamstrings SLR (normally 70-80 degrees)/ 90/90- supine, SLR with other knee straight, compare both sides & apply overpressure (positive test tightness of proximal- then position pt at 90,90 and attempt to extend knee (positive test tightness of distal hamstring )- can compare visually or measure with goni (same landmarks as knee flexion), but will not be measuring TRUE joint, always unaffected side first

Manual Muscle Testing

Gross Strength Screening (sitting, supine)Flexion, extension, abduction, adduction, IR/ER

Specific muscle testingHip FlexionIliopsoasPositionSitting. Hands flat on table (march)ResistanceDistal Femur (don't let me push you down)StabilizationPosterior trunk/backGM Sidelying (on opposite side)

Hip ExtensionHamstrings and Glut MaxPositionProne (watch for compensation, push up against my hand)ResistanceDistal femurStabilizationLateral pelvisGMSidelying (on opposite side)

Hip Extension with knee flexionGlut Max (isolates)PositionProne. Knee flexed to 90 degreesResistanceDistal femurStabilizationLateral pelvisGMSidelying

Hip AbductionGlut medius and minimus SLRPositionSidelying. Slight bend in lower leg. ResistanceDistal femur, lateral aspectStabilizationLateral pelvisGMSupine

Hip Adduction SLRPositionSidelying. Top limb either flexed in front or behind lower limbResistanceDistal femur, medial aspect StabilizationLateral PelvisGMSupine

Hip External RotationObturators, Gemellae, Piriformis, Quadratus femoris, Glut MaxPositionSitting (bring foot towards other)ResistanceMedial ankleStabilizationLateral KneeGMSupine. Limb straight (rotate toe in)

Hip Internal Rotation Glut medius and minimus and TFLPositionSittingResistanceLateral ankleStabilizationMedial kneeGMSupine. Limb straight (rotate toe out)

Knee ExtensionQuadriceps FemorisPositionSitting. Therapist on chair or standing (chair is preferable).ResistanceDistal TibiaStabilizationDistal Femur (kick straight out, now half way)GMSidelying

Knee FlexionHamstringsPositionProneResistanceDistal Posterior TibiaStabilizationDistal FemurGMSidelying

Goniometric Measurements do PROM, get end feel, then AROM, then PROM measurements do unaffected side first!Passive Range of Motion Screening. - Of which ankle movement is deficient (short sitting or long with towel under knee)- Hindfoot inversion & eversion performed in prone

Talocrural DorsiflexionPositionSitting with legs over edge or long sitting with knees bent and ankle off table. Fulcrumlateral malleolus or lateral calcaneusProx armFibular headDistal armParallel to 5th MT (above, in same plane)AAOS ROM20 degreesEnd Feelfirm

Talocrural PlantarflexionSame as dorsiflexionAAOS ROM50 degreesEnd feelFirm

Forefoot Inversion (talocrural joint)PositionSame (bring toes toward midline & up)FulcrumAnterior ankle midway between malleoliProx ArmTibial tuberosityDistal Arm2nd MTAAOS ROM35 degreesEnd feelFirmForefoot eversionPositionSameAlignmentSameAAOS ROM15 degreesEnd feelFirm or hard

Hindfoot InversionPositionProne with feet off of tableFulcrumPosterior ankle, midway between malleoliProx armPosterior midline, lower legDistal armPosterior midline of calcaneousAAOS ROM0-4 naturally, 4-32 degrees activelyEnd feelFirm

Hindfoot eversionPositionSameAlignment SameAAOS ROM5 degreesEnd feelHard or firm1st MTP Extension (use hand goni, on bottom of foot)Fulcrum lateral aspect of first MT jointProx arm1st MT Distal arm proximal phalanxAAOS ROM70 degreesEnd feelfirm

1st MTP Flexion (use hand goni, on top of foot)PositionSameAlignment SameAAOS ROM45 degreesEnd feelFirm

Muscle length testing

Gastroc: supine with knee straightSoleus: supine with knee flexed (towel/bolster)

Function:Full range of DF is required to descend steps (21-36 degrees)Manual Muscle TestingNo + or for the ankle!!

Gross strength Screening

Dorsiflexion with inversion Tibialis AnteriorPosition Short sitting - Therapist sits on stoolResistance Distal foot StabilizationProximal to ankle Alternate Knee flexed to 90 degrees. Patient sitting

Inversion in plantar flexion Tibialis PosteriorPositionSame as previous except ankle in plantar flexionResistanceMedial/Distal footStabilizationProximal to ankle, lateral aspectAlternate True AG position is sidelying

Eversion Peroneous Longus and brevisPositionShort sitting - Therapist on stool. Ankle in plantarflexionResistanceDistal/Lateral footStabilizationProximal to ankle, medial aspectAlternate True AG position is sidelying

Plantar Flexion Gastroc/Soleus 10 calf raisesPoor + rangeFair - More than Fair 1 repFar + 2-3 repsG 4-6 repsG+7-9 repsN10 reps

Demonstrate non WB in proneSoleus knee flexed to 90* - pt PF toward ceilingGastroc knee extended

Great toe tested in supineHallux and toe MP and IP flexion flexor hallicus brevis/longus

Hallux and toe MP and IP extension extensor hallicus longus/brevisHallux and toe DIP and PIP flexion as per book

Subtalar Neutral Assessment- part of gross screen if you get ankle case study

Normal STN = 4 degrees of varus

In prone, feet hanging off table make 3 lines grasp lateral foot with one hand grasp talus (in between two malleoli) with other move back & forth until you fill talus is neutral angle of 3 pen marks should show a hindfoot varus ~4degrees